Hospital case-volume is associated with case-fatality after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Inverse association between hospital case-volume and case-fatality has been observed for various nonsurgical interventions and surgical procedures. AIMS: To study the impact of hospital case-volume on outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS: We included aSAH patients who underwent aneurysm coiling or clipping from tertiary care medical centers across three continents using the Dr Foster Stroke GOAL database 2007-2014. Hospitals were categorized by annual case-volume (low volume: <41/year; intermediate: 41-70/year; high: >70/year). Primary outcome was 14-day in-hospital case-fatality. We calculated proportions, and used multiple logistic regression to adjust for age, sex, differences in comorbidity or disease severity, aneurysm treatment modality, and hospital. RESULTS: We included 8525 patients (2363 treated in low volume hospitals, 3563 treated in intermediate volume hospitals, and 2599 in high-volume hospitals). Crude 14-day case-fatality for hospitals with low case-volume was 10.4% (95% confidence interval (CI) 9.2-11.7%), for intermediate volume 7.0% (95% CI 6.2-7.9%; adjusted odds ratio (OR) 0.63 (95%CI 0.47-0.85)) and for high volume 5.4% (95% CI 4.6-6.3%; adjusted OR 0.50 (95% CI 0.33-0.74)). In patients with clipped aneurysms, adjusted OR for 14-day case-fatality was 0.46 (95% CI 0.30-0.71) for hospitals with intermediate case-volume and 0.42 (95% CI 0.25-0.72) with high case-volume. In patients with coiled aneurysms, adjusted OR was 0.77 (95% CI 0.55-1.07) for hospitals with intermediate case-volume and 0.56 (95% CI 0.36-0.87) with high case-volume. CONCLUSIONS: Even within a subset of large, tertiary care centers, intermediate and high hospital case-volume is associated with lower case-fatality after aSAH regardless of treatment modality, supporting centralization to higher volume centers.

Evaluation of patient satisfaction and experience towards pharmacist-administered vaccination services in Western Australia.

Background Pharmacist-administered vaccination services have been available in various countries for several years. In 2014, Western Australian (WA) legislation was introduced to allow pharmacist immunisers to administer the influenza vaccine to consumers 18 years and older. Objective To determine consumer satisfaction with pharmacist-administered influenza vaccination services in WA and identify factors associated with opinions to extend the service to include other vaccines. Setting Thirteen WA community pharmacies. Method In 2015, 133 pharmacies in WA offered pharmacist-administered influenza vaccinations. Of the 133 pharmacies, a purposive sample of 10% (13) were invited to participate in this 2016 study. Following vaccination, consumers were given a questionnaire and asked to evaluate the service and if they would support expansion of the service to include other vaccinations. Main outcome measure Consumer satisfaction with aspects of the service using a 5-point Likert scale. Results A total of 434 (66.8%) questionnaires were completed at the 13 pharmacies and returned. The majority of consumers (99.5%) were satisfied with the service overall, and 97.2% advised they would receive a vaccination from a community pharmacist in the future. Over 60% would like vaccinations to expand to other conditions. Women and those who would again have their influenza vaccine from the pharmacist were particularly supportive of this expansion. Conclusion Consumer satisfaction with pharmacist-administered vaccinations was high. Consumers found the service convenient, comfortable and professional. The majority of respondents supported expansion of pharmacist-administered vaccination services to a wider range of vaccines.

Understanding treatment non-adherence in schizophrenia and bipolar disorder: a survey of what service users do and why.

BACKGROUND: Approximately half of service users with schizophrenia or bipolar disorder do not fully follow treatment recommendations. Studies of adherence have not adequately explored the frequency, consequences and meanings of non-adherence behaviours from service users' perspectives. This study contributes to a more fine-grained understanding of treatment choices and the support service users require in order to maximise benefit from their medications. METHODS: This was a mixed-methods questionnaire study, employing quantitative and thematic qualitative analyses. Thirty-five individuals with a diagnosis of, and receiving psycho-pharmaceutical treatment for, schizophrenia or bipolar disorder answered online or telephone questions about whether, how, and why they deviated from their treatment recommendations, and what support they currently and would like to receive. RESULTS: Over half of participants identified themselves as being non-adherent, however when asked in detail about intentional and unintentional adherence, 77% reported deviating from treatment recommendations. Critically, 29% were non-adherent and satisfied with being so. Service users' satisfaction with their support was positively correlated with satisfaction with their medication. Participants' made treatment choices in order to live well. Both side-effects and symptoms could be obstacles to adherence, but feeling well also impacted on participants' treatment choices. Treatment choices were often made in the context of living well day-to-day, and did not necessarily take into account longer-term effects of non-adherence. Participants wanted more information about their medications, better emotional support (including better access to psychological therapies) and stability in their relationships with health professionals. CONCLUSIONS: This study suggests that non-adherence, both intentional and unintentional, is common amongst individuals with diagnoses of schizophrenia and bipolar disorder, and that this often occurs without health professionals' knowledge or support. Treatment choices reflect a desire to live well, but are often driven by short-term needs. Given access to more information, and importantly to emotional support, service users could be helped to make treatment choices that adequately reflect the long-term risks of non-adherence, as well as allowing them to live well day-to-day. More research is required better to understand the meanings and complexities of service users' treatment choices.