A prospective randomized study comparing transnasal and peroral 5-mm ultrathin endoscopy.

BACKGROUND/PURPOSE: Differences in patient tolerance, acceptance, and satisfaction of esophagogastroduodenoscopy (EGD) between transnasal (TN) and peroral (PO) routes using a 5-mm video endoscope. METHODS: A total of 220 enrolled patients were assigned randomly to two groups undergoing EGD-110 patients each for TN and PO. The successful rate, procedure time, and adverse events were recorded. After the procedure, patients answered a validated questionnaire of tolerance, acceptance, and satisfaction. RESULTS: There were 6 failures (5.7%) of nasal intubation and two nasal bleeding (2%) among 105 TN-EGD procedures. All PO patients (n=102) completed EGD successfully without adverse event. Compared to PO, the procedure of TN achieved lower successful rate (94% vs. 100%, p=0.01), was complicated with epistaxis (2% vs. 0%) and took longer (mean ± SD 19.9 ± 6.1 min vs. 16.8 ± 6.4 min, p=0.0001). The patients undergoing TN-EGD indicated less discomfort during passing pharynx (scores of 2.1 ± 2.0 vs. 3.1 ± 2.6, p=0.011) but more pain during inserting scope (scores of 2.2 ± 1.6 vs. 1.5 ± 1.8, p=0.0001). Eventually, there were no significant differences between TN and PO regarding the overall procedure discomfort (scores of 10.7 ± 6.6 vs. 11.1 ± 7.8 scores, p=0.9), satisfaction (scores of 41.2 ± 4.2 vs. 41.3 ± 4.6, p=0.91), and acceptability (87.8% vs. 94.2%, p=0.91). CONCLUSION: PO intubation seems an excellent alternative method when using a 5-mm ultrathin endoscopy because it achieves comparable patient tolerance, acceptance, and satisfaction as TN intubation, takes less time and causes lower intubation failure and epistaxis.

Less is more? The impact of trauma volume on the positive rate of head computed tomography scans in head trauma patients.

OBJECTIVE: Few studies have assessed the impact of trauma volume on the operational efficiency of emergency departments. Herein, we evaluate the association between trauma volume with the positive rate of head computed tomography scans in head trauma patients in a tertiary care hospital. METHODS: This is a retrospective cohort review involving all head trauma patients presenting to a tertiary care hospital. Trauma census, head trauma patient volume, the number of emergent head CT scans, and the number of positive head CT scans were collected on a monthly basis. Comparison was primarily made between the trauma patient volume and the positive rate of head CT scans. RESULTS: 25,549 trauma patients were reviewed. Of these, 5,168 (20.2%) sustained head trauma and 3,336 head CT scans were performed with mean 29.1% positive rate of substantial head injuries. The monthly data were analyzed and a statistically significant correlation between monthly trauma volume and decrease in positive rate of head CT scan was identified (Pearson r = -0.51, P = 0.02). With introducing different cut-point values of trauma volume, we identified the threshold of trauma census as approximately 4.9 and 8.8% higher than mean monthly trauma volume in discriminating significant decrease of positive rate of head CT scans.

Mind the information gap: fertility rate and use of cesarean delivery and tocolytic hospitalizations in Taiwan.

BACKGROUND: Physician-induced demand (PID) is an important theory to test given the longstanding controversy surrounding it. Empirical health economists have been challenged to find natural experiments to test the theory because PID is tantamount to strong income effects. The data requirements are both a strong exogenous change in income and two types of treatment that are substitutes but have different net revenues. The theory implies that an exogenous fall in income would lead physicians to recoup their income by substituting a more expensive treatment for a less expensive treatment. This study takes advantages of the dramatic decline in the Taiwanese fertility rate to examine whether an exogenous and negative income shock to obstetricians and gynecologists (ob/gyns) affected the use of c-sections, which has a higher reimbursement rate than vaginal delivery under Taiwan's National Health Insurance system during the study period, and tocolytic hospitalizations. METHODS: The primary data were obtained from the 1996 to 2004 National Health Insurance Research Database in Taiwan. We hypothesized that a negative income shock to ob/gyns would cause them to provide more c-sections and tocolytic hospitalizations to less medically-informed pregnant women. Multinomial probit and probit models were estimated and the marginal effects of the interaction term were conducted to estimate the impacts of ob/gyn to birth ratio and the information gap. RESULTS: Our results showed that a decline in fertility did not lead ob/gyns to supply more c-sections to less medically-informed pregnant women, and that during fertility decline ob/gyns may supply more tocolytic hospitalizations to compensate their income loss, regardless of pregnant women's access to health information. CONCLUSION: The exogenous decline in the Taiwanese fertility rate and the use of detailed medical information and demographic attributes of pregnant women allowed us to avoid the endogeneity problem that threatened the validity of prior research. They also provide more accurate estimates of PID.JEL Classification: I10, I19, C23, C25.

Declining fertility and the use of cesarean delivery: evidence from a population-based study in Taiwan.

OBJECTIVE: To test the hypothesis that declining fertility would affect the number of cesarean sections (c-sections) on maternal demand, but not medically indicated c-sections. DATA SOURCES: The 1996-2004 National Health Insurance Research Database in Taiwan for all singleton deliveries. STUDY DESIGN: Retrospective population-based, longitudinal study. Estimation was performed using multinomial probit models. PRINCIPAL FINDINGS: Results revealed that declining fertility had a significant positive effect on the probability of having a c-section on maternal request but not medically indicated c-section. CONCLUSIONS: Our findings offer a precautionary note to countries experiencing a fertility decline. Policies to contain the rise of c-sections should understand the role of women's preferences, especially regarding cesarean deliveries on maternal request.

Factors associated with tocolytic hospitalizations in Taiwan: evidence from a population-based and longitudinal study from 1997 to 2004.

BACKGROUND: The use of tocolytic hospitalization in antenatal care is controversial and worthy of more research. We investigated individual, institutional, and area factors that affect the use of tocolytic hospitalizations in Taiwan where fertility has rapidly declined. METHODS: Longitudinal data from the 1996 to 2004 National Health Insurance Research Database in Taiwan were used to identify tocolytic hospitalizations. The probit model was used to estimate factors associated with tocolytic hospitalizations. RESULTS: The decline in fertility was significantly associated with the probability of tocolytic hospitalizations. Several physician and institutional factors-including physician's age, hospital ownership, accreditation status, bed size, and teaching status-were also significantly correlated to the dependent variables. CONCLUSIONS: The provision of inpatient tocolysis is influenced not only by clinical considerations but also by physician, institutional, and area factors unrelated to clinical need. Fertility declines in Taiwan may have led obstetricians/gynecologists to provide more tocolysis to make up for their lost income. If the explanation is further validated, reimbursement policies may need to be reviewed to correct for overuse of inpatient tocolysis. The correlation could also be explained by the increasing use of artificial reproductive technologies and higher social value of newborns. In addition, the physician and institutional variations observed in the study indicate potential misuse of inpatient tocolysis that warrant further investigation.