Making the Case for Palliative Care at the System Level: Outcomes Data.

BACKGROUND: A recent trend in health care is to integrate palliative care (PC) programs across multiple hospitals to reduce variation, improve quality, and reduce cost. OBJECTIVE: The study objective was to demonstrate the benefits of PC for a system. METHODS: The study was a descriptive study using retrospective medical records in seven federated hospitals where PC developed differently before system integration. Measured were length of stay (LOS), mortality, readmissions, saved intensive care unit (ICU) days, cost avoidance, and hospice referrals. RESULTS: PC services within the first 48 hours of admission demonstrate a shorter LOS (5.08 days), reduced costs 40% ($2,362 per day), and decreased mortality (1.01 versus 1.10) for one hospital. Readmissions at 30, 60, and 90 days after a PC consult decreased (61.5%, 47.0%, and 42.1%, respectively). Annual pre- and postprogram referrals to hospice increased (65 to 107). Using modified matched pairs, LOS of PC patients seen within 48 hours of admission average 1.67 days less compared to non-PC patients. LOS for ICU patients with PC services in the ICU within the first 48 hours decreased by 1.12 days. Overall cost avoidance was 1.5 times total cost for PC programs systemwide. One pilot project using a full-time physician in the ICU reduced cost more than $600,000, with 315 saved ICU days, annualized. Systemwide, 69.3% of all referrals to hospice were made by the PC service. CONCLUSION: Early involvement of PC services emerged as advantageous to the net benefit. Given that health care's changing landscape will increasingly include bundled payment and risk holding strategies to improve quality and reduce cost in health care systems, systemwide PC will play a vital role.

Did the pre-1980 use of in-stream structures improve streams? A reanalysis of historical data.

In the 1930s, after only three years of scientific investigation at the University of Michigan Institute for Fisheries Research, cheap labor and government-sponsored conservation projects spearheaded by the Civilian Conservation Corps allowed the widespread adoption of in-stream structures throughout the United States. From the 1940s through the 1970s, designs of in-stream structures remained essentially unchanged, and their use continued. Despite a large investment in the construction of in-stream structures over these four decades, very few studies were undertaken to evaluate the impacts of the structures on the channel and its aquatic populations. The studies that were undertaken to evaluate the impact of the structures were often flawed. The use of habitat structures became an "accepted practice," however, and early evaluation studies were used as proof that the structures were beneficial to aquatic organisms. A review of the literature reveals that, despite published claims to the contrary, little evidence of the successful use of in-stream structures to improve fish populations exists prior to 1980. A total of 79 publications were checked, and 215 statistical analyses were performed. Only seven analyses provide evidence for a benefit of structures on fish populations, and five of these analyses are suspect because data were misclassified by the original authors. Many of the changes in population measures reported in early publications appear to result from changes in fishing pressure that often accompanied channel modifications. Modern evaluations of channel-restoration projects must consider the influence of fishing pressure to ensure that efforts to improve fish habitat achieve the benefits intended. My statistical results show that the traditional use of in-stream structures for channel restoration design does not ensure demonstrable benefits for fish communities, and their ability to increase fish populations should not be presumed.

A geomorphic explanation for a meander cutoff following channel relocation of a coarse-bedded river.

The Veteran's Fishing section of the Blackledge River in central Connecticut was relocated in the late 1950s. The relocation resulted in an unstable channel despite extensive efforts to prevent erosion. Overbank erosion and meander cutoffs were investigated using detailed survey data, characterizations of sediment deposits, flow modeling, and a moment-stability analysis. Limited reworking of revetment boulders indicate that riprap bank material was immobile during a 1979 flood event responsible for the formation of the cutoff channel. A moment-stability analysis factor-of-safety value of 1.1 supports the conclusion that riprap was not directly eroded from the banks. Alluvial particles with d(95) values ranging up to 120 mm were deposited along a bar downstream from the cutoff channel at flows estimated to be below a 1.5-year recurrence interval flow. Development of the bar deposit resulted in locally elevated water surfaces at high flow. The resulting overbank flow across the meander neck to the adjacent downstream bend led to the creation of an upstream migrating knickpoint, the erosion of approximately 16,000-year-old sediments, and the subsequent meander cutoff. The results of the study indicate that traditional erosion-control measures cannot prevent extreme channel adjustments if the geomorphic processes that control sediment continuity also are not considered.

Long-term effect of instream habitat-improvement structures on channel morphology along the Blackledge and Salmon rivers, Connecticut, USA.

Habitat-improvement structures on the Blackledge and Salmon rivers date back to the 1930s and 1950s. Forty of these structures were investigated to determine their long-term impact on channel morphology. These structures include designs that continue to be used in modern restoration efforts. During the intervening period since these structures were introduced, several major floods have affected the two channels. The floods include three flows in excess of the 50-year event, including the flood of record, which has an estimated recurrence interval of almost 300 years. Despite the extreme flooding, many structures were discovered in varying conditions of operation. Grade-control structures and low-flow deflectors generally create some low-flow habitat (P = 0.815) but do not produce the depth of water predicted by design manuals (P < 0.0001). Unintended erosion has developed in response to many of the channel modifications especially along the outside of meanders. In addition, the mode of failure of grade-control structures has created localized channel widening with associated bank erosion. Meanwhile, cover structures have produced a 30% reduction in streamside vegetation with over 75% less overhead cover than unaltered reaches. Based on these results, it is important for prospective designers to carefully consider the long-term impacts of instream structures when developing future channel-restoration projects.