On the Impact of Treatment Restrictions for the Indigent Suffering from a Chronic Disease: The Case of Compassionate Dialysis

We analyze a congested healthcare delivery setting resulting from emergency treatment of a chronic disease on a regular basis. A prominent example of the problem of interest is congestion in the emergency room (ER) at a publicly funded safety net hospital resulting from recurrent arrivals of uninsured end-stage renal disease patients needing dialysis (a.k.a. compassionate dialysis). Unfortunately, this is the only treatment option for un/under-funded patients (e.g., undocumented immigrants) with ESRD, and it is available only when the patient’s clinical condition is deemed as life-threatening after a mandatory protocol, including an initial screening assessment in the ER as dictated and communicated by hospital administration and county policy. After the screening assessment, the so-called treatment restrictions are in place, and a certain percentage of patients are sent back home; the ER, thus, serves as a screening stage. The intention here is to control system load and, hence, overcrowding via restricting service (i.e., dialysis) for recurrent arrivals as a result of the chronic nature of the underlying disease. In order to develop a deeper understanding of potential unintended consequences, we model the problem setting as a stylized queueing network with recurrent arrivals and restricted service subject to the mandatory screening assessment in the ER. We obtain analytical expressions of fundamental quantitative metrics related to network characteristics along with more sophisticated performance measures. The performance measures of interest include both traditional and new problem-specific metrics, such as those that are indicative of deterioration in patient welfare because of rejections and treatment delays. We identify cases for which treatment restrictions alone may alleviate or lead to severe congestion and treatment delays, thereby impacting both the system operation and patient welfare. The fundamental insight we offer is centered around the finding that the impact of mandatory protocol on network characteristics as well as traditional and problem-specific performance measures is nontrivial and counterintuitive. However, impact is analytically and/or numerically quantifiable via our approach. Overall, our quantitative results demonstrate that the thinking behind the mandatory protocol is potentially naive. This is because the approach does not necessarily serve its intended purpose of controlling system-load and overcrowding.

Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage

Background and Purpose: Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). Methods: We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. Results: Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17–9.22] and 5.36 [95% CI, 2.20–13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53–737). Conclusions: The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.

Treatment restrictions in patients with severe stroke are associated with an increased risk of death

Introduction Treatment restrictions in the first 2 days after intracerebral haemorrhage have been independently associated with an increased risk of early death. It is unknown whether these restrictions also affect mortality if these are installed several days after stroke onset. Patients and methods Sixty patients with severe functional dependence at day 4 after ischaemic stroke or intracerebral haemorrhage were included in this prospective two-centre cohort study. The presence of treatment restrictions was assessed at the day of inclusion. Information about mortality, functional outcome (modified Rankin scale) score and quality of life (visual analogue scale) was recorded 6 months after stroke onset. Poor outcome was defined as modified Rankin scale >3. Satisfactory quality of life was defined as visual analogue scale ≥ 60. Results At 6 months, 30 patients had died, 19 survivors had a poor functional outcome and 9 patients had a poor quality of life. Treatment restrictions were independently associated with mortality at 6 months (adjusted relative risk, 1.30; 95% confidence interval, 1.06–1.59; p = 0.01), but not with functional outcome. Discussion Our findings were observed in 60 selected patients with severe stroke. Conclusion The instalment of treatment restrictions by itself may increase the risk of death after stroke, even if the first 4 days have passed. In future stroke studies, this potential confounder should be taken into account. Quality of life was satisfactory in the majority of the survivors, despite considerable disability.

Presence of Concomitant Systemic Cancer is Not Associated with Worse Functional Long-Term Outcome in Patients with Intracerebral Hemorrhage

Background: Data on clinical characteristics and outcome of patients with intracerebral hemorrhage (ICH) and concomitant systemic cancer disease are very limited. Methods: Nine hundred and seventy three consecutive primary ICH patients were analyzed using our prospective institutional registry over a period of 9 years (2006-2014). We compared clinical and radiological parameters as well as outcome - scored using the modified Rankin Scale (mRS) and analyzed in a dichotomized fashion as favorable outcome (mRS = 0-3) and unfavorable outcome (mRS = 4-6) - of ICH patients with and without cancer. Relevant imbalances in baseline clinical and radiological characteristics were adjusted using propensity score (PS) matching. Results: Prevalence of systemic cancer among patients with ICH was 8.5% (83/973). ICH patients with cancer were older (77 [70-82] vs. 72 [63-80] years; p = 0.002), had more often prior renal dysfunction (19/83 [22.9%] vs.107/890 [12.0%]; p = 0.005), and smaller hemorrhage volumes (10.1 [4.8-24.3] vs. 15.3 [5.4-42.9] mL; p = 0.017). After PS-matching there were no significant differences neither in mortality nor in functional outcome both at 3 months (mortality: 33/81 [40.7%] vs. 55/158 [34.8%]; p = 0.368; mRS = 0-3: 28/81 [34.6%] vs. 52/158 [32.9%]; p = 0.797) and 12 months (mortality: 39/78 [50.0%] vs. 70/150 [46.7%]; p = 0.633; mRS = 0-3: 25/78 [32.1%] vs. 53/150 [35.3%]; p = 0.620) among patients with and without concomitant systemic cancer. ICH volume tended to be highest in patients with hematooncologic malignancy and smallest in urothelial cancer. Conclusions: Patients with ICH and concomitant systemic cancer on average are older; however, they show smaller ICH volumes compared to patients without cancer. Yet, mortality and functional outcome is not different in ICH patients with and without cancer. Thus, the clinical history or the de novo diagnosis of concomitant malignancies in ICH patients should not lead to unjustified treatment restrictions.

Bharadwaj Aushadalay

This case provides an opportunity to identify and discuss issues in sustenance of an incumbent's strategy in the changing environment. The context is the practice of Nadi Nidan (pulse diagnosis) and treatment of disorders based on this according to Ayurveda, the ancient system of Indian medicine. It describes the functioning of Bharadwaj Aushadhalay, an Ayurveda clinic run by Vaidyaji since 1955 and presents the history of the clinic, the process by which Vaidyaji learnt the practice of Nadi Nidan, the profile of the patients, the mode of treatment, restrictions imposed by Vaidyaji on the patients, their response and competitive pressures on the system. The case also provides a brief sketch of Ayurveda, its principles, currents trends in the education and research in Ayurveda, and recent advances in diagnostic tools and techniques. The case can be used in courses of Strategic Management in the module on Strategies for Sustainable Competitive Advantage and Knowledge Management.