BackgroundLittle is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality.Methods and resultsUsing data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing.From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables.ConclusionsThe majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.

E mergency departments (EDs) act as the safety net for the nation's health care system. With increasing unemployment and subsequent lack of health and dental insurance, many patients have few options outside of EDs to obtain care. As a result, the ED has become an alternative care site for patients without insurance who have toothaches or other dental pain [1,2,3]. In 2006 alone, dental caries accounted for an estimated 330,757 visits to EDs across the United States. These visits, 45% of which were made by uninsured patients, accounted for approximately $110 million in charges [1]. ED visits for dental complaints have been shown to make up 0.7%-0.9% of all ED visits; the highest utilization is by those 19-35 years of age; dental visits constitute 1.3% of all ED visits by patients in that age group [2].Previous studies have demonstrated that being uninsured is a significant factor promoting utilization of EDs for dental-related complaints [2]. In North Carolina, only 2 of the 5 academic medical centers have an affiliated dental school. In addition, most hospitals do not have an on-call dentist readily available. Follow-up care is virtually impossible for the uninsured to find if they do not have any financial resources. Further compounding this problem is the fact that only 58% of federally qualified health centers offer any dental services [4]. Additionally, as many states attempt to reconcile large health care budgets, many are considering reducing or eliminating optional benefits such as dental care from their Medicaid covered services [5,6]. In Maryland, ED visits for dental complaints increased 12% the year after Medicaid stopped dental reimbursement [6].The profile of patients presenting to the ED with dental complaints in the state of North Carolina is poorly characterized. Prior reports have suggested that nontraumatic dental disease is preventable and usually has limited morbidity, and that the most cost-effective care model is early intervention and treatment [7]. What remains unclear is the role that North Carolina EDs currently play in dental care. The goal of this paper is to provide a description of patient visits to the ED of a North Carolina academic health center for dental related complaints. MethodsThe study involved examining the medical records of all patients who presented to the ED of a major urban teaching hospital between 7/1/10 and 6/30/11. Institutional Review Board review and approval was obtained according to institution policy.

Methods: We used procedure codes to retrospectively review all CTPA studies performed across a multisite medical system in the mid-Atlantic region in 2017, using a radiology database. All scans were manually reviewed and classified as positive, negative, or indeterminate. One investigator radiologist classified all indeterminate studies. Multivariable comparative analysis to explore whether years of experience of emergency department (ED) providers (less than or greater than five years of practice), academic versus community hospital ED providers, or total numbers of studies ordered per physician, were associated with positive scan rate. positive scan rate (PSR) equals the number of positive CTPA divided by total number of CTPA ordered. Chi-squared and Fisher exact tests as appropriate were used to compare rates of positive scans between certain provider characteristics and between certain patient characteristics. Results: A total of 13,389 scans verified in 2017 with 10,032 (75%) originating from the ED with an average PSR of 7.2%. The odds of a positive scan decreased with each additional 10 scans ordered by emergency physicians. Providers who ordered fewer scans had higher PSR. For every addition 10 CTPA ordered the individual physician PSR decreased (Table 1). Of the emergency physicians, 7% ordered at least 9 times the average number of scans (23% of ED scans; average PSR, 5.7%.) emergency physicians with five or more years of experience had a significantly higher PSR than physicians with less than five years of experience (7.81 vs 6.37, respectively; p¼0.0207) with an odds ratio of 1.25 (98% CI, 1.03-1.5.) emergency physicians at academic centers had a higher PSR compared to emergency physicians at community hospitals (8.82 versus 6.78, respectively; p ¼ 0.0018) with an odds ratio of 1.33 (95% CI, 1.11-1.5.) Conclusion: Attending emergency physicians who ordered more CTPA had lower diagnostic accuracy compared to peers who ordered fewer CTPA. Emergency physicians working at academic medical centers had significantly better PSR when compared to those at community hospitals. Physicians with more than 5 years of experience had higher PSR than physicians with less than five years of experience.

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