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Every government engages in budgeting and public financial management to run the affairs of state. Effective budgeting empowers states to prioritize policies, allocate resources, and discipline bureaucracies, and it contributes to efficacious fiscal and macroeconomic policies. Budgeting can be transparent, participatory, and promote democratic decision-making, or it can be opaque, hierarchical, and encourage authoritarian rule. This book compares budgetary systems around the world by examining the economic, political, cultural, and institutional contexts in which they are formulated, adopted, and executed. The second edition has been updated with new data to offer a more expansive set of national case studies, with examples of budgeting in China, India, Indonesia, Iraq, and Nigeria. Chapters also discuss Brexit and the European Union's struggle to require balances budgets during the Euro Debt Crisis. Additionally, the authors provide a deeper analysis of developments in US budgetary policies from the Revolutionary War through the Trump presidency.
Introduction: Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods: The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results: Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion: This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.
Introduction: All emergency departments (EDs) across Canada can identify a group of high frequency users, which are typically defined in the literature as eight to ten visits per year. Although frequent users of the ED are well-studied in the literature, there is little published in terms of identifying the “super-user” group who present to the ED much more often than 10 visits per year. Faced with multiple co-morbidities and a high mortality rate, the ED is often the most appropriate environment to manage this population. In order to inform future initiatives to improve health outcomes, we aimed to identify the specific characteristics of this super-user group. Methods: A retrospective chart review was conducted using the electronic medical record from the Thunder Bay Regional Health Sciences Centre to identify patients who had at least 25 visits in the year 2017. A total of 75 patients presented to the ED greater than 25 times in 2017. The following data was then collected on each individual patient: demographic characteristics including age, gender, address, access to a primary care provider. In addition, we collected date, time, diagnoses at each visit, admission rate and surgical interventions. Results: Our preliminary results reveal this population presents to the ED on average 32 times per year. The population is 53% male. Most have a private address and half have a primary care provider for all 2017 with one quarter having a primary care provider for part of the year. The percentage of visits for infections was 30%, mental health and addictions presentations comprised 28% of the visits, with gastrointestinal and cardiac visits comprising a total 22% of the visits. Approximately 7% of visits required admission to hospital, and the average length of stay was 5 days. Conclusion: Super-users of the ED are a unique population that are typically well connected with primary care and have a very low admission and surgical rate. The most common reasons for visit are infections and mental health and addictions. The next steps include collecting mortality data. This data should be used to inform ED and community initiatives aimed at improved health outcomes for this population.
Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.
Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.
Innovation Concept: Dizziness is an increasingly common presenting complaint in the emergency department (ED), accounting for >2% of visits annually or almost 30% of visits in patients aged over 65. Approximately half of all cases of dizziness in older adults are caused by benign paroxysmal positional vertigo (BPPV). The use of computerized tomography (CT) to rule out serious but rare underlying central nervous system (CNS) causes in patients with dizziness in the ED is increasing despite guidelines supporting the use of clinical exam maneuvers such as the Dix-Hallpike test and therapeutic canalith repositioning maneuvers. Evidence indicates that these clinical tools are underutilized due to clinician discomfort or lack of understanding in performing and interpreting the maneuvers, supporting brief and accessible clinical resources that incorporate video examples to address this. Methods: Through an iterative process the authors have developed a smartphone app that is designed to facilitate the clinical diagnosis of BPPV and provide treatment maneuvers where appropriate. The app is being tested by clinicians practicing emergency medicine or primary care in Northern Ontario. Curriculum, Tool, or Material: The BPPV Tool is designed as a step-wise guide to diagnose BPPV. Clinicians will be prompted to perform specific exam maneuvers based on clinical findings, and can follow short example videos or written directions. Potentially precipitated nystagmus is described along with example videos. Provocative tests include the Dix-Hallpike and Supine Roll. If appropriate, the clinician will be prompted to perform therapeutic repositioning maneuvers such as the Epley or Gufoni, with associated sample videos, descriptions, and billing information where available. If at any point a clinician's exam findings are not in keeping with a diagnosis of BPPV, they will be alerted to this and stop progressing through the app. Conclusion: The BPPV Tool is an accessible and easily disseminated smartphone app designed to improve clinician comfort in reliably diagnosing BPPV. Diagnosing this common condition clinically is supported in the literature and can reduce the number of unnecessary CT scans performed, which would reduce healthcare costs and ED length of stay for these visits, and could reduce the number of patient transfers from peripheral sites for imaging.
On the 1st of August 2010 guidelines aimed at ensuring the safe supply of over-the -counter codeine containing medicinal products came to force in Ireland.
The study aimed to examine the frequency of use as well as reasons for the use of non-prescription codeine containing medicines in an Irish psychiatric population before and after the introduction of regulations on the supply of codeine containing medicines.
Self administered questionnaires were designed and administered to patients before and after the introduction of guidelines regulating the sale of non-prescribed codeine containing medicines in Ireland. The results were compiled and analysed using descriptive statistics and chi-square test.
Significantly more patients reported that they often or regularly used codeine containing medicines before the introduction of the regulation compared to the period after that(33.3% vs. 17.4%, x2 = 6.354, p = 0.01). Significantly more patients also reported that others had expressed concerns about the frequency with which they used codeine containing medicines before the introduction of the regulation compared to the period after the introduction of the regulation (15.5% vs. 4.8%, x2 = 7.29, p = 0.03). Finally, significantly more patients stated that they would use codeine containing medicines either for the ‘feel good’ effect or to curb cravings before the introduction of the regulation than after the introduction of the regulation (15.9% vs. 1.9%, p = 0.00).
Tight regulations on the supply of non-prescription codeine containing medicines have the potential to reduce the abuse of such medicine among psychiatric patients in general.
Introduction: Planning for the future emergency physician (EP) workforce will be a significant challenge for decision makers given the rise in emergency department (ED) visits and no concurrent increase in resident positions. EP workforce planning must incorporate physician supply, as well as current and forecasted patient demand. Nova Scotia has undertaken the process of developing a planning model to support policy decision making. We hypothesize that Nova Scotia will require increased resident positions and recruitment from other provinces to meet future patient demand. Methods: We have developed an age structured population model that tracks the number of clinical full-time equivalent (FTE) EPs by their age and shows the “variance” (i.e., supply – demand = variance) over a 30 year planning horizon. This model represents all Level 1, 2, 3, and 4 EDs in Nova Scotia. Current physician supply was calculated based on FTE staffing levels. The current patient demand was based on historical volume and acuity of patients and converted to an FTE demand estimate. Forecasted demand was predicted to increase at an average rate of 0.5% per year. We varied the number of residents trained and the number of EPs recruited from outside the province to examine the effect on the EP workforce. Our initial model will reflect the current training environment and will be referred to as the “current state”. In our 3 scenarios, we increased the number of residents and recruited physicians by 50%, individually and then together. Our outcome measure will be the variance in FTE. Results: The current state showed that the province will have a deficit of 51 FTE EPs over the next 30 years. In scenario 1, a 50% increase in both resident training streams eliminated all variance, while in scenario 2, the increase in recruitment reduced the FTE variance to 34 FTE positions unfilled. In scenario 3, the variance was 0. Conclusion: We feel that this CTAS weighted volumes perspective is important for clinical services planning but the siting, sizing, and synergizing of EDs in a region will involve other inputs. Its important to recognize that we have made the assumption that all physicians starting to work in Nova Scotia will be a 1 FTE. Future iterations will examine the effect of more realistic FTE definitions that account for administrative, teaching and research activities.
Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.
Public works spending was an integral component of John F. Kennedy’s fiscal policy. Drawing on a wide range of archival evidence from the Kennedy Presidential Library, we show how the administration worked to pass a $2.5 billion infrastructure bill that would give the presidency unilateral authority in determining where and when those funds would be spent. Contrary to recent accounts that emphasize Kennedy’s role in promoting massive tax cuts in 1963–64, the 1962 Public Works Acceleration Act was a key fiscal instrument that Kennedy advocated prior to the administration’s push for tax reform. Moreover, the public works policy was strictly Keynesian—designed as a proactive countercyclical “stabilizer” that would generate budget deficits in order to make up for slack in a recession. Kennedy’s plan faced stiff resistance in Congress and the history of the law offers important lessons for why infrastructure programs are often disregarded as countercyclical instruments.
Introduction: Emergency department (ED) over-crowding and increased wait times are a growing problem. Many interventions have been proposed to decrease patient length of stay and increase patient flow. Early disposition planning is one method to accomplish this goal. In this study we developed statistical models to predict patient admission based on ED administrative data. The objective of this study was to predict patient admission early in the visit with goal of preparation of the acute care bed and other resources. Methods: Retrospective administrative ED data from the Thunder Bay Regional Health Sciences Centre was obtained for the period May 2014 to April 2015. Data were divided into training and testing groups with 80% of data used to train the statistical models. Logistic regression models were developed using administrative variables (i.e., age, sex, mode of arrival, and triage level). Model accuracy was evaluated using sensitivity, specificity, and area under the curve measures. To predict hourly bed requirements, the probability of admission was summed to calculate a pooled bed requirement estimate. The estimated hourly bed requirement was then compared to the historical hourly demand. Results: The logistic regression models had a sensitivity of 23%, specificity of 97%, and an area under the curve of 0.78. Although, admission prediction for a particular individual was satisfactory, the hourly pooled probabilities showed better results. The predicted hourly bed requirements were close to historical demand for beds when compared. Conclusion: I have shown that the number of acute care beds required on an hourly basis can be predicted using triage administrative data. Early admission bed planning would allow resources to be managed more effectively. In addition, during periods of hospital over capacity, managers would be able to prioritize transfers and discharges based on early estimates of ED demand for beds.
A few studies have examined the association between vitamin D and telomere length, and fewer still have examined the relationship in black or male populations. We investigated the cross-sectional association between the vitamin D metabolite 25-hydroxyvitamin D (25(OH)D) concentration in plasma and relative leucocyte telomere length (LTL) in 1154 US radiologic technologists who were 48–93 years old (373 white females, 278 white males, 338 black females, 165 black males). Plasma 25(OH)D concentration was measured by the chemiluminescence immunoassay, and relative LTL was measured by quantitative PCR. Logistic regression was used to obtain OR and 95 % CI for long v. short (based on median) LTL in relation to continuous 25(OH)D, quartiles of 25(OH)D and 25(OH)D deficiency. We found no significant association between continuous 25(OH)D and long LTL in all participants (Ptrend=0·440), nor in white females (Ptrend=0·845), white males (Ptrend=0·636), black females (Ptrend=0·967) or black males (Ptrend=0·484). Vitamin D deficiency (defined as 25(OH)D<30 nmol/l), however, was significantly associated with short LTL in whites (P=0·024), but not in other groups. In this population, we found little evidence to support associations between 25(OH)D and long LTL over the entire range of 25(OH)D in the overall study population or by sex and race.
Introduction: The Thunder Bay Regional Health Sciences Centre (TBRHSC) Emergency Department (ED) has experienced an all patient increase in visits ranging from 1.5 to 6% per year since 2004. As a regional referral centre with no dedicated pediatric ED, TBRHSC is the sole emergency provider. Given the rising visits, we have investigated the pattern of pediatric visits, rates of admission to hospital and for a subset of years the investigations completed. Methods: Pediatric visits from 2004 to 2014 were summarized for the TBRHSC ED. The pattern of visits was examined along with the rate of admission to hospital. We also investigated the trend in acuity over the study period. Laboratory and imaging data are purged 1 year after each visit and were not available prior to 2011 but were summarized for the remainder of the years to identify the rates of all investigations completed. Results: From 2004 to 2014 there was a total increase in visits of 7.5% with the average annual admission rate ranging from 5 to 6.3%. The month to month variability in visits over the study period was high with a minimum of 1292 in August 2004 and a maximum of 2488 in October 2009. Nearly all patients were either CTAS II, III or IV, with level III having the highest occurrence. The mean investigation rate was approximately 16, 0.8, 24, and 2.3% of patients having laboratory, CT, x-ray and ultra-sound completed, respectively. Conclusion: Pediatric patients are an important subset of all patients visiting the ED. They often require special resources and at the TBRHSC use specific treatment spaces. In addition, there is a limited number of pediatric inpatient hospital beds. Managers could use the timing of visits, number of visits and admission rates to examine resource use and the probability of exceeding capacity. This study also provides baseline information on the rates of investigations, especially imaging such as CT which can have long-term radiological consequences.
The U.K. 1.2 metre Schmidt Telescope acquired its first full aperture objective prism in 1975. This was a very low dispersion prism (2400 Å/mm at 4300 Å) which has been found to be particularly useful in searching for faint QSO’s.
The Edinburgh-Cape Bright QSO Survey is a very small sub-set of the Edinburgh Cape Blue Object Survey, which is a major survey to discover blue stellar objects brighter than B~18 in the southern sky. It will cover an area of sky of 10,000 square degrees with |b|>30 and dec <0. The blue stellar objects are selected by automatic techniques from U and B pairs of UK Schmidt Telescope plates scanned with the COSMOS measuring machine. Follow-up photometry and spectroscopy is being obtained with the SAAO telescopes to classify the types of objects brighter than B=16.5, with some of the more stubborn objects being subjected to AAO service spectroscopy. Some preliminary results for the 6% QSO minority are presented in this paper and comparison is made with the Palomar-Green QSO Survey in the north, which we find to be at least a factor of two incomplete.
During 1990 we surveyed the southern sky using a multi-beam receiver at frequencies of 4850 and 843 MHz. The half-power beamwidths were 4 and 25 arcmin respectively. The finished surveys cover the declination range between +10 and −90 degrees declination, essentially complete in right ascension, an area of 7.30 steradians. Preliminary analysis of the 4850 MHz data indicates that we will achieve a five sigma flux density limit of about 30 mJy. We estimate that we will find between 80 000 and 90 000 new sources above this limit. This is a revised version of the paper presented at the Regional Meeting by the first four authors; the surveys now have been completed.
The Coalition’s invasion and occupation left the Iraqis with new budgetary institutions, the mandate to boost investment spending, an effort to build budgeting capacity, and donor requirements to develop budgetary processes consistent with international best practices. The Coalition Provisional Authority imposed rudimentary budgetary templates in the form of the 2003 and 2004 budgets, followed by a set of CPA-issued orders that defined the budgetary process, empowered the Ministry of Finance, and provided an initial framework for the central government’s fiscal relations with provincial and local governments. The Coalition layered these changes in budgetary rules and organizations on Saddam Hussein’s institutional arrangements, which Saddam, in turn, had layered on British and Ottoman budgetary practices. Then the June 2004 transfer of power raised critical questions about the success of the Coalition’s budgetary state-building efforts in Iraq. Would the Iraqis accept, take ownership, and invest in the CPA’s budgetary institutions, or abandon them? Would these rules and procedures be sustainable and serve the Iraqis in their efforts to make budgetary decisions in politically and economically difficult times? What budgetary decisions would they make? What political and economic obstacles confronted the Iraqis in their efforts to budget effectively? The answers to these questions and the practical successes and long-term sustainability of these freshly imposed institutions would be tested in day-to-day budgeting. This chapter provides a detailed examination of how the Iraqis’ buy-in, ownership, and investment in the budgetary process occurred as they faced harsh fiscal challenges, ongoing security threats, and political instability. In this way, Iraq’s ownership and continued use of these new budgetary rules, procedures, and organizations served as important tests of the Coalition’s capacity to transform Iraqi institutions.