Effect of cancer waiting time standards in the English National Health Service: a threshold analysis.

BACKGROUND: The English National Health Service has multiple waiting time standards relating to cancer diagnosis and treatment. Targets can have unintended effects, such as prioritisation based on targets instead of clinical need. In this case, a `threshold effect' will appear as a spike in hospitals just meeting the target. METHODS: We conducted a retrospective study of publicly available cancer waiting time data, including a 2-week wait for a specialist appointment, a 31-day decision to first treatment and a 62-day referral to treatment standard that attracted a financial penalty. We examined the performance of hospital trusts against these targets by financial year to look for threshold effects, using Cattaneo et al. manipulation density test. RESULTS: Trust performance against cancer waiting targets declined over time, and this trend accelerated since the start of the Covid-19 pandemic. Statistical evidence of a threshold effect for the 2-week and 31-day standard was only present in a few years. However, there was strong statistical evidence of a threshold effect for the 62-day standard across all financial years (p < 0.01). CONCLUSION: The data suggests that the effect of threshold targets alters hospital behaviour at target levels but does not do so equally for all standards. Evidence of threshold effects for the 62-day standard was particularly strong, possibly due to some combination of a smaller volume of eligible patients, a larger penalty, multiple waypoints where hospitals can intervene, baseline performance against the target and where the target is set (i.e. how much headroom is available). RCTs of the use of threshold targets and of different designs for such targets in the future would be extremely informative.

Changes in Time to Initial Physician Contact and Cancer Stage Distribution during the COVID-19 Pandemic in Patients with Head and Neck Squamous Cell Carcinoma at a Large Hungarian Cancer Center.

The aim of our study was to compare the characteristics and time to initial physician contact in patients with head and neck squamous cell carcinoma (HNSCC) before and during the COVID-19 pandemic at a large Hungarian cancer center. This was a retrospective study of patients 18 years or older presenting at the regional cancer center of Pécs Clinical Center with HNSCC between 1 January 2017, and 15 March 2020 (the pre-COVID-19 period) and between 16 March 2020, and 13 May 2021 (the COVID-19 period). Demographic and clinical data were collected, and the time between initial symptom onset and initial physician contact (TTP) was determined. Descriptive and exploratory statistical analyses were performed. On average, the number of patients diagnosed with HNSCC per month during the pandemic decreased by 12.4% compared with the pre-COVID-19 period. There was a significant increase in stage I and stage II cancers (from 15.9% to 20.3% and from 12.2% to 13.8%, respectively; p < 0.001); a decrease in stage III and IVa,c cancers; and a significant increase in stage IVb cancers (from 6% to 19.9%; p < 0.001) during the pandemic. The median TTP increased during the pandemic from 43 to 61 days (p = 0.032). To our knowledge, this is the first study investigating the effect of COVID-19 on patients with HNSCC in the Central-Eastern European region. We found a bidirectional shift in cancer stages and increased TTP during the pandemic. Our findings highlight the necessity for more nuanced analyses of the effects of COVID-19.

Outcome evaluation of technical strategies on reduction of patient waiting time in the outpatient department at Kilimanjaro Christian Medical Centre-Northern Tanzania.

BACKGROUND: The Tanzania healthcare system is beset by prolonged waiting time in its hospitals particularly in the outpatient departments (OPD). Previous studies conducted at Kilimanjaro Christian Medical Centre (KCMC) revealed that patients typically waited an average of six hours before receiving the services at the OPD making KCMC have the longest waiting time of all the Zonal and National Referral Hospitals. KCMC implemented various interventions from 2016 to 2021 to reduce the waiting time. This study evaluates the outcome of the interventions on waiting time at the OPD. METHODS: This is an analytical cross-sectional mixed method using an explanatory sequential design. The study enrolled 412 patients who completed a structured questionnaire and in-depth interviews (IDI) were conducted among 24 participants (i.e., 12 healthcare providers and 12 patients) from 3rd to 14th July, 2023. Also, a documentary review was conducted to review benchmarks with regards to waiting time. Quantitative data analysis included descriptive statistics, bivariable and multivariable. All statistical tests were conducted at 5% significance level. Thematic analysis was used to analyse qualitative data. RESULTS: The findings suggest that post-intervention of technical strategies, the overall median OPD waiting time significantly decreased to 3 h 30 min IQR (2.51-4.08), marking a 45% reduction from the previous six-hour wait. Substantial improvements were observed in the waiting time for registration (9 min), payment (10 min), triage (14 min for insured patients), and pharmacy (4 min). Among the implemented strategies, electronic medical records emerged as a significant predictor to reduced waiting time (AOR = 2.08, 95% CI, 1.10-3.94, p-value = 0.025). IDI findings suggested a positive shift in patients' perceptions of OPD waiting time. Problems identified that still need addressing include, ineffective implementation of block appointment and extension of clinic days was linked to issues of ownership, organizational culture, insufficient training, and ineffective follow-up. The shared use of central modern diagnostic equipment between inpatient and outpatient services at the radiology department resulted in delays. CONCLUSION: The established technical strategies have been effective in reducing waiting time, although further action is needed to attain the global standard of 30 min to 2 h OPD waiting time.

Effect of transportation distance and lairage time on selected behaviors and carcass parameters in zebu cattle-a study using the animal focal sampling method.

The objective of this study was to evaluate the effect of the transport distance and lairage time on behavioral indicators of zebu beef cattle in the resting pen of a slaughterhouse using the focal animal technique. Eight lots of male zebu cattle, Nelore, aged approximately 4 years old, weighing on average 500 ± 28.5 kg-1, from different municipalities, transported by land, were evaluated. The lots were grouped into two categories: short distance (> 500 km) and long distance (> 500 km). Five focal animals per evaluated lot were used in each cycle of behavior observation, randomly chosen, and visually identified. The animal focal sampling method was used, with instantaneous recording, every 5 min per animal/h. A video camera was used and placed at a fixed point in the corral. After slaughtering, bruises and carcass pH were evaluated. The respiratory rate (RR) was measured in two moments, 30 min after unloading (RR_I) and 1 h before slaughtering (RR_F); behavioral data were divided into four lairage periods (1st, 2nd, 3rd, and 4th) equally and evaluated as repeated measures over time. The lairage time lowered the behaviors of headbutting (NCHBs), pushing (PsH), mounting (MT), and chasing away (CA), (p = 0.0001), and these behaviors were more evident in animals transported for short distances in the initial resting times, decreasing as they remained in the resting pen. There was effect of distance on the initial and final pH of the carcass, being greater in the short distance (p = 0.047). There was no effect of distance or lairage time on initial or final RR (p > 0.05). In addition, animals transported over long distances showed less carcass injuries, which were observed during post mortem inspection. It is concluded that animals transported over short distances present a greater number of agonistic behaviors, such as NCHBs, MT, PsH, and CA, predisposing to higher rates of bruising during lairage and more accentuated changes in the final pH of the meat.

Dissatisfaction-considered waiting time prediction for outpatients with interpretable machine learning.

Long waiting time in outpatient departments is a crucial factor in patient dissatisfaction. We aim to analytically interpret the waiting times predicted by machine learning models and provide patients with an explanation of the expected waiting time. Here, underestimating waiting times can cause patient dissatisfaction, so preventing this in predictive models is necessary. To address this issue, we propose a framework considering dissatisfaction for estimating the waiting time in an outpatient department. In our framework, we leverage asymmetric loss functions to ensure robustness against underestimation. We also propose a dissatisfaction-aware asymmetric error score (DAES) to determine an appropriate model by considering the trade-off between underestimation and accuracy. Finally, Shapley additive explanation (SHAP) is applied to interpret the relationship trained by the model, enabling decision makers to use this information for improving outpatient service operations. We apply our framework in the endocrinology metabolism department and neurosurgery department in one of the largest hospitals in South Korea. The use of asymmetric functions prevents underestimation in the model, and with the proposed DAES, we can strike a balance in selecting the best model. By using SHAP, we can analytically interpret the waiting time in outpatient service (e.g., the length of the queue affects the waiting time the most) and provide explanations about the expected waiting time to patients. The proposed framework aids in improving operations, considering practical application in hospitals for real-time patient notification and minimizing patient dissatisfaction. Given the significance of managing hospital operations from the perspective of patients, this work is expected to contribute to operations improvement in health service practices.

Reducing Waiting Times and Admission Periods through Pre-Admission Testing: A Quality Improvement Study on In-Hospital Renal Biopsy.

Background: Admission for renal biopsy is considered the gold standard for diagnosing kidney disease. However, prolonged waiting times for admission can lead to delayed diagnosis. Despite this issue, there are currently no studies demonstrating how to improve the efficiency of renal biopsy procedures. Methods: We initiated a quality improvement project to implement pre-admission testing (PAT) for renal biopsy from 2016 to 2024 (until 15 April). Our evaluation focused on waiting times for admission, length of admission periods, hospitalization expenses, percentage of cases with no renal biopsy performed, incidence of severe bleeding due to renal biopsy, and percentage of cases with adequate tissue samples obtained. Additionally, we highlighted the time periods during the outbreak of SARS-CoV-2. Results: The highest annual case number was observed in time period 1 (168.3/year). Following the outbreak of SARS-CoV-2, there was a notable decrease in case numbers during time period 2 (119.8), which then increased to 143.0 in time period 3 (post-SARS-CoV-2 era). The mean waiting time was 13.72 ± 40.30 days for time period 1 and 10.00 ± 47.80 days for time period 2, without statistical significance. Following the implementation of PAT, patients now only need to wait approximately 0.76 days for admission, representing a significant reduction in waiting time. Subsequently, following the implementation of PAT, the waiting time decreased significantly to 2.09 ± 2.65 days. Additionally, hospitalization expenses per patient significantly decreased from approximately USD 69.62 ± 97.09 to USD 41.66 ± 52.82. The percentage of missed biopsy is significantly low (p < 0.001). Severe bleeding events (indicated as embolization and blood transfusion) were consistent across the three time periods (p = 0.617). Conclusions: The implementation of PAT can improve the pre-admission process for renal biopsy, resulting in decreased waiting times, fewer missed appointments, shorter admission durations, and reduced hospitalization expenses. We propose implementing PAT for outpatient individuals awaiting in-hospital renal biopsy procedures to mitigate delayed diagnosis, reduce pre-admission waiting periods, and streamline admission processes, thereby enhancing overall patient care efficiency.

Competing Risks Analysis of Kidney Transplant Waitlist Outcomes: Two Important Statistical Perspectives.

Modern competing risks analysis has 2 primary goals in clinical epidemiology as follows: (i) to maximize the clinician's knowledge of etiologic associations existing between potential predictor variables and various cause-specific outcomes via cause-specific hazard models, and (ii) to maximize the clinician's knowledge of noteworthy differences existing in cause-specific patient risk via cause-specific subdistribution hazard models (cumulative incidence functions [CIFs]). A perfect application exists in analyzing the following 4 distinct outcomes after listing for a deceased donor kidney transplant (DDKT): (i) receiving a DDKT, (ii) receiving a living donor kidney transplant (LDKT), (iii) waitlist removal due to patient mortality or a deteriorating medical condition, and (iv) waitlist removal due to other reasons. It is important to realize that obtaining a complete understanding of subdistribution hazard ratios (HRs) is simply not possible without first having knowledge of the multivariable relationships existing between the potential predictor variables and the cause-specific hazards (perspective #1), because the cause-specific hazards form the "building blocks" of CIFs. In addition, though we believe that a worthy and practical alternative to estimating the median waiting-time-to DDKT is to ask, "what is the conditional probability of the patient receiving a DDKT, given that he or she would not previously experience one of the competing events (known as the cause-specific conditional failure probability)," only an appropriate estimator of this conditional type of cumulative incidence should be used (perspective #2). One suggested estimator, the well-known "one minus Kaplan-Meier" approach (censoring competing events), simply does not represent any probability in the presence of competing risks and will almost always produce biased estimates (thus, it should never be used).

[Waiting time to transcatheter aortic valve implantation (TAVI) and mortality during wait period in Algeria]. / Délais d'attente d'implantation de valve aortique transcutanée (TAVI) et mortalité durant la période d'attente en Algérie.

BACKGROUND: Trans Aortic Valve Implantation (TAVI) has become the primary treatment for aortic stenosis in patients over 75 years old. Despite its clinical efficacy, it's adoption in emerging countries remains low due to the high cost of prostheses and limited healthcare funding resources. This leads to prolonged waiting times for the TAVI procedure, which may lead to complications; these data are missing particularly in emerging countries. AIMS: To describe waiting time for TAVI and mortality rate in this waiting period. MATERIALS AND METHODS: This was prospective registry, patients referred for TAVI were prospectively followed; waiting time was calculated from the first visit after referral to TAVI implantation, clinical and, call fellow up was performed every 3 months. We divided patients into two groups: Group 1 (G1) patients still awaiting TAVI (105 patients), and those who underwent TAVI (36 patients). Group 2 (G2) patients who died while awaiting TAVI (16 patients, 10,2 %). RESULTS: Demographic characteristics were similar, with a tendency for older age in G2 (79.5 ± 5.7 years vs. 82.5 ± 7.4 years, p=0,06). G2 exhibited more left ventricular ejection fraction (LVEF) impairment (8.5% vs. 25%, p=0,03) and a higher rate of severe heart failure with dyspnea stages III or IV (2.8% vs. 12.5%, p<0,001). The mean follow-up in G1 was 242.9 ± 137.4 days; the waiting time for TAVI was 231.7 ± 134.1 days, and the average time between the first consultation and death while awaiting TAVI (G2) was 335.1 ± 167.4 days. CONCLUSION: in our series, waiting time is high due to limited Trans aortic heart valve availability, mortality during this wait exceeds 10%. Adverse prognostic factors include impaired LVEF and severe dyspnea stages III or IV.

Waiting Times in Prostate Cancer Diagnosis and Treatment: A Ten-Year Experience in A Nigerian Teaching Hospital.

INTRODUCTION: Prostate cancer is still the leading male cancer and the leading cause of cancer deaths in Nigeria, and other low- and middle-income countries (LMIC) in Sub-Saharan Africa. Early diagnosis is essential to ensuring prompt treatment and reducing morbidity and mortality. Reducing the waiting times for diagnosis and treatment is therefore important. AIMS AND OBJECTIVES: To study prostate cancer management waiting times, to serve as a baseline in improving the quality of cancer care in the Nigerian populace. PATIENTS AND METHODS: This was a ten-year retrospective study of waiting times of all histologically-confirmed prostate cancer patients seen at Alex-Ekwueme Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria. Statistical analysis was done SPSS version 26. A P-value less than 0.05 was considered statistically significant. RESULTS: A total of 189 patients presented with prostate cancer; however, 73 patients with complete data were analysed. The mean age of the patients was 71.48±8.16 years. The median duration of symptoms before presentation was 6 months. The mean total prostate-specific antigen was 82.08±54.9ng/mL. The mean duration between the first visit to the definitive diagnosis was 6.53±11.68 months with a median of 1 month. The median duration from visit to treatment was 3 months with a mean of 9.71±13.4 months. There were no associations between occupation, highest educational level, financial constraints, and the different waiting times studied (P>0.05). CONCLUSION: The waiting times for prostate cancer management were unduly prolonged in this study; patient-related factors did not influence this wait. INTRODUCTION: Le cancer de la prostate est toujours le principal cancer chez les hommes et la principale cause de décès par cancer au Nigéria et dans d'autres pays à revenu faible et intermédiaire (PFR) en Afrique subsaharienne. Un diagnostic précoce est essentiel pour garantir un traitement rapide et réduire la morbidité et la mortalité. Il est donc important de réduire les délais d'attente pour le diagnostic et le traitement. OBJECTIFS: Étudier les délais d'attente dans la prise en charge du cancer de la prostate, afin de servir de référence pour améliorer la qualité des soins contre le cancer dans la population nigériane. PATIENTS ET MÉTHODES: Il s'agit d'une étude rétrospective de dix ans sur les délais d'attente de tous les patients atteints de cancer de la prostate confirmé histologiquement et traités à l'hôpital universitaire fédéral Alex-Ekwueme, à Abakaliki, dans l'État d'Ebonyi, au Nigéria. L'analyse statistique a été réalisée avec la version 26 du logiciel SPSS. Une valeur de P inférieure à 0,05 a été considérée comme statistiquement significative. RÉSULTATS: Un total de 189 patients ont présenté un cancer de la prostate ; cependant, seuls les 73 patients avec des données complètes ont été analysés. L'âge moyen des patients était de 71,48±8,16 ans. La durée médiane des symptômes avant la présentation était de 6 mois. La concentration moyenne d'antigène spécifique de la prostate (PSA) total était de 82,08±54,9 ng/mL. La durée moyenne entre la première visite et le diagnostic définitif était de 6,53±11,68 mois, avec une médiane de 1(1) mois. La durée médiane entre la visite et le traitement était de 3 mois, avec une moyenne de 9,71±13,4 mois. Aucune association n'a été observée entre l'occupation, le plus haut niveau d'éducation, les contraintes financières et les différents délais d'attente étudiés (P>0,05). CONCLUSION: Les délais d'attente pour la prise en charge du cancer de la prostate étaient anormalement prolongés dans cette étude ; les facteurs liés au patient n'ont pas influencé cette attente. MOTS-CLÉS: Cancer de la prostate, Délai d'attente, Délai, Diagnostic, Traitement.

Effects of lipids on the rate-limiting steps in the dark-to-light transition of Photosystem II core complex of Thermostichus vulcanus.

In our earlier works, we have shown that the rate-limiting steps, associated with the dark-to-light transition of Photosystem II (PSII), reflecting the photochemical activity and structural dynamics of the reaction center complex, depend largely on the lipidic environment of the protein matrix. Using chlorophyll-a fluorescence transients (ChlF) elicited by single-turnover saturating flashes, it was shown that the half-waiting time (Δτ 1/2) between consecutive excitations, at which 50% of the fluorescence increment was reached, was considerably larger in isolated PSII complexes of Thermostichus (T.) vulcanus than in the native thylakoid membrane (TM). Further, it was shown that the addition of a TM lipid extract shortened Δτ 1/2 of isolated PSII, indicating that at least a fraction of the 'missing' lipid molecules, replaced by detergent molecules, caused the elongation of Δτ 1/2. Here, we performed systematic experiments to obtain information on the nature of TM lipids that are capable of decreasing Δτ 1/2. Our data show that while all lipid species shorten Δτ 1/2, the negatively charged lipid phosphatidylglycerol appears to be the most efficient species - suggesting its prominent role in determining the structural dynamics of PSII reaction center.

Preslaughter factors affecting mobility, blood parameters, bruising, and muscle pH of finished beef cattle in the United States.

Decades of work have focused on reducing fear, stress, and discomfort in cattle during the preslaughter phase by improving and promoting animal handling, transportation, and management processes. Even still, there is limited information about the effects of preslaughter factors on animal welfare and meat quality outcomes in finished cattle in the United States. This study aimed to track individual animals through the slaughter process to identify preslaughter factors associated with key welfare and quality outcomes. A total of 454 cattle from one commercial slaughter facility were studied. Preslaughter factors assessed included distance traveled, truck waiting time, lairage density, lairage duration, and season. Animal characteristics, i.e., body weight, breed, and sex, were also recorded. One trained observer scored the mobility of all cattle using the North American Meat Institute's 1-4 scale (i.e., normal to extremely reluctant to move). Exsanguination blood was collected and analyzed for cortisol, creatine kinase, and lactate. Carcass bruising was scored using a modified version of the National Beef Quality Audit's bruise-scoring methodology (i.e., no bruise, one bruise ≤ the size of a deck of cards, one bruise > than the size of a deck of cards, and multiple bruises). Ultimate muscle pH was measured 32 to 36 h postmortem. Multi-predictor models were selected for each outcome variable using Akaike Information Criterion. Continuous outcome variables were analyzed using linear mixed-effect models and categorical outcome variables with mixed-effect logistic regression models. Longer truck waiting times were associated with increased cortisol (P = 0.04) and lactate (P = 0.02) concentrations. Similarly, increased lairage duration was associated with increased creatine kinase concentrations (P = 0.05) and the odds of cattle being bruised (P = 0.03). Less space allowance per animal in lairage was associated with increased odds of cattle having impaired mobility (P = 0.01). There was a seasonal effect for many of the measured outcomes; the summer season was associated with greater lactate concentrations (P < 0.0001), increased odds of impaired mobility (P < 0.0001), and increased odds of carcass bruising (P = 0.003). The findings of this study indicate that many of the preslaughter factors assessed influence critical welfare and meat quality outcomes of finished beef cattle, warranting future research and consideration.

Milestoning estimators of dissipation in systems observed at a coarse resolution.

Many nonequilibrium, active processes are observed at a coarse-grained level, where different microscopic configurations are projected onto the same observable state. Such "lumped" observables display memory, and in many cases, the irreversible character of the underlying microscopic dynamics becomes blurred, e.g., when the projection hides dissipative cycles. As a result, the observations appear less irreversible, and it is very challenging to infer the degree of broken time-reversal symmetry. Here we show, contrary to intuition, that by ignoring parts of the already coarse-grained state space we may-via a process called milestoning-improve entropy-production estimates. We present diverse examples where milestoning systematically renders observations "closer to underlying microscopic dynamics" and thereby improves thermodynamic inference from lumped data assuming a given range of memory, and we hypothesize that this effect is quite general. Moreover, whereas the correct general physical definition of time reversal in the presence of memory remains unknown, we here show by means of physically relevant examples that at least for semi-Markov processes of first and second order, waiting-time contributions arising from adopting a naive Markovian definition of time reversal generally must be discarded.

An Electronic Health Record-Based Automated Self-Rescheduling Tool to Improve Patient Access: Retrospective Cohort Study.

BACKGROUND: In many large health centers, patients face long appointment wait times and difficulties accessing care. Last-minute cancellations and patient no-shows leave unfilled slots in a clinician's schedule, exacerbating delays in care from poor access. The mismatch between the supply of outpatient appointments and patient demand has led health systems to adopt many tools and strategies to minimize appointment no-show rates and fill open slots left by patient cancellations. OBJECTIVE: We evaluated an electronic health record (EHR)-based self-scheduling tool, Fast Pass, at a large academic medical center to understand the impacts of the tool on the ability to fill cancelled appointment slots, patient access to earlier appointments, and clinical revenue from visits that may otherwise have gone unscheduled. METHODS: In this retrospective cohort study, we extracted Fast Pass appointment offers and scheduling data, including patient demographics, from the EHR between June 18, 2022, and March 9, 2023. We analyzed the outcomes of Fast Pass offers (accepted, declined, expired, and unavailable) and the outcomes of scheduled appointments resulting from accepted Fast Pass offers (completed, canceled, and no-show). We stratified outcomes based on appointment specialty. For each specialty, the patient service revenue from appointments filled by Fast Pass was calculated using the visit slots filled, the payer mix of the appointments, and the contribution margin by payer. RESULTS: From June 18 to March 9, 2023, there were a total of 60,660 Fast Pass offers sent to patients for 21,978 available appointments. Of these offers, 6603 (11%) were accepted across all departments, and 5399 (8.9%) visits were completed. Patients were seen a median (IQR) of 14 (4-33) days sooner for their appointments. In a multivariate logistic regression model with primary outcome Fast Pass offer acceptance, patients who were aged 65 years or older (vs 20-40 years; P=.005 odds ratio [OR] 0.86, 95% CI 0.78-0.96), other ethnicity (vs White; P<.001, OR 0.84, 95% CI 0.77-0.91), primarily Chinese speakers (P<.001; OR 0.62, 95% CI 0.49-0.79), and other language speakers (vs English speakers; P=.001; OR 0.71, 95% CI 0.57-0.87) were less likely to accept an offer. Fast Pass added 2576 patient service hours to the clinical schedule, with a median (IQR) of 251 (216-322) hours per month. The estimated value of physician fees from these visits scheduled through 9 months of Fast Pass scheduling in professional fees at our institution was US $3 million. CONCLUSIONS: Self-scheduling tools that provide patients with an opportunity to schedule into cancelled or unfilled appointment slots have the potential to improve patient access and efficiently capture additional revenue from filling unfilled slots. The demographics of the patients accepting these offers suggest that such digital tools may exacerbate inequities in access.

The Role of Point-of-Care Testing to Improve Acute Care and Health Care Services.

Health care is one of the most important services that need to be provided to any community. Many challenges exist in delivering proper and effective health services, including ensuring timely delivery, providing adequate care through effective management and achieving good outcomes. Point-of-care testing (POCT) plays a crucial role in delivering urgent and appropriate health services, especially in peripheral communities, emergency situations, disaster areas and overcrowded areas. We collected and reviewed secondary data about point-of-care testing from PubMed, Scopus and Google Scholar. Our findings emphasize that POCT provides fast care with minimal waiting time, avoids unnecessary investigations, aids in triage, and provides decision-makers with a clear understanding of the patient's condition to make informed decisions. We recommend point-of-care testing as a frontline investigation in emergency departments, intensive care units, peripheral hospitals, primary health care centers, disaster areas and field hospitals. Point-of-care testing can improve the quality of health services and ensure the provision of necessary health care.

Effects of private health insurance on waiting time in public hospitals.

The Australian government pays $6.7 billion per year in rebates to encourage Australians to purchase private health insurance (PHI) and an additional $6.1 billion to cover services provided in private hospitals. What is the justification for large government subsidies to a private industry when all Australians already have free coverage under Medicare? The government argues that more people buying PHI will relieve the burden on the public system and may reduce waiting times. However, the evidence supporting this is sparse. We use an instrumental variable approach to study the causal effects of higher PHI coverage in the area on waiting times in public hospitals in the same area. The instrument used is area-level average house prices, which correlate with average income and wealth, thus influencing the purchase of PHI due to tax incentives, but not directly affecting waiting times in public hospitals. We use 2014-2018 hospital admission and elective surgery waiting list data linked at the patient level from the Victorian Center for Data Linkage. These data cover all inpatient admissions in all hospitals in Victoria (both public and private hospitals) and those registered on the waiting list for elective surgeries in public hospitals in Victoria. We find that one percentage point increase in PHI coverage leads to about 0.34 days (or 0.5%) reduction in waiting times in public hospitals on average. The effects vary by surgical specialities and age groups. However, the practical significance of this effect is limited, if not negligible, despite its statistical significance. The small effect suggests that raising PHI coverage with the aim to taking the pressure off the public system is not an effective strategy in reducing waiting times in public hospitals. Alternative policies aiming at improving the efficiency of public hospitals and advancing equitable access to care should be a priority for policymakers.

Impact of time from diagnosis to chemotherapy on prognosis in advanced pancreatic cancer.

BACKGROUND: Due to the aggressive nature and poor prognosis of advanced pancreatic cancer, prompt initiation of treatment is critical. We investigated the effect of the interval between cancer diagnosis and initiation of chemotherapy on survival in patients with advanced pancreatic cancer. METHODS: In this retrospective, single-centre study, consecutive patients with advanced pancreatic cancer between April 2013 and March 2022 were analyzed. Data were extracted from the electronic medical records of patients who received chemotherapy for metastatic, locally advanced or resectable pancreatic cancer or who received chemotherapy due to either being intolerant of or declining surgery. We compared overall survival between two groups: the early waiting time group (waiting time ≤30 days from diagnosis to chemotherapy initiation) and the elective waiting time group (waiting time ≥31 days). Prognostic factors, including biliary drainage, were considered. The impact of waiting time on survival was assessed by univariate and multivariate analyses with Cox proportional hazard models. A 1:1 propensity score matching approach was used to balance bias, accounting for significant poor prognosis factors, age and sex. RESULTS: The study involved 137 patients. Overall survival exhibited no statistically significant difference between the early and elective waiting time groups (207 and 261 days, P = 0.2518). Univariate and multivariate analyses identified poor performance status and metastasis presence as predictors of worse prognosis. This finding persisted post propensity score matching (275 and 222 days, P = 0.8223). CONCLUSIONS: Our study revealed that initiating chemotherapy ˃30 days later does not significantly affect treatment efficacy compared to within 30 days of diagnosis.

Effect of waiting time for radiotherapy after last induction chemotherapy on prognosis of locally advanced nasopharyngeal carcinoma.

BACKGROUND: The effect of radiotherapy waiting time after last induction chemotherapy (IC-RT) on prognosis of patients with locally advanced nasopharyngeal carcinoma (LANPC) needs further discussion. METHODS: Three hundred and six patients with LANPC diagnosed pathologically by induction chemotherapy (IC) and radiotherapy (RT) from 2013 to 2018 were selected for this study. RESULTS: The IC-RT was a risk factor for the post-treatment progression of LANPC (OR = 1.017 95%CI: 1.003-1.031), For patients with LANPC, the IC-RT > 40 days significantly reduced 5-year PFS (70% vs. 55%; p = 0.0012), 5-year OS (84% vs. 73%; p = 0.028), 5-year DMFS (80% vs. 66%; p = 0.003), 5-year LRFS (77% vs. 67%; p = 0.012). Indicating that patients with stage IVa who IC-RT > 40 days were found to be a significant predictor of aggravated PFS (HR = 2.69; 95%CI: 1.57-4.6), OS (HR = 2.55; 95%CI: 1.29-5.03), DMFS (HR = 3.07; 95%CI: 1.64-5.76) and LRFS (HR = 2.26; 95%CI: 1.21-4.21). CONCLUSION: The prognosis of patients will be adversely affected if the IC-RT exceeds 40 days, especially for stage IVa patients.

Improving Waiting Time for Chemotherapy with Ahead-of-Time Drug Preparation.

Waiting time for chemotherapy infusion is a fundamental factor to measure quality of care. It has been shown that a prolonged waiting time is related to a higher incidence of anticipatory nausea and poor patient adherence to scheduled appointments and recommended oncology treatment programs. Some chemotherapy regimens can be prepared hours ahead-of-time, due to long stability. We aimed to study the effect of an informatic-led workflow redesign intervention, facilitating workflow changes in the Oncology Pharmacy, on patient waiting time. This intervention included changes on EHR processes and the chemotherapy CPOE. Their main effect was allowing ahead-of-time preparation of selected chemotherapy regimes. We conducted a cross sectional study, comparing waiting times pre and post intervention periods. A total of 4600 programmed chemotherapy episodes were included. We found a 26.5 % decrease in the mean wait time in the post intervention period (p > 0.02). We were able to show a decrease in waiting time and a measurable impact of the intervention. This evaluation produced valuable and actionable data for Oncology units and adds a valuable, Latin American experience to the literature.

The Impact of Waiting Time-to-Surgery on Survival in Endometrial Cancer Patients.

BACKGROUND: Endometrial cancer (EC) is the most common gynecological cancer in developed countries and a standard treatment of surgery should be performed as expediently as possible. Delay time to surgery and survival was debated. The aim of this investigation was to evaluate the effect of time-interval between diagnosis and surgery (TDS) in EC patients with regards to prognosis and mortality rates. METHODS: This retrospective study was conducted between January 2009 and May 2021 at Bhumibol Adulyadej Hospital, Thailand. Subjects were EC cases who underwent primary surgery during the study period. Cases with partial treatment were disqualified from the study. Subjects who underwent surgery before and after 6 weeks were classified as early and delayed surgery groups. Baseline and clinical characteristics were collected and analyzed. RESULTS: During the study period, 419 EC cases were recruited. The mean age of participants was 56.8 years. Two-thirds (338/491) of subjects were menopausal. Endometrioid histology (406/491) was the most common histology subtype. Five years disease free survival (DFS) of early and delayed surgery groups were comparable at a percentage of 82.5 and 83.0, respectively. Among advanced stage and non-endometrioid EC cases, the delayed surgery group had significantly shorter DFS than the early group. Advanced stage, high grade and positive lympho-vascular space invasion (LVSI) were independent factors for poor DFS. Predictive factors for mortality were advanced stage and tumor recurrence. CONCLUSION: The TDS was not a prognostic factor for disease recurrence or overall mortality. Time to surgery equal to or more than 6 weeks gave worse prognosis for DFS among advanced stage or non-endometrioid histology EC.

The impact of the COVID-19 pandemic in the clinical assistance to breast cancer patients.

PURPOSE: We aimed to disclose the impact of the pandemic on breast cancer patients in a specialized breast cancer center (BCC). METHODS: A total of 501 breast cancer patients with a first appointment in the BCC from April 1st, 2019 to March 31st, 2021 were divided into four consecutive periods of 6 months. Data from the homologous semesters was compared. Patients with an appointment in the BCC during the study period were eligible for the secondary aim of our study (BCC workload). RESULTS: After the pandemic declaration (period 3), we found a decrease in the referral by screening programs (p = 0.002) and a reduction in the waiting time between the primary care referral and the first BCC appointment (p < 0.001). There were higher rates of palpable axillary nodes (p = 0.001), an increase in N stage 2 and 3 (p = 0.050), and a trend for primary endocrine therapy as the first treatment (p = 0.021) associated with higher rates of complete axillary node dissection (p = 0.030). In period 4, there were more outward diagnoses (p = 0.003) and a higher rate of surgery as the first treatment (p = 0.013). CONCLUSION: COVID-19 pandemic implied a more advanced nodal stage, which may be related to the delay in breast cancer screening.