Rural implications of Medicare's post-acute-care transfer payment policy.

PubMed

Schoenman, Julie A; Mueller, Curt D

2005-01-01

Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the full DRG payment only when the patient's length of stay (LOS) is short relative to the geometric mean LOS for the DRG; otherwise, the full DRG payment is received. This policy originally applied to 10 DRGs beginning in fiscal year 1999 and was expanded to additional DRGs in FY2004. The Secretary may include other DRGs and types of PAC settings in future expansions. This article examines how the initial policy change affected rural and urban hospitals and investigates the likely impact of the FY2004 expansion and other possible future expansions. The authors used 1998-2001 Medicare Provider Analysis and Review (MEDPAR) data to investigate changes in hospital discharge patterns after the original policy was implemented, compute the change in Medicare revenue resulting from the payment change, and simulate the expected revenue reductions under expansions to additional DRGs and swing-bed discharges. Neither rural nor urban hospitals appear to have made a sustained change in their discharge behavior so as to limit their exposure to the transfer policy. Financial impacts from the initial policy were similar in relative terms for both types of hospitals and would be expected to be fairly similar for an expansion to additional DRGs. On average, including swing-bed discharges in the transfer policy would have a very small financial impact on small rural hospitals; only hospitals that make extensive use of swing beds after a short inpatient stay might expect large declines in total Medicare revenue. Rural hospitals are not disproportionately harmed by the PAC transfer policy. An expanded policy may even benefit rural hospitals by recognizing their lower use of post-acute-care and readjusting DRG weights so that they are paid more appropriately when providing the full course of inpatient care.

Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care.

PubMed

Breuckmann, F; Remberg, F; Böse, D; Lichtenberg, M; Kümpers, P; Pavenstädt, H; Waltenberger, J; Fischer, D

2016-03-01

This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.

Urban Telemedicine Enables Equity in Access to Acute Illness Care.

PubMed

Ronis, Sarah D; McConnochie, Kenneth M; Wang, Hongyue; Wood, Nancy E

2017-02-01

Children with care for acute illness available through the Health-e-Access telemedicine model at childcare and schools were previously found to have 22% less emergency department (ED) use than counterparts without this service, but they also had 24% greater acute care use overall. We assessed the hypothesis that increased utilization reflected improved access among impoverished inner-city children to a level experienced by more affluent suburban children. This observational study compared utilization among children without and with telemedicine access, beginning in 1993, ending in 2007, and based on 84,287 child-months of billing claims-based observation. Health-e-Access Telemedicine was initiated in stepwise manner over 187 study-months among 74 access sites (childcare, schools, community centers), beginning in month 105. Children dwelled in inner city, rest-of-city Rochester, NY, or in surrounding suburbs. Rate of total acute care visits (office, ED, telemedicine) was measured as visits per 100 child-years. Observed utilization rates were adjusted in multivariate analysis for age, sex, insurance type, and season of year. When both suburban and inner-city children lacked telemedicine access, overall acute illness visits were 75% greater among suburban than inner-city children (suburban:inner-city rate ratio 1.75, p < 0.0001). After telemedicine became available to inner-city children, their overall acute visits approximated those of suburban children (suburban:inner-city rate ratio 0.80, p = 0.07), whereas acute visits among suburban children remained at least (worst-case comparison) 56% greater than inner-city children without telemedicine (rate ratio 1.56, p < 0.0001). At baseline, overall acute illness utilization of suburban children exceeded that of inner-city children. Overall utilization for inner-city children increased with telemedicine to that of suburban children at baseline. Without telemedicine, however, inner-city use remained substantially less than for suburban counterparts. Health-e-Access Telemedicine redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.

Rural Hospital Patient Safety Systems Implementation in Two States

ERIC Educational Resources Information Center

Longo, Daniel R.; Hewett, John E.; Ge, Bin; Schubert, Shari

2007-01-01

Context and Purpose: With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals. Methods: Survey of all acute care hospitals in Utah and…

Cardiac acute care nurse practitioner and 30-day readmission.

PubMed

David, Daniel; Britting, Lorraine; Dalton, Joanne

2015-01-01

The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.

Surgical rescue: The next pillar of acute care surgery.

PubMed

Kutcher, Matthew E; Sperry, Jason L; Rosengart, Matthew R; Mohan, Deepika; Hoffman, Marcus K; Neal, Matthew D; Alarcon, Louis H; Watson, Gregory A; Puyana, Juan Carlos; Bauzá, Graciela M; Schuchert, Vaishali D; Fombona, Anisleidy; Zhou, Tianhua; Zolin, Samuel J; Becher, Robert D; Billiar, Timothy R; Forsythe, Raquel M; Zuckerbraun, Brian S; Peitzman, Andrew B

2017-02-01

The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. Epidemiological study, level III; therapeutic/care management study, level IV.

Myocardial infarction in Québec rural and urban populations between 1995 and 1997.

PubMed

Loslier, Julie; Vanasse, Alain; Niyonsenga, Théophile; Courteau, Josiane; Orzanco, Gabriela; Hemiari, Abbas

2007-01-01

There is abundant evidence of health inequities between urban and rural populations. The purpose of this paper is to describe the socioeconomic characteristics of Québec urban and rural populations and the relation between rurality and incidence of myocardial infarction (MI), care management and outcomes. Socioeconomic data by census subdivisions were available from the 1996 Canadian census, representing 7,137,245 individuals. Data on patients with MI were taken from the provincial administrative health database (MED-ECHO), which is managed by the Ministry of Health and contains clinical and demographic information collected when patients are released from acute care hospitals in Québec. We included a total of 37,678 cases compiled over the 3 years of follow-up in the analyses. Residents of rural areas with low urban influence have higher MI incidence rates than all of the other populations in the study. In comparison with urban populations, their observed rural counterparts are at a disadvantage with regard to education, employment and income. Although angioplasty and coronary artery bypass graft surgery rates were higher in more urban areas, the survival rate was lower than in rural areas. This study revealed geographic heterogeneity of MI incidence, revascularization rates and survival rates among urban and rural populations.

Health service utilisation amongst urban Aboriginal and Torres Strait Islander children aged younger than 5 years registered with a primary health-care service in South-East Queensland.

PubMed

Hall, Kerry K; Chang, Anne B; Anderson, Jennie; Arnold, Daniel; Otim, Michael; O'Grady, Kerry-Ann F

2018-06-01

The majority of Australia's Aboriginal and/or Torres Strait Islander children live in urban areas; however, little is known about their health service use. We aimed to describe health service utilisation amongst a cohort of urban Aboriginal and/or Torres Strait Islander children aged <5 years. We analysed health service utilisation data collected in an ongoing prospective cohort study of children aged <5 years registered with an Aboriginal-owned and operated primary health-care service. Enrolled children were followed monthly for 12 months, with data on health service utilisation collected at baseline and at each monthly follow-up. Health service utilisation rates, overall and by service provider and reason for presentation, were calculated and reported as incidence rates per 100 child-months with the corresponding 95% confidence intervals (CIs). Between February 2013 and November 2015, 180 children were enrolled, and 1541 child-months of observation were available for analysis. The overall incidence of health service utilisation was 52.5 per 100 child-months (95% CI 48.7-56.5); 81% of encounters were with general practitioners. Presentation rates were the highest for acute respiratory illnesses (30.7/100 child-months, 95% CI 27.8-33.9). In this community, acute respiratory illnesses are predominant causes of health service utilisation in young children. The health-care utilisation profile of these children presents important opportunities for health promotion and intervention. © 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

The Soothing Sea: A Virtual Coastal Walk Can Reduce Experienced and Recollected Pain

PubMed Central

Tanja-Dijkstra, Karin; Pahl, Sabine; White, Mathew P.; Auvray, Melissa; Stone, Robert J.; Andrade, Jackie; May, Jon; Mills, Ian; Moles, David R.

2017-01-01

Virtual reality (VR) distraction has become increasingly available in health care contexts and is used in acute pain management. However, there has been no systematic exploration of the importance of the content of VR environments. Two studies tested how interacting with nature VR influenced experienced and recollected pain after 1 week. Study 1 (n = 85) used a laboratory pain task (cold pressor), whereas Study 2 (n = 70) was a randomized controlled trial with patients undergoing dental treatment. In Study 1, nature (coastal) VR reduced both experienced and recollected pain compared with no VR. In Study 2, nature (coastal) VR reduced experienced and recalled pain in dental patients, compared with urban VR and standard care. Together, these data show that nature can improve experience of health care procedures through the use of VR, and that the content of the VR matters: Coastal nature is better than urban. PMID:29899576

Women's health status and use of health services in a rapidly growing peri-urban area of South Africa.

PubMed

Hoffman, M; Pick, W M; Cooper, D; Myers, J E

1997-07-01

Women's health in South Africa and particularly women living in peri-urban areas is being influenced by three major factors. These include the political transition that is occurring in the country, urbanization and the international interest in women's health. Changes in the delivery of health care to the population, and in particular to women are being planned. It is therefore important that data are available for the purpose of planning and evaluation of health services. This paper describes a household survey in which 661 women were interviewed. Socio-demographic patterns of women living in a rapidly urbanizing area were determined and related to health status, use of health services and knowledge of the services. Poverty appeared to be an overriding factor affecting the health of the population. One third of the women were living in unserviced shacks. There was a high rate of unemployment and those who were employed worked in low status jobs and earned very little. Rates of reported acute and chronic illness were lower than described elsewhere in similar household interview surveys. A third of the acute illnesses were due to respiratory disease. Reported rates of diabetes and hypertension were low indicating undiagnosed disease in the area. Being a member of an alliance household-a mixture of family, friends and lodgers-was the main predictor of acute illness. For chronic disease, age and increasing educational status were the main predictors. Knowledge of services apart from those for cervical cancer screening was good. The latter improved with increasing education, urbanization and being a member of an alliance household. As many of the women lived in unserviced areas and had little or no income the provision of infrastructural services and development programs are essential if their health is to be improved. The existing health services need to be developed to provide a comprehensive primary care service with special attention being paid to the health of women. The service should be close to their homes and be affordable. The information gathered in this survey will be used to plan services for women in the area and will act as baseline data for evaluation.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.

PubMed

Gonzales, Ralph; Aagaard, Eva M; Camargo, Carlos A; Ma, O John; Plautz, Mark; Maselli, Judith H; McCulloch, Charles E; Levin, Sara K; Metlay, Joshua P

2011-07-01

Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01). Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness. Copyright © 2011 Elsevier Inc. All rights reserved.

Nurses' meaning of caring with patients in acute psychiatric hospital settings: a grounded theory study.

PubMed

Chiovitti, Rosalina F

2008-02-01

The concept of caring is described as intangible, abstract, and invisible in nursing practice. This has translated into a view of caring as a personal choice or natural obligation rather than a deliberate process. While there has been movement to delineate caring within nursing in general, the psychiatric nurse's perspective on caring has been absent from theoretical works and measures constructed to describe nurse's work. To develop a substantive grounded theory of caring from the perspective of Registered Nurses working with patients in three Canadian acute psychiatric hospital settings. The qualitative research design of grounded theory methodology was used to develop a theory of caring. Three urban, acute psychiatric hospital settings in Canada. Two were general hospitals and one was a psychiatric hospital. Registered Nurses (N=17) licensed with the College of Nurses of Ontario. In-depth interviews with Registered Nurses were conducted using theoretical sampling. The data were analysed using constant comparative analysis. Protective empowering is the basic social psychological process that represents Registered Nurses' caring with patients in acute psychiatric hospital settings. Nurses accomplish protective empowering through six main categories of: (1) respecting the patient; (2) not taking the patient's behaviour personally; (3) keeping the patient safe; (4) encouraging the patient's health; (5) authentic relating; and (6) interactive teaching. The six main categories were accomplished through 27 subcategories. In the theory of protective empowering, the goal is to help patients participate in activities contributing to convalescence, health, and/or quality of life. The theory of protective empowering provides six main categories and 27 subcategories that can be transferred to funding formulas, patient health record documentation systems, nurse orientation and education programs, nurse role descriptions, and used in guiding discussions about organizational values of patient-centred care within a collaborative multidisciplinary context.

Moving on? Predictors of Intent to Leave among Rural and Remote RNs in Canada

ERIC Educational Resources Information Center

Stewart, Norma J.; D'Arcy, Carl; Kosteniuk, Julie; Andrews, Mary Ellen; Morgan, Debra; Forbes, Dorothy; MacLeod, Martha L. P.; Kulig, Judith C.; Pitblado, J. Roger

2011-01-01

Context: Examination of factors related to the retention or voluntary turnover of Registered Nurses (RNs) has mainly focused on urban, acute care settings. Purpose: This paper explored predictors of intent to leave (ITL) a nursing position in all rural and remote practice settings in Canada. Based on the conceptual framework developed for this…

Access, quality, and costs of care at physician owned hospitals in the United States: observational study.

PubMed

Blumenthal, Daniel M; Orav, E John; Jena, Anupam B; Dudzinski, David M; Le, Sidney T; Jha, Ashish K

2015-09-02

To compare physician owned hospitals (POHs) with non-POHs on metrics around patient populations, quality of care, costs, and payments. Observational study. Acute care hospitals in 95 hospital referral regions in the United States, 2010. 2186 US acute care hospitals (219 POHs and 1967 non-POHs). Proportions of patients using Medicaid and those from ethnic and racial minority groups; hospital performance on patient experience metrics, care processes, risk adjusted 30 day mortality, and readmission rates; costs of care; care payments; and Medicare market share. The 219 POHs were more often small (<100 beds), for profit, and in urban areas. 120 of these POHs were general (non-specialty) hospitals. Compared with patients from non-POHs, those from POHs were younger (77.4 v 78.4 years, P<0.001), less likely to be admitted through an emergency department (23.2% v. 29.0%, P<0.001), equally likely to be black (5.1% v 5.5%, P=0.85) or to use Medicaid (14.9% v 15.4%, P=0.75), and had similar numbers of chronic diseases and predicted mortality scores. POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30 day mortality, 30 day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia. Although POHs may treat slightly healthier patients, they do not seem to systematically select more profitable or less disadvantaged patients or to provide lower value care. © Blumenthal et al 2015.

Sex differences in health care-seeking behavior for acute coronary syndrome in a low income country, Peru.

PubMed

Pastorius Benziger, Catherine; Bernabe-Ortiz, Antonio; Miranda, J Jaime; Bukhman, Gene

2011-06-01

: Recognizing reasons for prehospital delay after symptoms of acute coronary syndrome (ACS) is established in developed countries yet evidence from Latin America is limited. We aimed to assess ACS symptom recognition, health care-seeking behavior, and confidence in local health care facilities to take care of ACS by gender in a sample of Peruvians. : A community-based interview survey in a peri-urban area in Lima, Peru. The 24-item study instrument included vignettes and questions assessing identification of urgent and emergent ACS symptoms, anticipated help-seeking behaviors, and confidence in local health care facilities. : In the study population (90 people; 45.6% men; mean age, 43.5 years), women were 4 times less likely to correctly attribute symptoms of chest pain to the heart (OR = 0.23; 95% CI: 0.063-0.87; P = 0.03). Women were much more likely to respond that a man would "Seek help" (OR = 4.54; 95% CI: 1.21-16.90; P = 0.024) and that "Yes," a woman would be less likely to seek help for chest pain symptoms (OR = 3.26; 95% CI: 1.13-9.41 P = 0.029) after adjusting for age, education level, age at migration, and history of chest pain. Women were less likely than men to think that their local Health Care Post would help them if they had a heart attack (2.1% vs. 14.6%; P = 0.04), and only 18.7% of women believed that their local emergency room would help them. : Our findings suggest women are less likely to seek help for chest pain and women and men in a peri-urban area in Peru are not confident in their local health care facility to treat urgent or emergent ACS symptoms.

Intensive care in a field hospital in an urban disaster area: lessons from the August 1999 earthquake in Turkey.

PubMed

Halpern, Pinchas; Rosen, Boaz; Carasso, Shemy; Sorkine, Patrick; Wolf, Yoram; Benedek, Paul; Martinovich, Giora

2003-05-01

To describe our experience with the implementation of intensive care in the setting of a field hospital, deployed to the site of a major urban disaster. Description of our experience during mission to Turkey; conclusions regarding implementation of intensive care at disaster sites. Military Field Hospital at Adapazari in Turkey. Civilian patients admitted for care at the field hospital. None. On August 17, 1999 a major earthquake occurred in western Turkey, causing approximately 16,000 fatalities and leaving >44,000 injured. Approximately 66,000 buildings were severely damaged or destroyed. A medical unit of the Israeli Defense Forces Medical Corps, consisting of 23 physicians, 13 nurses, nine paramedics, 13 medics, laboratory and roentgen technicians, pharmacists, and associated support personnel, were sent to Adapazari in Turkey. The field hospital treated approximately 1,200 patients over a period of 2 wks, 70 surgical operations were performed, 20 babies were delivered, and a variety of medical, surgical, orthopedic, and pediatric/neonatal care was provided. The 12-bed intensive care unit operated by the unit, was staffed by three physicians and eight nursing/paramedic personnel. Patient mix was: a total of 63 patients, among them five with major trauma, 20 with acute cardiac disease, 15 patients with various acute medical conditions, and 11 surgical and postoperative patients. Three patients were intubated and mechanically ventilated (one cardiogenic pulmonary edema and two major trauma). The intensive care unit provided the following functions to the field hospital: care of the critically ill and injured, preparation for and implementation of transportation of such patients, pre- and postoperative care for major surgical procedures, expertise, and equipment for the care of very ill patients throughout the field hospital. In suitable circumstances, an intensive care capability should be an integral part of medical expeditions to major disasters.

Resource Use Study In COPD (RUSIC): A prospective study to quantify the effects of COPD exacerbations on health care resource use among COPD patients

PubMed Central

FitzGerald, J Mark; Haddon, Jennifer M; Bradley-Kennedy, Carole; Kuramoto, Lisa; Ford, Gordon T

2007-01-01

BACKGROUND: There is increasing interest in health care resource use (HRU) in Canada, particularly in resources associated with acute exacerbations of chronic obstructive pulmonary disease (COPD). OBJECTIVE: To identify HRU due to exacerbations of COPD. METHODS: A 52-week, multicentre, prospective, observational study of HRU due to exacerbations in patients with moderate to severe COPD was performed. Patients were recruited from primary care physicians and respirologists in urban and rural centres in Canada. RESULTS: In total, 524 subjects (59% men) completed the study. Their mean age was 68.2±9.4 years, with a forced expiratory volume in 1 s of 1.01±0.4 L. Patients had significant comorbidities. There were 691 acute exacerbations of COPD, which occurred in 53% of patients: 119 patients (23%) experienced one acute exacerbation, 70 patients (13%) had two acute exacerbations and 89 patients (17%) had three or more acute exacerbations. Seventy-five patients were admitted to hospital, with an average length of stay of 13.2 days. Fourteen of the patients spent time in an intensive care unit (average length of stay 5.6 days). Factors associated with acute exacerbations of COPD included lower forced expiratory volume in 1 s (P<0.001), high number of respiratory medications prescribed (P=0.037), regular use of oral corticosteroids (OCSs) (P=0.008) and presence of depression (P<0.001). Of the 75 patients hospitalized, only 53 received OCSs, four received referral for rehabilitation and 15 were referred for home care. CONCLUSIONS: The present study showed a high prevalence of COPD exacerbations, which likely impacted on HRU. There was evidence of a lack of appropriate management of exacerbations, especially with respect to use of OCSs, and referral for pulmonary rehabilitation and home care. PMID:17464378

Addiction and suicidal behavior in acute psychiatric inpatients.

PubMed

Ries, Richard K; Yuodelis-Flores, Christine; Roy-Byrne, Peter P; Nilssen, Odd; Russo, Joan

2009-01-01

This study aims to evaluate the relationship of alcohol/drug use and effect severities to the degree of suicidality in acutely admitted psychiatric patients. Both degree of substance dependency and degree of substance-induced syndrome were analyzed. In addition, length of stay, involuntary status, and against medical advice discharge status were determined as they related to these variables. Structured clinical admissions and discharge ratings were gathered from 10,667 consecutive, single-case individual records, from an urban acute care county psychiatric hospital. Data indicate that of the most severely suicidal group, 56% had substance abuse or dependence, 40% were rated as having half or more of their admission syndrome substance induced, and most had nonpsychotic diagnoses. There was an inverse relationship between degree of substance problem and length of stay. Although these patients more commonly left against medical advice, and were readmitted more frequently, they were less likely to be involuntarily committed. A large, potentially lethal, and highly expensive subgroup of patients has been characterized, which might be called the "New Revolving Door acute psychiatric inpatient." This group, which uses the most expensive level of care in the mental health system but is substantially addiction related, poses special challenges for inpatient psychiatric units, addiction treatment providers, and health care planners.

The physician's office: can it influence adult immunization rates?

PubMed

Nowalk, Mary Patricia; Bardella, Inis Jane; Zimmerman, Richard Kent; Shen, Shunhua

2004-01-01

To determine which office and patient factors affect adult influenza and pneumococcal vaccination rates. Patient interviews and self-administered surveys of office managers. In a 2-stage random cluster sample, 22 practices in 4 strata (Veterans' Affairs, rural, urban/suburban, and inner city) and 15 patients per physician in each practice (n = 946) were selected. Office managers completed a questionnaire regarding office practices and logistics affecting immunizations. Data were examined using chi2 and regression analyses without and with patient factors in the models. Practice factors significantly related to influenza vaccination status were stratum (VA OR = 2.04; 95% CI = 1.18, 3.53; P < .05 vs inner-city), time allotted for acute care visits (16-20 min vs 10-15 min OR = 2.49; 95% CI = 1.68, 3.09; P < .001), the practice not having a source of free vaccines (OR = .43; 95% CI = .3, .62; P < .001), and the interaction between being an urban/suburban practice and having a source of free flu vaccines (OR = 4.0; 95% CI = 2.63, 6.09; P < .001). Practice factors related to pneumococcal vaccination status were the number of immunization promotion activities (> or = 3 vs 0-2 OR = 1.97; 95% CI = 1.33, 2.94; P = .002) and the time allotted for acute care visits (16-20 min vs 10-15 min OR = 1.94; 95% CI = 1.18, 3.19; P = .011). When practice and patient factors were combined in the analyses, patient factors were more important. Although patient factors are more important than practice factors, practices that allot more time for acute care visits and use more immunization promotion activities have higher vaccination rates.

Rural versus urban academic hospital mortality following stroke in Canada.

PubMed

Fleet, Richard; Bussières, Sylvain; Tounkara, Fatoumata Korika; Turcotte, Stéphane; Légaré, France; Plant, Jeff; Poitras, Julien; Archambault, Patrick M; Dupuis, Gilles

2018-01-01

Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada. To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals. We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate. A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities. Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada's universal health care system.

The Geographic Distribution, Ownership, Prices, and Scope of Practice at Retail Clinics

PubMed Central

Rudavsky, Rena; Pollack, Craig Evan; Mehrotra, Ateev

2009-01-01

BACKGROUND As a new model of care in the United States (US), retail clinics have generated much interest. Located physically within a retail store, they provide simple acute and preventive care services for a fixed price and without an appointment. OBJECTIVE To describe where retail clinics have opened in the US, their ownership structure, scope of practice, prices, acceptance of insurance, and the fraction of the population that lives within a short driving distance of a clinic. DESIGN Cross-sectional descriptive study SAMPLE All retail clinics operating in the US as of August 2008 MEASUREMENTS Population living within five and ten-minute driving distances of a retail clinic RESULTS In August 2008, 42 operators ran 982 clinics in 33 states; 88.4% were located in urban areas. An estimated 13.4% and 35.8% of the US urban population lives within a five-minute and ten-minute driving distance respectively from a retail clinic. The proportion of the population that lives close to a retail clinic is higher than 50 percent in some cities such as Nashville (56.7% five-minute, 93.7% ten-minute) and Minneapolis-St. Paul, MN (50.9%, 96.0%). The majority of retail clinic operators (25, 59.5%) are hospital chains and/or physician groups, but they only operate 11.4% of the clinics nationally. Simple acute conditions, skin conditions, and immunizations make up the majority of retail clinics’ limited scope of practice. Across operators, those without insurance paid on average $78 for a sore throat visit and $63 for an adult tetanus booster vaccine. In a random sample of clinics, we found that 97% accepted private insurance, 93% accepted Medicare fee-for-service, and 60% accepted some form of Medicaid. LIMITATIONS Geographic access is only one of many factors that influence whether an individual visits a retail clinic CONCLUSIONS Retail clinics can provide care for simple acute conditions and immunizations for a significant segment of the urban US population. PRIMARY FUNDING California Healthcare Foundation PMID:19721019

Disparities in outpatient and home health service utilization following stroke: results of a 9-year cohort study in Northern California.

PubMed

Chan, Leighton; Wang, Hua; Terdiman, Joe; Hoffman, Jeanne; Ciol, Marcia A; Lattimore, Bernadette Ford; Sidney, Steven; Quesenberry, Charles; Lu, Qi; Sandel, M Elizabeth

2009-11-01

To examine whether there are disparities in utilization of outpatient and home care services after stroke. Retrospective cohort study. The Kaiser Permanente of Northern California health care system, which provides health care for approximately 3.3 million members. A total of 11,119 patients hospitalized for a stroke between 1996 and 2003 and followed for 1 year. Receipt of outpatient rehabilitation (physical therapy, occupational therapy, speech pathology, or physical medicine and rehabilitation/physiatry visits), and/or home health care. There were significant differences in outpatient rehabilitation visits and home health enrollment during the year after acute care discharge for all the parameters under study. Older age and female gender were associated with less outpatient rehabilitation treatment, but these subpopulations were more likely to be enrolled in home health care. Non-whites, patients from urban areas, those with ischemic strokes, and those with longer acute care hospital stays had relatively more outpatient rehabilitation and were also more likely to be enrolled in the home health program. In addition, patients living in geographic areas with a median household income of $80,000 or more had significantly more outpatient rehabilitation visits than did patients living in lower income areas. Variations in outpatient rehabilitation visits and in home health care exist in this large integrated health system in terms of age, gender, race/ethnicity, residence area, type of stroke, and length of stay in an acute care hospital. The Kaiser Permanente integrated health care system seems to have outpatient stroke rehabilitation and home health programs that are providing care without disparities in relation to non-white populations, but other disparities appear to exist that may be related to socioeconomic factors, referral patterns, family support systems, or other cultural factors that have not been identified.

One-year follow-up of persons discharged from a locked intermediate care facility.

PubMed

Lamb, H Richard; Weinberger, Linda E

2005-02-01

This study examined outcomes during a one-year follow-up for persons who were discharged from a locked intermediate care facility in an urban area in California. The purpose of this study was to determine the extent to which persons with severe mental illness can be successfully transferred from an intermediate care facility to lower levels of care. A total of 101 persons consecutively discharged were studied by record review and by obtaining information from facility staff members, therapists, case managers, and other community caretakers. During the follow-up period 56 percent of the patients who were discharged from the intermediate care facility were not able to demonstrate even minimal functioning in the community. These persons spent 90 or more days in locked or highly structured institutions that provided 24-hour care (including jail) or had five or more acute hospitalizations. However, 44 percent spent less than 90 days in these institutions and had fewer than five acute hospitalizations. Thirty-three percent were not known to have spent any time in an institution or hospital. The high rate of recidivism shown in this cohort suggests that the current emphasis on transferring patients from more structured, intermediate inpatient services to lower levels of care is not effective for a majority of patients. Furthermore, the poor clinical outcomes found in this cohort did not seem to be offset by any reduction in overall governmental costs because of the high use of acute and intermediate hospitalization and the costs of the criminal justice system.

Post-hospital medical respite care and hospital readmission of homeless persons.

PubMed

Kertesz, Stefan G; Posner, Michael A; O'Connell, James J; Swain, Stacy; Mullins, Ashley N; Shwartz, Michael; Ash, Arlene S

2009-01-01

Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This article examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital.

Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons

PubMed Central

Kertesz, Stefan G.; Posner, Michael A.; O’Connell, James J.; Swain, Stacy; Mullins, Ashley N.; Michael, Shwartz; Ash, Arlene S.

2009-01-01

Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This paper examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, Respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital. PMID:19363773

Estimated financial savings associated with health information exchange and ambulatory care referral.

PubMed

Frisse, Mark E; Holmes, Rodney L

2007-12-01

Data and financial models based on an operational health information exchange suggest that health care delivery costs can be reduced by making clinical data available at the time of care in urban emergency departments. Reductions are the result of decreases in laboratory and radiographic tests, fewer admissions for observation, and lower overall emergency department costs. The likelihood of reducing these costs depends on the extent to which clinicians alter their workflow and take into account information available through the exchange from other institutions prior to initiating a treatment plan. Far greater savings can be realized in theory by identifying individuals presenting to emergency departments whose acute and long-term care needs are more suitably addressed at lower costs in ambulatory settings or medical homes. These alternative ambulatory settings can more effectively address the chronic care needs of those who receive most of their care in emergency departments. To support a shift from emergency room care to clinic care, health care information available through the health information exchange must be made available in both emergency department and ambulatory care settings. If practice workflow and patient behavior can be changed, a more effective and efficient care delivery system will be made possible through the secure exchange of clinical information across regional settings. These projections support the case for the financial viability of regional health information exchanges and motivate participation of hospitals and ambulatory care organizations-particularly in urban settings.

A chart review of morbidity patterns among adult patients attending primary care setting in urban Odisha, India: An International Classification of Primary Care experience.

PubMed

Swain, Subhashisa; Pati, Sandipana; Pati, Sanghamitra

2017-01-01

Disease burden estimations based on sound epidemiological research provide the foundation for designing health services. Patients visiting a primary care often present with symptoms and signs. Understanding the burden is crucial for developing countries including India. The project aimed to record the reasons for encounter (RFE) at primary care settings for estimating the burden at the health-care facility. This cross-sectional study was undertaken at four urban health dispensaries of Bhubaneswar, Odisha, with the aim to explore the prevailing patterns of diseases among patients attending these facilities. Data collection spanned from May to October 2012. At each center, patients' information on age, sex, religion, and presenting illness was extracted from the outpatient records over these time period. Data were entered and analyzed in SPSS version 20, and the International Classification of Primary Care-2 was used for coding the illnesses. In total, 2249 patient's records were extracted over 12 weeks. Out of them, 1241 (55.2%) were male with mean age of 41.8 (±15.8) years vis-à -vis 38.2 (±14.1) years for females. Around 151 (6.7%) had 2 or more symptoms or conditions. Overall, the most common categories were general and unspecified followed by digestive-related symptoms in both sexes. The most common symptoms among males were fever (11.4%), heart burn (8.1%), and vertigo or dizziness (3.6%). Similar pattern was seen among females. Respiratory (17.0%) and cardiovascular (10.2%) problems were the most common RFEs among males and females. The most common RFEs for acute care among males and females were fever, allergic rhinitis, upper respiratory tract infection, and acute bronchitis. Leading RFEs for chronic care among males were hypertension uncomplicated, heart burn, low back pain, whereas among females, hypertension and heartburn were mostly seen. Primary care settings are experiencing both communicable and non-communicable diseases along with injuries. Understanding the distribution of the diseases are essential to design appropriate service package at primary care.

Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation

PubMed Central

Blakeman, Tom; Griffith, Kathryn; Lasserson, Dan; Lopez, Berenice; Tsang, Jung Y; Campbell, Stephen; Tomson, Charles

2016-01-01

Objectives Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care. Design An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method. Setting Clinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result. Participants A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and ‘overdiagnosis’. Results There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia. Conclusions The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs. PMID:27729353

Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial.

PubMed

Sidebottom, Abbey C; Jorgenson, Ann; Richards, Hallie; Kirven, Justin; Sillah, Arthur

2015-02-01

Heart failure (HF) is associated with a high symptom burden and reduced quality of life (QOL). Models integrating palliative care (PC) into HF care have been proposed, but limited research is available on the outcomes of such models. Our aim was to assess if inpatient PC for HF patients is associated with improvements in symptom burden, depressive symptoms, QOL, or differential use of services. Patients hospitalized with acute HF were randomized to receive a PC consult with follow-up as determined by provider or standard care. Two hundred thirty-two patients (116 intervention/116 control) from a large tertiary-care urban hospital were recruited over a 10-month period. Primary outcomes were symptom burden, depressive symptoms, and QOL measured at baseline, 1, and 3 months. Secondary outcomes included advance care planning (ACP), inpatient 30-day readmission, hospice use, and death. Improvements were greater at both 1 and 3 months in the intervention group for primary outcome summary measures after adjusting for age, gender, and marital status differences between study groups. QOL scores increased by 12.92 points in the intervention and 8 points in the control group at 1 month (difference+4.92, p<0.001). Improvement in symptom burden was 8.39 in the intervention group and 4.7 in the control group at 1 month (+3.69, p<0.001). ACP was the only secondary outcome associated with the intervention (hazard ratio [HR] 2.87, p=0.033). An inpatient PC model for patients with acute HF is associated with short-term improvement in symptom burden, QOL, and depressive symptoms.

Evaluation of SOCOM Wireless Monitor in Trauma Patients

DTIC Science & Technology

2015-02-01

DOD Award W81XWH-11-2-0098 page 7 Do all trauma patients benefit from tranexamic acid ? J Trauma Acute Care Surg 2014...2015 11) Valle EJ, Allen CJ, Van Haren RM, Jouria JM, Li H, Livingstone AS, Proctor KG: Tranexamic acid may have undesirable actions in some trauma...Livingstone AS, Proctor KG: Do all patients benefit from tranexamic acid ? The experience of an urban level 1 trauma center. Presented at 72nd Annual

Rural versus urban academic hospital mortality following stroke in Canada

PubMed Central

Turcotte, Stéphane; Légaré, France; Plant, Jeff; Poitras, Julien; Archambault, Patrick M.; Dupuis, Gilles

2018-01-01

Introduction Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada. Objectives To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals. Materials and methods We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate. Results A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities. Conclusion Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system. PMID:29385173

Understanding Reasons for Delay in Seeking Acute Stroke Care in an Underserved Urban Population

PubMed Central

Hsia, Amie W.; Castle, Amanda; Wing, Jeffrey J.; Edwards, Dorothy F.; Brown, Nina C.; Higgins, Tara M.; Wallace, Jasmine L.; Koslosky, Sara S.; Gibbons, M. Chris; Sánchez, Brisa N.; Fokar, Ali; Shara, Nawar; Morgenstern, Lewis B.; Kidwell, Chelsea S.

2011-01-01

Background and Purpose Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. Methods A survey of respondents’ likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with acute stroke patients or proxy. Results In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of stroke patients interviewed actually called 911 first (OR 63.9; 95% CI 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of stroke patients reported significant delay in seeking medical attention, and almost half said the reason for delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, while 35% cited having no other transportation options. Conclusions In this predominantly black urban population, while 89% of community volunteers report the intent of calling 911 during a stroke only 12% of actual stroke patients did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke. PMID:21546471

Patterns of post-acute health care utilization after a severe traumatic brain injury: Results from the PariS-TBI cohort.

PubMed

Jourdan, Claire; Bayen, Eleonore; Darnoux, Emmanuelle; Ghout, Idir; Azerad, Sylvie; Ruet, Alexis; Vallat-Azouvi, Claire; Pradat-Diehl, Pascale; Aegerter, Philippe; Weiss, Jean-Jacques; Azouvi, Philippe

2015-01-01

To assess brain injury services utilization and their determinants using Andersen's model. Prospective follow-up of the PariS-TBI inception cohort. Out of 504 adults with severe traumatic brain injury (TBI), 245 survived and 147 received a 4-year outcome assessment (mean age 33 years, 80% men). Provision rates of medical, rehabilitation, social and re-entry services and their relations to patients' characteristics were assessed. Following acute care discharge, 78% of patients received physiotherapy, 61% speech/cognitive therapy, 50% occupational therapy, 41% psychological assistance, 63% specialized medical follow-up, 21% community re-entry assistance. Health-related need factors, in terms of TBI severity, were the main predictors of services. Provision of each therapy was significantly associated with corresponding speech, motor and psychological impairments. However, care provision did not depend on cognitive impairments and cognitive therapy was related to pre-disposing and geographical factors. Community re-entry assistance was provided to younger and more independent patients. These quantitative findings illustrate strengths and weaknesses of late brain injury care provision in urban France and highlight the need to improve treatment of cognitive impairments.

The rate of antibiotic utilization in Iranian under 5-year-old children with acute respiratory tract illness: A nationwide community-based study

PubMed Central

Mostafavi, Nasser; Rashidian, Arash; Karimi-Shahanjarini, Akram; Khosravi, Ardeshir; Kelishadi, Roya

2015-01-01

Background: To investigate the prevalence of antibiotic usage in children aged <5 years with acute respiratory tract illness (ARTI) in Iran. Materials and Methods: Data were collected from a national health survey conducted in 2010 (Iran's Multiple Indicator Demographic and Health Survey). Participants of this cross-sectional study were selected by multistage stratified cluster-random sampling from 31 provinces of Iran. Parents of children with <5 years of age responded to questions about the occurrence of any cough during the previous 2 weeks, referral to private/governmental/other health care systems, and utilization of any oral/injection form of antibiotics. Data were analyzed using SPSS software18. The chi-square test was used to determine antibiotic consumption in various gender and residency groups and also a place of residence with the referral health care system. Results: Of the 9345 children under 5 years who participated in the study, 1506 cases (16.2%) had ARTI during 2 weeks prior to the interview, in whom 1143 (75.9%) were referred to urban or rural health care centers (43.4 vs. 30.4%; P < 0.001). Antibiotics were utilized by 715 (62.6%) of affected children. Injection formulations were used for 150 (13.1%) patients. The frequency of receiving antibiotics was higher in urban than in rural inhabitants (66.0% vs. 57.7% P < 0.05). Conclusion: The prevalence of total and injection antibiotics usage in children <5 years with ARTI is alarmingly high in Iran. Therefore, interventions to reduce antibiotic use are urgently needed. PMID:26487870

Understanding the unique characteristics of suicide in China: national psychological autopsy study.

PubMed

Yang, Gong-Huan; Phillips, Michael R; Zhou, Mai-Geng; Wang, Li-Jun; Zhang, Yan-Ping; Xu, Dong

2005-12-01

To compare the characteristics of suicides in the four main demographic groups: urban males, urban females, rural males and rural females in order to help clarify the demographic pattern of suicides in China. A detailed psychological autopsy survey instrument was independently administered to 895 suicide victims in family members and close associates from 23 geographically representative locations from around the country. Pesticide ingestion accounted for 58% (519) of all suicides and 61% (318/519) of deaths were due to unsuccessful medical resuscitation. A substantial proportion (37%) of suicide victims did not have a mental illness. Among the 563 victims with mental illness, only 13% (76/563) received psychiatric treatment. Compared to other demographic groups, young rural females who died from suicide had the highest rate of pesticide ingestion (79%), the lowest prevalence of mental illness (39%), and the highest acute stress from precipitating life events just prior to the suicide. Many suicides in China are impulsive acts of deliberate self-harm following acute interpersonal crises. Prevention of suicides in China must focus on improving awareness of psychological problems, improving mental health services, providing alternative social support networks for managing acute interpersonal conflicts, limiting access to pesticides, and improving the resuscitation skills of primary care providers.

Individual and community determinants of calling 911 for stroke among African Americans in an urban community.

PubMed

Skolarus, Lesli E; Murphy, Jillian B; Zimmerman, Marc A; Bailey, Sarah; Fowlkes, Sophronia; Brown, Devin L; Lisabeth, Lynda D; Greenberg, Emily; Morgenstern, Lewis B

2013-05-01

African Americans receive acute stroke treatment less often than non-Hispanic whites. Interventions to increase stroke preparedness (recognizing stroke warning signs and calling 911) may decrease the devastating effects of stroke by allowing more patients to be candidates for acute stroke therapy. In preparation for such an intervention, we used a community-based participatory research approach to conduct a qualitative study exploring perceptions of emergency medical care and stroke among urban African American youth and adults. Community partners, church health teams, and church leaders identified and recruited focus group participants from 3 black churches in Flint, MI. We conducted 5 youth (11-16 years) and 4 adult focus groups from November 2011 to March 2012. A content analysis approach was taken for analysis. Thirty-nine youth and 38 adults participated. Women comprised 64% of youth and 90% of adult focus group participants. All participants were black. Three themes emerged from the adult and youth data: (1) recognition that stroke is a medical emergency; (2) perceptions of difficulties within the medical system in an under-resourced community, and; (3) need for greater stroke education in the community. Black adults and youth have a strong interest in stroke preparedness. Designs of behavioral interventions to increase stroke preparedness should be sensitive to both individual and community factors contributing to the likelihood of seeking emergency care for stroke.

A One Month Review of the Types of Medical Emergencies and their Treatment Outcomes at Two Urban Public Health Clinics.

PubMed

Chew, B H; Than, T L; Chew, K S; Jamaludin, N K; Hassan, H

2012-12-01

Our study was to examine prevalence and treatment outcomes of medical emergencies at two urban public health clinics in the Petaling district, Selangor, Malaysia. A prospective universal sampling was employed to recruit all emergencies over one month period (12 April to 11 May 2011). A structured case record form was used to capture demographic data, whether the index case was selfpresenting or decided by health care workers as a medical emergency, presenting complaints, diagnoses, concurrent chronic diseases and their treatment outcomes at the clinic level. Emergency presentations and diagnoses were classified according to the International Classification of Primary Care, revised second edition (ICPC-2-R). A total of 125 medical emergencies with 276 presenting complaints were recorded. The mean age was 30.7 years old (SD 19.9). The prevalence of medical emergency was 0.56% (125/22,320). Chief complaints were mainly from ICPC-2-R chapter R (respiratory system) and chapter A (general and unspecified), 40.0% and 28.0% respectively. The most common diagnosis was acute exacerbation of bronchial asthma (34.6%). Forty percent were referred to hospitals. After adjusting for age and gender, patients who presented with painful emergency (OR 4.9 95% CI 2.0 to 11.7), cardiovascular emergency (OR 63.4 95% CI 12.9 to 310.4) and non-respiratory emergency were predictors of hospital referral (OR 4.6 95% CI 1.1 to 19.1). There was about one medical emergency for every 200 patients presenting to these urban public polyclinics which were mainly acute asthma. More than half were discharged well and given a follow-up.

Walk-in Model for Ill Care in an Urban Academic Pediatric Clinic.

PubMed

Warrick, Stephen; Morehous, John; Samaan, Zeina M; Mansour, Mona; Huentelman, Tracy; Schoettker, Pamela J; Iyer, Srikant

2018-04-01

Since the Institute of Medicine's 2001 charge to reform health care, there has been a focus on the role of the medical home. Access to care in the proper setting and at the proper time is central to health care reform. We aimed to increase the volume of patients receiving care for acute illnesses within the medical home rather than the emergency department or urgent care center from 41% to 60%. We used quality improvement methods to create a separate nonemergency care stream in a large academic primary care clinic serving 19,000 patients (90% Medicaid). The pediatric primary care (PPC) walk-in clinic opened in July 2013 with service 4 hours per day and expanded to an all-day clinic in October 2013. Statistical process control methods were used to measure the change over time in the volume of ill patients and visits seen in the PPC walk-in clinic. Average weekly walk-in nonemergent ill-care visits increased from 61 to 158 after opening the PPC walk-in clinic. The percentage of nonemergent ill-care visits in the medical home increased from 41% to 45%. Visits during regular clinic hours increased from 55% to 60%. Clinic cycle time remained unchanged. Implementation of a walk-in care stream for acute illness within the medical home has allowed us to provide ill care to a higher proportion of patients, although we have not yet achieved our predicted volume. Matching access to demand is key to successfully meeting patient needs. Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation.

PubMed

Blakeman, Tom; Griffith, Kathryn; Lasserson, Dan; Lopez, Berenice; Tsang, Jung Y; Campbell, Stephen; Tomson, Charles

2016-10-11

Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care. An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method. Clinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result. A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and 'overdiagnosis'. There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia. The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Determinants of childhood mortality in slums of Karachi, Pakistan.

PubMed

D'souza, R M; Bryant, J H

1999-01-01

Pakistan has an infant mortality rate (IMR) of 90.5/1000 live births, and the country's child mortality level of 117.5 is worse than in other South Asian countries. Rapid population growth combined with rural-to-urban migration has led to the creation of urban slums in which morbidity levels are usually higher than in rural populations. A study was conducted in January 1993 in 6 slums of Karachi where the Aga Khan University has operated primary health care programs since 1985. Researchers recorded the deaths of 347 children under age 5 years old due to diarrhea and acute respiratory infections (ARI) during 1989-93. 235 mothers of these children were interviewed. The following are discussed as risk factors for under-5 child mortality: the use of traditional healers, poor nutritional status, incomplete or no immunization, the quick change of healers, inappropriate child care arrangements, mother's literacy, who decides about outside treatment, short birth interval, bottle feeding, and nuclear family structure. Maternal autonomy, appropriate health-seeking behavior, and child-rearing processes identified in the study point to the need for intervention strategies which go beyond the usual primary health care initiatives and involve communities in developing social support systems for mothers.

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program.

PubMed

Jones, Craig A; Clement, Loran T; Hanley-Lopez, Jean; Morphew, Tricia; Kwong, Kenny Yat Choi; Lifson, Francene; Opas, Lawrence; Guterman, Jeffrey J

2005-08-01

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.

[Frequency of pain as a reason for visiting a primary care clinic and its influence on sleep].

PubMed

Calsina-Berna, Agnès; Moreno Millán, Nemesio; González-Barboteo, Jesús; Solsona Díaz, Luis; Porta Sales, Josep

2011-11-01

To determine the frequency of pain as a reason to visit a Primary Care doctor and to investigate the influence of pain on sleep disturbances. Cross-sectional descriptive study. Urban Primary Health Care Centre. The first five patients who came to the primary health care centre with an appointment were included. Those who came with pain were labelled as cases, the others as controls. Socio-demographic variables, background, use of co-analgesics, Pittsburgh Sleep Quality Index (a global PSQI score greater than 5 indicated "poor sleepers"). For the cases, pain intensity was also assessed, chronology and kind of pain, the system affected and treatment. A total of 206 patients were included and 31 excluded. The mean age was 50 years and 56% were women. Pain was the reason for consultation in 39% of the patients, of whom 78% had acute pain, 80% nociceptive, 75% incidental and 71% musculoskeletal. The average VAS score was 4.98. A total of 62% were receiving treatment according to the first step of the WHO pain ladder. Forty-five per cent of patients were categorized as "good sleepers". The multivariate analysis showed that acute pain (P=.022) and pain intensity (P=.035) in men appeared as independent factors of sleep disturbances; in women there were no statistically significant variables. In our study, a high percentage of patients came to the primary health care centre for pain, mainly musculoskeletal. In men, there is a clear relationship between sleep disturbances, pain intensity and acute pain. Further research is needed to study this topic in depth, in order to alleviate pain and improve the sleep quality in our patients. Copyright © 2010 Elsevier España, S.L. All rights reserved.

Knowledge and recognition of SIRS and sepsis among pediatric nurses.

PubMed

Jeffery, Alvin D; Mutsch, Karen Steffen; Knapp, Lisa

2014-01-01

A large amount of research demonstrates the importance of key interventions in reducing mortality rates of pediatric patients with sepsis (Dellinger et al., 2008). Assessment and recognition of declining status must occur for interventions to be initiated. Of health care practitioners, nurses typically spend the most time with patients, and they must be knowledgeable in recognizing the systemic inflammatory response syndrome and sepsis while also being aware of the importance of prompt intervention. The literature does not discuss pediatric nurses' knowledge of systemic inflammatory response syndrome (SIRS)/sepsis recognition. The purpose of this study was to assess the knowledge of acute and critical care pediatric nurses of SIRS diagnostic criteria, sepsis guidelines, and the importance of SIRS recognition. This cross-sectional, quantitative, correlational descriptive study included 242 acute and critical care pediatric nurses at a 490-bed urban pediatric hospital. Participants completed an original questionnaire with face and content validity regarding SIRS criteria, sepsis guidelines, priority interventions, and attitude toward the importance of SIRS recognition. Findings demonstrated a significant knowledge deficit among participants in several key areas of SIRS/sepsis recognition. The mean score was 60.8% ± 7.4%. Item analyses demonstrated nurses easily recognize septic shock but have difficulty recognizing patients in earlier stages of the sepsis continuum. Significant confusion was evident regarding the role of blood pressure and serum lactic acid levels in diagnosing sepsis. It is recommended that an educational intervention be created for acute and critical care pediatric nurses to aid them in recognizing sepsis in its earlier stages.

Individual and community determinants of calling 911 for stroke among African Americans in an urban community

PubMed Central

Skolarus, Lesli E.; Murphy, Jillian B.; Zimmerman, Marc A.; Bailey, Sarah; Fowlkes, Sophronia; Brown, Devin L.; Lisabeth, Lynda D.; Greenberg, Emily; Morgenstern, Lewis B.

2013-01-01

Background African Americans receive acute stroke treatment less often than non-Hispanic Whites. Interventions to increase stroke preparedness (recognizing stroke warning signs and calling 911) may decrease the devastating effects of stroke by allowing more patients to be candidates for acute stroke therapy. In preparation for such an intervention, we used a community-based participatory research approach to conduct a qualitative study exploring perceptions of emergency medical care and stroke among urban African American youth and adults. Methods and Results Community partners, church health teams, and church leaders identified and recruited focus group participants from 3 African American churches in Flint, Michigan. We conducted 5 youth (11-16 years) and 4 adult focus groups from November 2011 to March 2012. A content analysis approach was taken for analysis. Thirty nine youth and 38 adults participated. Women comprised 64% of youth and 90% of adult focus group participants. All participants were African American. Three themes emerged from the adult and youth data: 1) recognition that stroke is a medical emergency; 2) perceptions of difficulties within the medical system in an under resourced community and; 3) need for greater stroke education in the community. Conclusions African American adults and youth have a strong interest in stroke preparedness. Designing behavioral interventions to increase stroke preparedness should be sensitive to both individual and community factors contributing to the likelihood of seeking emergency care for stroke. PMID:23674311

Innovative partnerships: the clinical nurse leader role in diverse clinical settings.

PubMed

Lammon, Carol Ann Barnett; Stanton, Marietta P; Blakney, John L

2010-01-01

The American Association of Colleges of Nursing in collaboration with leaders in the health care arena has developed a new role in nursing, the clinical nurse leader (CNL). The CNL is a master's-prepared advanced nurse generalist, accountable for providing high-quality, cost-effective care for a cohort of patients in a specific microsystem. Although initial implementation of the CNL has been predominantly in urban acute care settings, the skill set of the CNL role is equally applicable to diverse clinical settings, such as smaller rural hospitals, home-based home care providers, long-term care facilities, schools, Veteran's Administration facilities, and public health settings. This article reports the strategies used and the progress made at The University of Alabama Capstone College of Nursing in the development of innovative partnerships to develop the role of the CNL in diverse clinical settings. With academia and practice working in partnership, the goal of transforming health care and improving patient outcomes can be achieved. Copyright © 2010 Elsevier Inc. All rights reserved.

Pediatric Acute Severe Neurologic Illness and Injury in an Urban and a Rural Hospital in the Democratic Republic of the Congo.

PubMed

Tshimangani, Taty; Pongo, Jean; Bodi Mabiala, Joseph; Yotebieng, Marcel; O'Brien, Nicole F

2018-05-01

Empirical knowledge suggests that acute neurologic disorders are common in sub-Saharan Africa, but studies examining the true burden of these diseases in children are scarce. We performed this prospective, observational study to evaluate the prevalence, clinical characteristics, treatment approaches, and outcomes of children suffering acute neurologic illness or injury (ANI) in an urban and rural site in the Democratic Republic of the Congo. Over 12 months, 471 out of 6,563 children admitted met diagnostic criteria for ANI, giving a hospital-based prevalence of 72/1,000 admissions. Two hundred and seventy-two children had clinical findings consistent with central nervous system infection but lacked complete diagnostic evaluation for definitive classification. Another 151 children were confirmed to have cerebral malaria ( N = 109, 23% of admissions), bacterial meningitis ( N = 38, 8% of admissions), tuberculous meningitis ( N = 3, 0.6% of admissions), or herpes encephalitis ( N = 1, 0.21% of admissions). Febrile convulsions, traumatic brain injury, and epilepsy contributed less significantly to overall hospital prevalence of ANI (3.19/1,000, 1.37/1,000, and 1.06/1,000, respectively). Overall mortality for the cohort was 21% (97/471). Neurologic sequelae were seen in another 31% of participants, with only 45% completing the study with a normal neurologic examination. This type of data is imperative to help plan effective strategies for illness and injury prevention and control, and to allow optimal use of limited resources in terms of provision of acute care and rehabilitation for these children.

Health care utilization for acute illnesses in an urban setting with a refugee population in Nairobi, Kenya: a cross-sectional survey

PubMed Central

2014-01-01

Background Estimates place the number of refugees in Nairobi over 100,000. The constant movement of refugees between countries of origin, refugee camps, and Nairobi poses risk of introduction and transmission of communicable diseases into Kenya. We assessed the care-seeking behavior of residents of Eastleigh, a neighborhood in Nairobi with urban refugees. Methods During July and August 2010, we conducted a Health Utilization Survey in Section II of Eastleigh. We used a multistage random cluster sampling design to identify households for interview. A standard questionnaire on the household demographics, water and sanitation was administered to household caretakers. Separate questionnaires were administered to household members who had one or more of the illnesses of interest. Results Of 785 households targeted for interview, data were obtained from 673 (85.7%) households with 3,005 residents. Of the surveyed respondents, 290 (9.7%) individuals reported acute respiratory illness (ARI) in the previous 12 months, 222 (7.4%) reported fever in the preceding 2 weeks, and 54 (1.8%) reported having diarrhea in the 30 days prior to the survey. Children <5 years old had the highest frequency of all the illnesses surveyed: 17.1% (95% CI 12.2-21.9) reported ARI, 10.0% (95% CI 6.2-13.8) reported fever, and 6.9% (3.8-10.0) reported diarrhea during the time periods specified for each syndrome. Twenty-nine [7.5% (95% CI 4.3-10.7)] hospitalizations were reported among all age groups of those who sought care. Among participants who reported ≥1 illness, 330 (77.0%) sought some form of health care; most (174 [59.8%]) sought health care services from private health care providers. Fifty-five (18.9%) participants seeking healthcare services visited a pharmacy. Few residents of Eastleigh (38 [13.1%]) sought care at government-run facilities, and 24 (8.2%) sought care from a relative, a religious leader, or a health volunteer. Of those who did not seek any health care services (99 [23.0%]), the primary reason was cost (44.8%), followed by belief that the person was not sick enough (34.6%). Conclusion Health care utilization in Eastleigh is high; however, a large proportion of residents opt to seek care at private clinics or pharmacies, despite the availability of accessible government-provided health care services in this area. PMID:24885336

Sensitization to mouse and cockroach allergens and asthma morbidity in urban minority youth: Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II).

PubMed

Fishbein, Anna B; Lee, Todd A; Cai, Miao; Oh, Sam S; Eng, Celeste; Hu, Donglei; Huntsman, Scott; Farber, Harold J; Serebrisky, Denise; Silverberg, Jonathan; Williams, L Keoki; Seibold, Max A; Sen, Saunak; Borrell, Luisa N; Avila, Pedro; Rodriguez-Cintron, William; Rodriguez-Santana, Jose R; Burchard, Esteban G; Kumar, Rajesh

2016-07-01

Pest allergen sensitization is associated with asthma morbidity in urban youth but minimally explored in Latino populations. Specifically, the effect of mouse sensitization on the risk of asthma exacerbation has been unexplored in Latino subgroups. To evaluate whether pest allergen sensitization is a predictor of asthma exacerbations and poor asthma control in urban minority children with asthma. Latino and African American children (8-21 years old) with asthma were recruited from 4 sites across the United States. Logistic regression models evaluated the association of mouse or cockroach sensitization with asthma-related acute care visits or hospitalizations. A total of 1,992 children with asthma in the Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II) cohorts were studied. Asthmatic children from New York had the highest rate of pest allergen sensitization (42% mouse, 56% cockroach), with the lowest rate in San Francisco (4% mouse, 8% cockroach). Mouse sensitization, more than cockroach, was associated with increased odds of acute care visits (adjusted odds ratio [aOR], 1.47; 95% CI, 1.07-2.03) or hospitalizations (aOR, 3.07; 95% CI, 1.81-5.18), even after controlling for self-reported race and site of recruitment. In stratified analyses, Mexican youth sensitized to mouse allergen did not have higher odds of asthma exacerbation. Other Latino and Puerto Rican youth sensitized to mouse had higher odds of hospitalization for asthma (aORs, 4.57 [95% CI, 1.86-11.22] and 10.01 [95% CI, 1.77-56.6], respectively) but not emergency department visits. Pest allergen sensitization is associated with a higher odds of asthma exacerbations in urban minority youth. Puerto Rican and Other Latino youth sensitized to mouse were more likely to have asthma-related hospitalizations than Mexican youth. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Current practices related to family presence during acute deterioration in adult emergency department patients.

PubMed

Youngson, Megan J; Currey, Judy; Considine, Julie

2017-11-01

To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department. Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration. Descriptive exploratory study using nonparticipatory observation. Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis. Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take. Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration. This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research. © 2017 John Wiley & Sons Ltd.

Clinical Transition Framework: Integrating Coaching Plans, Sampling, and Accountability in Clinical Practice Development.

PubMed

Boyer, Susan A; Mann-Salinas, Elizabeth A; Valdez-Delgado, Krystal K

The clinical transition framework (CTF) is a competency-based practice development system used by nursing professional development practitioners to support nurses' initial orientation or transition to a new specialty. The CTF is applicable for both new graduate and proficient nurses. The current framework and tools evolved from 18 years of performance improvement and research projects engaged in both acute and community care environments in urban and rural settings. This article shares core CTF concepts, a description of coaching plans, and a professional accountability statement as experienced within the framework.

Fecal contamination of drinking water supplies in and around Chandigarh and correlation with acute gastroenteritis.

PubMed

Neelam, Taneja; Malkit, Singh; Pooja, Rao; Manisha, Biswal; Shiva, Priya; Ram, Chander; Meera, Sharma

2012-12-01

Acute gastroenteritis due to Vibrio cholerae and Enterotoxigenic E. coli is a common problem faced in the hot and humid summer months in north India. The study was undertaken to evaluate drinking water supplies for fecal coliforms, V. cholerae and Enterotoxigenic E. coli in urban, semiurban and rural areas in and around Chandigarh and correlate with occurrence of acute gastroenteritis occurring from the same region. Drinking water sample were collected from various sources from April to October 2004 from a defined area. Samples were tested for fecal coliforms and E. coli count. E. coli were screened for heat labile toxin (LT) also. Stool samples from cases of acute gastroenteritis from the same region and time were collected and processed for V. cholerae, Enterotoxigenic E. coli (ETEC) and others like Salmonella, Shigella and Aeromonas spp. A total of 364 water samples were collected, (251 semi urban, 41 rural and 72 from urban areas). 116 (31.8%) samples were contaminated with fecal coliforms (58.5% rural, 33.4% semiurban and 11.1% of samples from urban areas). E. coli were grown from 58 samples. Ninety two isolates of E. coli were tested for enterotoxins of which 8 and 24 were positive for LT and ST respectively. V. cholerae were isolated from 2 samples during the outbreak investigation. Stored water samples showed a significantly higher level of contamination and most of Enterotoxigenic E. coli were isolated from stored water samples. A total of 780 acute gastroenteritis cases occurred; 445 from semiurban, 265 rural and 70 from urban areas. Out of 189 stool samples submitted, ETEC were the commonest (30%) followed by V. cholerae (19%), Shigellae (8.4%), Salmonellae (2.1%) and Aeromonas (2.6%). ST-ETEC (40/57) were commoner than LT-ETEC (17/57). In the present study, high levels of contamination of drinking water supplies (32.1%) correlated well with cases of acute gastroenteritis. Majority of cases of acute gastroenteritis occurred in the semi urban corresponding with high level of contamination (33.4%). The highest level of water contamination was seen in rural areas (58.5%) but the number of acute gastroenteritis cases were lesser (33.9%) as ponds were infrequently used for drinking purpose. Safer household water storage and treatment is recommended to prevent acute gastroenteritis, together with point-of-use water quality monitoring.

Differences in Caregiver-Reported Health Problems and Health Care Use in Maltreated Adolescents and a Comparison Group from the Same Urban Environment

PubMed Central

Schneiderman, Janet U.; Kools, Susan; Negriff, Sonya; Smith, Sharon; Trickett, Penelope K.

2014-01-01

Maltreated youth have a high prevalence of acute and chronic mental and physical health problems, but it is not clear whether these problems are related to maltreatment or to a disadvantaged environment. To compare health status and health care use of maltreated youth receiving child protective services to comparison youth living in the same community, we conducted a secondary analysis of caregiver reports for 207 maltreated adolescents (mean age 11.9 years) and 142 comparison adolescents (mean age 12.3 years) living in urban Los Angeles, using questionnaire data from a larger longitudinal study framed in a socio-ecological model. Caregivers included biological parents, relatives, and unrelated caregivers. Analyses included t-test, MANOVA, chi-square, and multivariable logistic regression. Caregivers reported similar rates of physical health problems but more mental health problems and psychotropic medicine use in maltreated youth than in the comparison youth, suggesting that maltreated youths’ higher rates of mental health problems could not be attributed to the disadvantaged environment. Although there were no differences in health insurance coverage, maltreated youth received preventive medical care more often than comparison youth. For all youth, having Medicaid improved their odds of receiving preventive health and dental care. Attention to mental health issues in adolescents receiving child welfare services remains important. Acceptance of Medicaid by neighborhood-based and/or school-based services in low-income communities may reduce barriers to preventive care. PMID:25557881

Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada.

PubMed

Alter, David A; Iron, Karey; Austin, Peter C; Naylor, C David

2004-03-03

Some have argued that Canada's uniquely restrictive approach to private health insurance keeps the socioeconomic elite inside the public system so that their demands and influence elevate the standard of service for all Canadian citizens. The extent to which this theory is a valid representation of Canadian health care is unknown. To explore how patients with acute myocardial infarction from different socioeconomic backgrounds perceive their care in Canada's universal health care system and to correlate patients' backgrounds and perceptions with actual care received. Prospective observational cohort study with follow-up telephone interviews of 2256 patients 30 days following acute myocardial infarction discharged from 53 hospitals across Ontario, Canada, between December 1999 and June 2002. Postdischarge use of cardiac specialty services; satisfaction with care; willingness to pay directly for faster service or more choice; and mortality according to income and education, adjusted for age, sex, ethnicity, clinical factors, onsite angiography capacity at the admitting hospital, and rural-urban residence. Compared with patients in lower socioeconomic strata, more affluent or better educated patients were more likely to undergo coronary angiography (67.8% vs 52.8%; P<.001), receive cardiac rehabilitation (43.9% vs 25.6%; P<.001), or be followed up by a cardiologist (56.7% vs 47.8%; P<.001). Socioeconomic differences in cardiac care persisted after adjustment for confounders. Despite receiving more specialized services, patients with higher socioeconomic status were more likely to be dissatisfied with their access to specialty care (adjusted RR, 2.02; 95% confidence interval, 1.20-3.32) and to favor out-of-pocket payments for quicker access to a wider selection of treatment options (30% vs 15% for patients with household incomes of Can 60 000 dollars or higher vs less than Can 30 000 dollars, respectively; P<.001). After adjusting for baseline characteristics, socioeconomic status was not significantly associated with mortality at 1 year following hospitalization for myocardial infarction. Compared with those with lower incomes or less education, upper middle-class Canadians gain preferential access to services within the publicly funded health care system yet remain more likely to favor supplemental coverage or direct purchase of services.

The RHESA-CARE study: an extended baseline survey of the regional myocardial infarction registry of Saxony-Anhalt (RHESA) design and objectives.

PubMed

Hirsch, Katharina; Bohley, Stefanie; Mau, Wilfried; Schmidt-Pokrzywniak, Andrea

2016-08-17

Cardiovascular disease (CVD) is a leading cause of death in Europe. In Germany, a declining mortality rate from acute myocardial infarction (AMI) has been observed in the last decades. Nevertheless, there are large differences between the federal states when looking at the mortality and morbidity of AMI. Saxony-Anhalt is one of the federal states with the highest mortality rates for AMI in Germany. In 2012, the regional myocardial infarction registry of Saxony-Anhalt (RHESA) was established to investigate the individual, infrastructural, and health care factors with respect to an urban (city of Halle) and rural (region of Altmark) population. For detailed observation the RHESA-CARE study was conducted in 2014. RHESA-CARE focuses on the symptoms during infarction, the behaviour of patients while alerting for infarction, the use of rehabilitation possibilities, and long-term care. RHESA-CARE is an extended baseline survey of AMI patients registered in RHESA who are aged 25 or more, and inhabitants of the city of Halle (Saale) or the district of Altmark in the federal state of Saxony-Anhalt, Germany. Detailed information was collected on classical and psychosocial cardiovascular risk factors as well as factors of alerting behaviour, first aid, and utilization of medical and rehabilitation services. High data quality is ensured by a detailed system of quality control. RHESA-CARE has the main objective to investigate factors that influence morbidity and mortality rates due to AMI. Another purpose is the comparison of a rural and urban patient population. It provides an opportunity to serve as a base for improvement of patients' behaviour and health care as well as further research.

Integrating Telemedicine in Urban Pediatric Primary Care: Provider Perspectives and Performance

PubMed Central

Wood, Nancy; Herendeen, Neil; ten Hoopen, Cynthia; Denk, Larry; Neuderfer, Judith

2010-01-01

Abstract Background: Health-e-Access, an urban telemedicine service, enabled 6,511 acute-illness telemedicine visits over a 7-year period for children at 22 childcare and school sites in Rochester, NY. Objectives: The aims of this article were to (1) describe provider attitudes and perceptions about efficiency and effectiveness of Health-e-Access and (2) assess hypotheses that (a) providers will complete a large proportion of the telemedicine visits attempted and (b) high levels of continuity with the primary care practice will be achieved. Design/Methods: This descriptive study focused on the 24-month Primary Care Phase in the development of Health-e-Access, initiated by the participation of 10 primary care practices. Provider surveys addressed efficiency, effectiveness, and overall acceptability. Performance measures included completion of telemedicine visits and continuity of care with the medical home. Results: Among survey respondents, the 30 providers who had completed telemedicine visits perceived that decision-making required slightly less time and total time required was slightly greater than for in-person visits. Confidence in diagnosis was somewhat less for telemedicine visits. Providers were comfortable collaborating with telemedicine assistants and confident that communications met parent needs. Among the 2,554 consecutive telemedicine visits attempted during the Primary Care Phase, 2,475 (96.9%) were completed by 47 providers. For visits by children with a participating primary care practice, continuity averaged 83.2% among practices (range, 28.1–92.9%). Conclusions: Providers perceived little or no advantage in efficiency or effectiveness to their practice in using telemedicine to deliver care; yet they used it effectively in serving families, completing almost all telemedicine visits requested, providing high levels of continuity with the medical home, and believing they communicated adequately with parents. PMID:20406114

Acute health problems due to recreational drug use in patients presenting to an urban emergency department in Switzerland.

PubMed

Liakoni, Evangelia; Dolder, Patrick C; Rentsch, Katharina; Liechti, Matthias E

2015-01-01

To describe acute toxicity of recreational drugs including novel psychoactive substances. We included all cases presenting at the emergency department (ED) of the University Hospital of Basel, Switzerland, between October 2013 and September 2014 with acute toxicity due to self-reported recreational drug use or with symptoms/signs consistent with acute toxicity. Isolated ethanol intoxications were excluded. Intoxications were confirmed with immunoassays and liquid chromatography coupled with mass spectrometry (LC-MS/MS), which also detected novel psychoactive substances. Among the 47,767 attendances at the ED, 216 were directly related to acute toxicity of recreational drugs. The mean patient age was 31 years and 69% were male. Analytical drug confirmation was available in 180 cases. Most presentations were related to cocaine (36%), cannabis (31%), opioids (13%), 3,4-methylenedioxy-methamphetamine (MDMA, 9%), other amphetamines (7%), benzodiazepines (7%), and lysergic acid diethylamide (LSD, 5%). The substances most commonly detected analytically were cannabis (37%), cocaine (33%), opioids (29%), benzodiazepines (21%), and amphetamines including MDMA (13%). Notably, there were only two cases of novel psychoactive substances (2,5-dimethoxy-4-bromophenethylamine [2C-B] and pentylone). The most frequent symptoms were tachycardia (31%), anxiety (27%), nausea or vomiting (23%), and agitation (22%). Severe complications included myocardial infarction (2), psychosis (10), seizures (10), and 1 fatality. Most patients were discharged home (68%), 8% were admitted to intensive care and 9% were referred to psychiatric care. Medical problems related to illicit drugs mostly concerned cocaine and cannabis and mainly involved sympathomimetic toxicity and/or psychiatric disorders. ED presentations associated with novel psychoactive substances appeared to be relatively rare.

Orientation program for hospital-based nurse practitioners.

PubMed

Bahouth, Mona N; Esposito-Herr, Mary Beth

2009-01-01

The transition from student to practicing clinician is often a challenging and difficult period for many nurse practitioners. Newly graduated nurse practitioners commonly describe feelings of inadequacy in assuming clinical responsibilities, lack of support by team members, unclear expectations for the orientation period, and role isolation. This article describes the formal nurse practitioner orientation program implemented at the University of Maryland Medical Center, a large urban academic medical center, to facilitate the transition of new nurse practitioners into the workforce. This comprehensive program incorporates streamlined administrative activities, baseline didactic and simulation-based critical care education, ongoing and focused peer support, access to formalized resources, and individualized clinical preceptor programs. This formalized orientation program has proven to be one of the key variables to successful integration of nurse practitioners into our acute care clinical teams.

Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs.

PubMed

Fakhry, Samir M; Martin, Brad; Al Harakeh, Hasan; Norcross, E Douglas; Ferguson, Pamela L

2013-04-01

Controlling inpatient costs is increasingly important. Identifying proportionately larger cost categories may help focus cost control efforts. The purpose of this study was to identify proportionate patient cost categories in trauma and acute care surgery (TACS) patients and determine subgroups in which the largest opportunities for cost savings might exist. Administrative data from our academic, urban, level I trauma center were used to identify all adult TACS patients from FY07 through FY11. We determined, on average, what proportion of the whole each cost category contributed to patients' total costs and examined the same proportions for subgroups of patients. We identified 6,008 TACS patients. Trauma patients (n = 3,904) made up 65% of the cohort (mean Injury Severity Score 13.2). Payers were: 22% government (Medicare, Medicaid, Champus), 27% private, 43% self-pay/indigent, 3% other, and 5% workers compensation. Nontrauma (general surgery) patients (n = 2,104) made up 35% of the cohort. Payers were: 44% government, 24% private, 29% self-pay/indigent, 2% other, and 1% workers compensation. Total inpatient costs were $141,304,993. Per patient costs rose from $17,245 in FY07 to $26,468 in FY11. In the aggregate, supplies, ICU stays, and ward stays represented the largest proportionate cost categories. On a per patient basis, however, ICU stays were by far the largest cost. Patients with ICU stay greater than 10 days were only 7% of all patients but accounted for 41% of total costs. Trauma and acute care surgery patients represent a significant and increasing institutional cost. Per patient ICU costs were the largest single category, suggesting that cost control efforts should focus heavily on critically ill patients. Nontrauma patients who require critical care have the highest per patient ICU costs and may represent a previously underappreciated opportunity for cost control. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Equity in patient experiences of primary care in community health centers using primary care assessment tool: a comparison of rural-to-urban migrants and urban locals in Guangdong, China.

PubMed

Zhong, Chenwen; Kuang, Li; Li, Lina; Liang, Yuan; Mei, Jie; Li, Li

2018-04-27

The equity of rural-to-urban migrants' health care utilization is already on China's agenda. The Chinese government has been embarking on efforts to improve the financial and geographical accessibility of health care for migrants by strengthening primary care services and providing universal coverage. Patient experiences are equally vital to migrants' health care utilization. To our knowledge, no studies have focused on equity in the patient experiences between migrants and locals. Based on a patient survey from Guangdong, China, which has a large number of rural-to-urban migrants, our study assessed the equity in the primary care patient experiences between rural-to-urban migrants and urban locals in the same health insurance context, since different forms of insurance can affect the patient experiences of primary care. We stratified our samples by different insurance types into three layers. We assessed primary care patient experiences using a validated Chinese version of the Primary Care Assessment Tool (PCAT), including eight primary care attributes. A 'PCAT total score' was calculated. Data were collected through face-to-face and one-on-one surveys in 2014. Propensity score matching (PSM) was used for each layer to generate comparable samples between rural-to-urban migrants and urban locals. Based on the matched dataset, a t-test was employed to compare the primary care patient experiences of the two groups. Using PSM, 220 patients in the rural-to-urban migrants group were matched to 220 patients in the urban locals group. After the matching, the observed confounding variables were balanced, and the PCAT scores were almost equal between the two groups. The only slight differences existed in the Urban Employee Basic Medical Insurance layer and in the without basic medical insurance coverage layer. Equity in the primary care patient experiences between rural-to-urban migrants and urban locals seems to have been achieved to some extent. However, there is room for improvement in the equity of coordination of care and comprehensiveness. Policy makers should consider strengthening these two dimensions by integrating the health care system. More attention should be focused on helping migrants break down language and cultural barriers and improving the patient-physician communication process.

Hospital Nursing Workforce Costs, Wages, Occupational Mix,and Resource Utilization.

PubMed

Welton, John M

2015-10-01

The objective of the study was to better understand how hospitals use different types of RNs, LPNs, and nurse aides in proprietary (for-profit), nonprofit, and government-owned hospitals and to estimate the wages, cost, and intensity of nursing care using a national data set. This is a cross-sectional observational study of 3,129 acute care hospitals in all 50 states and District of Columbia using data from the 2008 Occupational Mix Survey administered by the Centers for Medicare &Medicaid Services (CMS). Nursing skill mix, hours, and labor costs were combined with other CMS hospital descriptive data, including type of hospital ownership, urban or rural location, hospital beds, and case-mix index. RN labor costs make up 25.5% of all hospital expenditures annually, and all nursing labor costs represent 30.1%, which is nearly a quarter trillion dollars ($216.7 billion) per year for inpatient nursing care. On average, proprietary hospitals employ 1.3 RNs per bed and 1.9 nursing personnel per bed in urban hospitals compared with 1.7 RNs per bed and 2.3 nursing personnel per bed for nonprofit and government-owned hospitals (P G .05). States with higher ratios of RN compared with LPN licenses used fewer LPNs in the inpatient setting. The findings from this study can be helpful in comparing nursing care across different types of hospitals, ownership, and geographic locations and used as a benchmark for future nursing workforce needs and costs.

Hospital nursing workforce costs, wages, occupational mix, and resource utilization.

PubMed

Welton, John M

2011-01-01

: The objective of the study was to better understand how hospitals use different types of RNs, LPNs, and nurse aides in proprietary (for-profit), nonprofit, and government-owned hospitals and to estimate the wages, cost, and intensity of nursing care using a national data set. : This is a cross-sectional observational study of 3,129 acute care hospitals in all 50 states and District of Columbia using data from the 2008 Occupational Mix Survey administered by the Centers for Medicare & Medicaid Services (CMS). Nursing skill mix, hours, and labor costs were combined with other CMS hospital descriptive data, including type of hospital ownership, urban or rural location, hospital beds, and case-mix index. : RN labor costs make up 25.5% of all hospital expenditures annually, and all nursing labor costs represent 30.1%, which is nearly a quarter trillion dollars ($216.7 billion) per year for inpatient nursing care. On average, proprietary hospitals employ 1.3 RNs per bed and 1.9 nursing personnel per bed in urban hospitals compared with 1.7 RNs per bed and 2.3 nursing personnel per bed for nonprofit and government-owned hospitals (P < .05). States with higher ratios of RN compared with LPN licenses used fewer LPNs in the inpatient setting. : The findings from this study can be helpful in comparing nursing care across different types of hospitals, ownership, and geographic locations and used as a benchmark for future nursing workforce needs and costs.

Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients.

PubMed

Chang, Andrew K; Bijur, Polly E; Davitt, Michelle; Gallagher, E John

2013-09-01

Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.

Key successes and challenges in providing mental health care in an urban male remand prison: a qualitative study.

PubMed

Samele, Chiara; Forrester, Andrew; Urquía, Norman; Hopkin, Gareth

2016-04-01

This study aimed to describe the workings of an urban male remand prison mental health service exploring the key challenges and successes, levels of integration and collaboration with other services. A purposive sampling was used to recruit key prison and healthcare professionals for in-depth interviews. A thematic analysis was used to analyse transcripts based on an initial coding frame of several predefined themes. Other key themes were also identified. Twenty-eight interviews were conducted. Prisoners referred to the service had complex, sometimes acute mental illness requiring specialist assessment and treatment. Key successes of the in-reach service included the introduction of an open referral system, locating a mental health nurse at reception to screen all new prisoners and a zoning system to prioritise urgent or non-urgent cases. Achieving an integrated system of healthcare was challenging because of the numerous internal and external services operating across the prison, a highly transient population, limited time and space to deliver services and difficulties with providing inpatient care (e.g., establishing the criteria for admission and managing patient flow). Collaborative working between prison and healthcare staff was required to enable best care for prisoners. The prison mental health in-reach service worked well in assessing and prioritising those who required specialist mental health care. Although the challenges of working within the prison context limited what the in-reach team could achieve. Further work was needed to improve the unit environment and how best to target and deliver inpatient care within the prison.

76 FR 51475 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-18

... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective...-related costs of acute care hospitals to implement changes arising from our continuing experience with...

78 FR 50495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-19

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment... Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective... prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to...

75 FR 50041 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-16

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals...

The South Carolina rural-urban HIV continuum of care.

PubMed

Edun, Babatunde; Iyer, Medha; Albrecht, Helmut; Weissman, Sharon

2017-07-01

The HIV continuum of care model is widely used by various agencies to describe the HIV epidemic in stages from diagnosis through to virologic suppression. It identifies the various points at which persons living with HIV (PLWHIV) within a population fail to reach their next step in HIV care. The rural population in the Southern United States is disproportionally affected by the HIV epidemic. The purpose of this study was to examine these rural-urban disparities using the HIV care continuum model and determine at what stages these differences become apparent. PLWHIV aged 13 years and older in South Carolina (SC) were identified using data from the enhanced HIV/AIDS Reporting System. The percentages of PLWHIV linked to care, retained in care, and virologically suppressed were determined. Rural versus urban residence was determined using the Office of Management and Budget classification. There were 14,523 PLWHIV in SC at the end of 2012; 11,193 (77%) of whom were categorized as urban and 3305 (22%) as rural. There was no difference between urban and rural for those who had received any care: 64% versus 64% (p = .61); retention in care 53% versus 53% (p = .71); and virologic suppression 49% versus 48% (p = .35), respectively. The SC rural-urban HIV cascade represents the first published cascade of care model using rural versus urban residence. Although significant health care disparities exist between rural and urban residents, there were no major differences between rural and urban residents at the various stages of engagement in HIV care using the HIV continuum of care model.

Factors driving customers to seek health care from pharmacies for acute respiratory illness and treatment recommendations from drug sellers in Dhaka city, Bangladesh

PubMed Central

Chowdhury, Fahmida; Sturm-Ramirez, Katharine; Mamun, Abdullah Al; Iuliano, A Danielle; Bhuiyan, Mejbah Uddin; Chisti, Mohammod Jobayer; Ahmed, Makhdum; Haider, Sabbir; Rahman, Mahmudur; Azziz-Baumgartner, Eduardo

2017-01-01

Background Pharmacies in Bangladesh serve as an important source of health service. A survey in Dhaka reported that 48% of respondents with symptoms of acute respiratory illness (ARI) identified local pharmacies as their first point of care. This study explores the factors driving urban customers to seek health care from pharmacies for ARI, their treatment adherence, and outcome. Methods A cross-sectional study was conducted among 100 selected pharmacies within Dhaka from June to December 2012. Study participants were patients or patients’ relatives aged >18 years seeking care for ARI from pharmacies without prescription. Structured interviews were conducted with customers after they sought health service from drug sellers and again over phone 5 days postinterview to discuss treatment adherence and outcome. Results We interviewed 302 customers patronizing 76 pharmacies; 186 (62%) sought care for themselves and 116 (38%) sought care for a sick relative. Most customers (215; 71%) were males. The majority (90%) of customers sought care from the study pharmacy as their first point of care, while 18 (6%) had previously sought care from another pharmacy and 11 (4%) from a physician for their illness episodes. The most frequently reported reasons for seeking care from pharmacies were ease of access to pharmacies (86%), lower cost (46%), availability of medicine (33%), knowing the drug seller (20%), and convenient hours of operation (19%). The most commonly recommended drugs were acetaminophen dispensed in 76% (228) of visits, antihistamine in 69% (208), and antibiotics in 42% (126). On follow-up, most (86%) of the customers had recovered and 12% had sought further treatment. Conclusion People with ARI preferred to seek care at pharmacies rather than clinics because these pharmacies were more accessible and provided prompt treatment and medicine with no service charge. We recommend raising awareness among drug sellers on proper dispensing practices and enforcement of laws and regulations for drug sales. PMID:28293104

Factors driving customers to seek health care from pharmacies for acute respiratory illness and treatment recommendations from drug sellers in Dhaka city, Bangladesh.

PubMed

Chowdhury, Fahmida; Sturm-Ramirez, Katharine; Mamun, Abdullah Al; Iuliano, A Danielle; Bhuiyan, Mejbah Uddin; Chisti, Mohammod Jobayer; Ahmed, Makhdum; Haider, Sabbir; Rahman, Mahmudur; Azziz-Baumgartner, Eduardo

2017-01-01

Pharmacies in Bangladesh serve as an important source of health service. A survey in Dhaka reported that 48% of respondents with symptoms of acute respiratory illness (ARI) identified local pharmacies as their first point of care. This study explores the factors driving urban customers to seek health care from pharmacies for ARI, their treatment adherence, and outcome. A cross-sectional study was conducted among 100 selected pharmacies within Dhaka from June to December 2012. Study participants were patients or patients' relatives aged >18 years seeking care for ARI from pharmacies without prescription. Structured interviews were conducted with customers after they sought health service from drug sellers and again over phone 5 days postinterview to discuss treatment adherence and outcome. We interviewed 302 customers patronizing 76 pharmacies; 186 (62%) sought care for themselves and 116 (38%) sought care for a sick relative. Most customers (215; 71%) were males. The majority (90%) of customers sought care from the study pharmacy as their first point of care, while 18 (6%) had previously sought care from another pharmacy and 11 (4%) from a physician for their illness episodes. The most frequently reported reasons for seeking care from pharmacies were ease of access to pharmacies (86%), lower cost (46%), availability of medicine (33%), knowing the drug seller (20%), and convenient hours of operation (19%). The most commonly recommended drugs were acetaminophen dispensed in 76% (228) of visits, antihistamine in 69% (208), and antibiotics in 42% (126). On follow-up, most (86%) of the customers had recovered and 12% had sought further treatment. People with ARI preferred to seek care at pharmacies rather than clinics because these pharmacies were more accessible and provided prompt treatment and medicine with no service charge. We recommend raising awareness among drug sellers on proper dispensing practices and enforcement of laws and regulations for drug sales.

Bundling Post-Acute Care Services into MS-DRG Payments

PubMed Central

Vertrees, James C.; Averill, Richard F.; Eisenhandler, Jon; Quain, Anthony; Switalski, James

2013-01-01

Objective A bundled hospital payment system that encompasses both acute and post-acute care has been proposed as a means of creating financial incentives in the Medicare fee-for-service system to foster care coordination and to improve the current disorganized system of post care. The objective of this study was to evaluate the statistical stability of alternative designs of a hospital payment system that includes post-acute care services to determine the feasibility of using a combined hospital and post-acute care bundle as a unit of payment. Methods The Medicare Severity-Diagnosis Related Groups (MS-DRGs) were subdivided into clinical subclasses that measured a patient's chronic illness burden to test whether a patient's chronic illness burden had a substantial impact on post-acute care expenditures. Using Medicare data the statistical performance of the MS-DRGs with and without the chronic illness subclasses was evaluated across a wide range of post-acute care windows and combinations of post-acute care service bundles using both submitted charges and Medicare payments. Results The statistical performance of the MS-DRGs as measured by R2 was consistently better when the chronic illness subclasses are included indicating that MS-DRGs by themselves are an inadequate unit of payment for post-acute care payment bundles. In general, R2 values increased as the post-acute care window length increased and decreased as more services were added to the post-acute care bundle. Discussion The study results suggest that it is feasible to develop a payment system that incorporates significant post-acute care services into the MS-DRG inpatient payment bundle. This expansion of the basic DRG payment approach can provide a strong financial incentive for providers to better coordinate care potentially leading to improved efficiency and outcome quality. PMID:24753970

Morbidity and process of care in urban Malaysian general practice: the impact of payment system.

PubMed

Teng, C L; Aljunid, S M; Cheah, Molly; Leong, K C; Kwa, S K

2003-08-01

The majority of primary care consultations in Malaysia occur in the general practice clinics. To date, there is no comprehensive documentation of the morbidity and practice activities in this setting. We reported the reasons for encounter, diagnoses and process of care in urban general practice and the influence of payment system on the morbidity and practice activities. 115 clinics in Kuala Lumpur, Ipoh and Penang participated in this study. General practitioners in these clinics completed a 2-page questionnaire for each of the 30 consecutive patients. The questionnaire requested for the following information: demographic data, reasons for encounter, important physical findings, diagnoses, investigations ordered, outpatient procedures performed, medical certificate given, medication prescribed and referral made. The morbidity (reasons for encounter and diagnoses) was coded using ICPC-2 and the medication data was coded using MIMS Classification Index. During 3481 encounters, 5300 RFEs (152 RFEs per 100 encounters) and 3342 diagnoses (96 diagnoses per 100 encounters) were recorded. The majority of the RFEs and diagnoses are in the following ICPC Chapters: Respiratory, General and unspecified, Digestive, Neurological, Musculoskeletal and Skin. The frequencies of selected aspects of the process of care (rate per 100 encounters) were: laboratory investigations 14.7, outpatient procedures 2.4, sick certification 26.9, referral 2.4, and medication prescription 244. Consultation for chronic diseases and acute infections were influenced more by demographic variables (age, employment) rather than payment system. Cash-paying patients were more likely to receive laboratory investigations and injections. This study demonstrated the breadth of clinical care in the general practice. Relatively fewer patients consulted specifically for preventive care and treatment of chronic diseases. The frequencies of outpatient procedures and referrals appeared to be low. Payment system results in important differences in patient mix and influences some types of practice activities.

Tele-Interpersonal Psychotherapy Acutely Reduces Depressive Symptoms in Depressed HIV-Infected Rural Persons: A Randomized Clinical Trial.

PubMed

Heckman, Timothy G; Heckman, Bernadette D; Anderson, Timothy; Lovejoy, Travis I; Markowitz, John C; Shen, Ye; Sutton, Mark

2017-01-01

Human immunodeficiency virus (HIV)-positive rural individuals carry a 1.3-times greater risk of a depressive diagnosis than their urban counterparts. This randomized clinical trial tested whether telephone-administered interpersonal psychotherapy (tele-IPT) acutely relieved depressive symptoms in 132 HIV-infected rural persons from 28 states diagnosed with Diagnostic and Statistical Manual of Mental Disorders-IV major depressive disorder (MDD), partially remitted MDD, or dysthymic disorder. Patients were randomized to either 9 sessions of one-on-one tele-IPT (n = 70) or standard care (SC; n = 62). A series of intent-to-treat (ITT), therapy completer, and sensitivity analyses assessed changes in depressive symptoms, interpersonal problems, and social support from pre- to postintervention. Across all analyses, tele-IPT patients reported significantly lower depressive symptoms and interpersonal problems than SC controls; 22% of tele-IPT patients were categorized as a priori "responders" who reported 50% or higher reductions in depressive symptoms compared to only 4% of SC controls in ITT analyses. Brief tele-IPT acutely decreased depressive symptoms and interpersonal problems in depressed rural people living with HIV.

Combined Protocol for Acute Malnutrition Study (ComPAS) in rural South Sudan and urban Kenya: study protocol for a randomized controlled trial.

PubMed

Bailey, Jeanette; Lelijveld, Natasha; Marron, Bethany; Onyoo, Pamela; Ho, Lara S; Manary, Mark; Briend, André; Opondo, Charles; Kerac, Marko

2018-04-24

Acute malnutrition is a continuum condition, but severe and moderate forms are treated separately, with different protocols and therapeutic products, managed by separate United Nations agencies. The Combined Protocol for Acute Malnutrition Study (ComPAS) aims to simplify and unify the treatment of uncomplicated severe and moderate acute malnutrition (SAM and MAM) for children 6-59 months into one protocol in order to improve the global coverage, quality, continuity of care and cost-effectiveness of acute malnutrition treatment in resource-constrained settings. This study is a multi-site, cluster randomized non-inferiority trial with 12 clusters in Kenya and 12 clusters in South Sudan. Participants are 3600 children aged 6-59 months with uncomplicated acute malnutrition. This study will evaluate the impact of a simplified and combined protocol for the treatment of SAM and MAM compared to the standard protocol, which is the national treatment protocol in each country. We will assess recovery rate as a primary outcome and coverage, defaulting, death, length of stay, average weekly weight gain and average weekly mid-upper arm circumference (MUAC) gain as secondary outcomes. Recovery rate is defined across both treatment arms as MUAC ≥125 mm and no oedema for two consecutive visits. Per-protocol and intention-to-treat analyses will be conducted. If the combined protocol is shown to be non-inferior to the standard protocol, updating guidelines to use the combined protocol would eliminate the need for separate products, resources and procedures for MAM treatment. This would likely be more cost-effective, increase availability of services, enable earlier case finding and treatment before deterioration of MAM into SAM, promote better continuity of care and improve community perceptions of the programme. ISRCTN, ISRCTN30393230 . Registered on 16 March 2017.

Presentations due to acute toxicity of psychoactive substances in an urban emergency department in Switzerland: a case series.

PubMed

Liakoni, Evangelia; Dolder, Patrick C; Rentsch, Katharina M; Liechti, Matthias E

2016-05-26

Although the recreational use of psychoactive substances is common there is only limited systematic collection of data on acute drug toxicity or hospital presentations, in particular regarding novel psychoactive substances (NPS) that have emerged on the illicit market in the last years. We included all cases presenting at the emergency department (ED) of the University Hospital of Basel, Switzerland, between October 2014 and September 2015 with acute toxicity due to self-reported recreational drug use or with symptoms/signs consistent with acute toxicity. Intoxications were confirmed using immunoassays and LC-MS/MS, detecting also novel psychoactive substances. Among the 50'624 attendances at the ED, 210 were directly related to acute toxicity of recreational drugs. The mean patient age was 33 years and 73 % were male. Analytical drug confirmation was available in 136 cases. Most presentations were reportedly related to cocaine (33 %), cannabis (32 %), and heroin (14 %). The most commonly analytically detected substances were cannabis (33 %), cocaine (27 %), and opioids excluding methadone (19 %). There were only two NPS cases; a severe intoxication with paramethoxymethamphetamine (PMMA) in combination with other substances and an intoxication of minor severity with 2,5-dimethoxy-4-propylphenethylamine (2C-P). The most frequent symptoms were tachycardia (28 %), anxiety (23 %), nausea or vomiting (18 %), and agitation (17 %). Severe complications included two fatalities, two acute myocardial infarctions, seizures (13 cases), and psychosis (six cases). Most patients (76 %) were discharged home, 10 % were admitted to intensive care, and 2 % were referred to psychiatric care. Most medical problems related to illicit drugs concerned cocaine and cannabis and mainly included sympathomimetic toxicity and/or psychiatric disorders confirming data from the prior year. Importantly, despite the dramatic increase in various NPS being detected in the last years, these substances were infrequently associated with ED presentations compared with classic recreational drugs.

Understanding the bereavement care roles of nurses within acute care: a systematic review.

PubMed

Raymond, Anita; Lee, Susan F; Bloomer, Melissa J

2017-07-01

To investigate nurses' roles and responsibilities in providing bereavement care during the care of dying patients within acute care hospitals. Bereavement within acute care hospitals is often sudden, unexpected and managed by nurses who may have limited access to experts. Nurses' roles and experience in the provision of bereavement care can have a significant influence on the subsequent bereavement process for families. Identifying the roles and responsibilities, nurses have in bereavement care will enhance bereavement supports within acute care environments. Mixed-methods systematic review. The review was conducted using the databases Cumulative Index Nursing and Allied Health Literature Plus, Embase, Ovid MEDLINE, PsychINFO, CareSearch and Google Scholar. Included studies published between 2006-2015, identified nurse participants, and the studies were conducted in acute care hospitals. Seven studies met the inclusion criteria, and the research results were extracted and subjected to thematic synthesis. Nurses' role in bereavement care included patient-centred care, family-centred care, advocacy and professional development. Concerns about bereavement roles included competing clinical workload demands, limitations of physical environments in acute care hospitals and the need for further education in bereavement care. Further research is needed to enable more detailed clarification of the roles nurse undertake in bereavement care in acute care hospitals. There is also a need to evaluate the effectiveness of these nursing roles and how these provisions impact on the bereavement process of patients and families. The care provided by acute care nurses to patients and families during end-of-life care is crucial to bereavement. The bereavement roles nurses undertake are not well understood with limited evidence of how these roles are measured. Further education in bereavement care is needed for acute care nurses. © 2016 John Wiley & Sons Ltd.

Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study.

PubMed

Hsia, Amie W; Edwards, Dorothy F; Morgenstern, Lewis B; Wing, Jeffrey J; Brown, Nina C; Coles, Regina; Loftin, Sarah; Wein, Andrea; Koslosky, Sara S; Fatima, Sabiha; Sánchez, Brisa N; Fokar, Ali; Gibbons, M Chris; Shara, Nawar; Jayam-Trouth, Annapurni; Kidwell, Chelsea S

2011-08-01

Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

RACIAL DISPARITIES IN TPA TREATMENT RATE FOR STROKE: A POPULATION-BASED STUDY

PubMed Central

Hsia, Amie W.; Edwards, Dorothy F.; Morgenstern, Lewis B.; Wing, Jeffrey J.; Brown, Nina C.; Coles, Regina; Loftin, Sarah; Wein, Andrea; Koslosky, Sara S.; Fatima, Sabiha; Fokar, Ali; Gibbons, M. Chris; Jayam-Trouth, Annapurni; Kidwell, Chelsea S.

2011-01-01

Background Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (IV tPA) utilization for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods Systematic chart abstraction was performed on consecutive hospitalized ischemic stroke patients from all seven acute care hospitals in the District of Columbia from Feb 1, 2008 to Jan 31, 2009. Results Of 1044 ischemic stroke patients, 74%% were black, 19% non-Hispanic white, 5% received IV tPA. Blacks were one third less likely than whites to receive IV tPA (3% vs. 10%, p<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% vs. 21%, p=0.004) and also less likely to be tPA-eligible (5% vs. 13%, p<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with IV tPA than whites (27% vs. 46%, p=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% vs. 76%, p=0.62). Conclusions In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with IV tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population. PMID:21719765

Initiating an online asthma management program in urban emergency departments: the recruitment experience.

PubMed

Joseph, Christine L M; Lu, Mei; Stokes-Bruzzelli, Stephanie; Johnson, Dayna A; Duffy, Elizabeth; Demers, Michele; Zhang, Talan; Ownby, Dennis R; Zoratti, Edward; Mahajan, Prashant

2016-01-01

The emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions. To assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals. In addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions. Of 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff. Emergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Determining level of care appropriateness in the patient journey from acute care to rehabilitation

PubMed Central

2011-01-01

Background The selection of patients for rehabilitation, and the timing of transfer from acute care, are important clinical decisions that impact on care quality and patient flow. This paper reports utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation. It examines reasons why acute level of care criteria are not met and explores differences in decision making between acute care and rehabilitation teams around patient appropriateness and readiness for transfer. Methods Cohort study of patients in a large acute referral hospital in Australia followed with the InterQual utilization review tool, modified to also include reasons why utilization criteria are not met. Additional data on team decision making about appropriateness for rehabilitation, and readiness for transfer, were collected on a subset of patients. Results There were 696 episodes of care (7189 bed days). Days meeting acute level of care criteria were 56% (stroke, hip fracture and joint replacement patients) and 33% (other patients, from the time of referral). Most inappropriate days in acute care were due to delays in processes/scheduling (45%) or being more appropriate for rehabilitation or lower level of care (30%). On the subset of patients, the acute care team and the utilization review tool deemed patients ready for rehabilitation transfer earlier than the rehabilitation team (means of 1.4, 1.3 and 4.0 days from the date of referral, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients became unstable. From when deemed stable by the rehabilitation team or utilization review, 9% and 11%, respectively, became unstable. Conclusions A high proportion of patient days did not meet acute level of care criteria, due predominantly to inefficiencies in care processes, or to patients being more appropriate for an alternative level of care, including rehabilitation. The rehabilitation team was the most accurate in determining ongoing medical stability, but at the cost of a longer acute stay. To avoid inpatients remaining in acute care in a state of 'terra nullius', clinical models which provide rehabilitation within acute care, and more efficient movement to a rehabilitation setting, is required. Utilization review could have a decision support role in the determination of medical stability. PMID:22040281

Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement.

PubMed

Snow, Richard; Granata, Jaymes; Ruhil, Anirudh V S; Vogel, Karen; McShane, Michael; Wasielewski, Ray

2014-10-01

Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. Historical claims data were analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency, or inpatient rehabilitation facility, during the ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs. The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172). The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. This association was sustained after adjusting for comorbidities, demographic characteristics, and procedural variables. Health-care providers can use this methodology to achieve an integrative, cost-effective, patient care pathway using preoperative physical therapy. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

Subacute and non-acute casemix in Australia.

PubMed

Lee, L A; Eagar, K M; Smith, M C

1998-10-19

The costs of subacute care (palliative care, rehabilitation medicine, psychogeriatrics, and geriatric evaluation and management) and non-acute care (nursing home, convalescent and planned respite care) are not adequately described by existing casemix classifications. The predominant treatment goals in subacute care are enhancement of quality of life and/or improvement in functional status and, in non-acute care, maintenance of current health and functional status. A national classification system for this area has now been developed--the Australian National Sub-Acute and Non-Acute Patient Classification System (AN-SNAP). The AN-SNAP system, based on analysis of over 30,000 episodes of care, defines four case types of subacute care (palliative care, rehabilitation, psychogeriatric care, and geriatric evaluation and management and one case type of non-acute care (maintenance care), and classifies both overnight and ambulatory care. The AN-SNAP system reflects the goal of management--a change in functional status or improvement in quality of life--rather than the patient's diagnosis. It will complement the existing AN-DRG classification.

Sexual orientation disclosure to health care providers among urban and non-urban southern lesbians.

PubMed

Austin, Erika Laine

2013-01-01

Concerns regarding sexual orientation disclosure to health care providers have been suggested as a barrier to care which may account for documented differences in the health care utilization of lesbians relative to heterosexual women. This study explored the correlates of sexual orientation disclosure to health care providers among 934 lesbian women living in urban and non-urban areas of the South. Psychosocial resources, such as self-esteem, social support, and mastery, along with several lesbian-specific experiences (proportion of lesbian, gay, bisexual, or transgender friends, access to the lesbian, gay, bisexual, or transgender community, degree of being "out"), were all independently associated with greater likelihood of having disclosed to a health care provider. Internalized homophobia and lesbian-related stigma decreased the likelihood of disclosure. Lesbians living in non-urban areas were significantly less likely to have disclosed than women in urban areas, suggesting that disclosure may present a special concern for populations in non-urban areas.

Nurses in Action: A Response to Cultural Care Challenges in a Pediatric Acute Care Setting.

PubMed

Mixer, Sandra J; Carson, Emily; McArthur, Polly M; Abraham, Cynthia; Silva, Krystle; Davidson, Rebecca; Sharp, Debra; Chadwick, Jessica

2015-01-01

Culturally congruent care is satisfying, meaningful, fits with people's daily lives, and promotes their health and wellbeing. A group of staff nurses identified specific clinical challenges they faced in providing such care for Hispanic and underserved Caucasian children and families in the pediatric medical-surgical unit of an urban regional children's hospital in the southeastern U.S. To address these challenges, an academic-practice partnership was formed between a group of nurse managers and staff nurses at the children's hospital and nursing faculty and graduate students at a local, research-intensive public university. Using the culture care theory, the partners collaborated on a research study to discover knowledge that would help the nursing staff resolve the identified clinical challenges. Twelve families and 12 healthcare providers participated. Data analysis revealed five care factors that participants identified as most valuable: family, faith, communication, care integration, and meeting basic needs. These themes were used to formulate nursing actions that, when applied in daily practice, could facilitate the provision of culturally congruent care for these children and their families. The knowledge generated by this study also has implications for healthcare organizations, nursing educators, and academic-practice partnerships that seek to ensure the delivery of equitable care for all patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Emergency eye care in rural Australia: role of internet.

PubMed

Kumar, S; Yogesan, K; Hudson, B; Tay-Kearney, M-L; Constable, I J

2006-12-01

Significant differences exist in the utilization of emergency eye care services in rural and urban Australia. Meanwhile, influence of internet-based technology in emergency eye care service utilization has not been established. This study aims to demonstrate, from a health provider perspective, an internet-based service's impact on emergency eye care in rural Australia. The teleophthalmology service was initiated in the Carnarvon Regional Hospital (CRH) of the Gascoyne region in Western Australia. A digital, slit lamp and fundus camera were used for the service. Economic data was gathered from the Department of Health of Western Australia (DOHWA), the CRH and the Lions Eye Institute. During the study period (January-December, 2003) 118 persons took part in teleophthalmology consultations. Emergency cases constituted 3% of these consultations. Previous year, there were seven eye-related emergency evacuations (inter-hospital air transfers) from the Gascoyne region to City of Perth. Analysis demonstrates implementation of internet-based health services has a marked impact on rural emergency eye care delivery. Internet is well suited to ophthalmology for the diagnosis and management of acute conditions in remote areas. Integration of such services to mainstream health care is recommended.

Occupational therapy practice in acute physical hospital settings: Evidence from a scoping review.

PubMed

Britton, Lauren; Rosenwax, Lorna; McNamara, Beverley

2015-12-01

Increased accountability and growing fiscal limitations in global health care continue to challenge how occupational therapy practices are undertaken. Little is known about how these changes affect current practice in acute hospital settings. This article reviews the relevant literature to further understanding of occupational therapy practice in acute physical hospital settings. A scoping review of five electronic databases was completed using the keywords Occupational therapy, acute hospital settings/acute physical hospital settings, acute care setting/acute care hospital setting, general medicine/general medical wards, occupational therapy service provision/teaching hospitals/tertiary care hospitals. Criteria were applied to determine suitability for inclusion and the articles were analysed to uncover key themes. In total 34 publications were included in the review. Analysis of the publications revealed four themes: (1) Comparisons between the practice of novice and experienced occupational therapists in acute care (2) Occupational therapists and the discharge planning process (3) Role of occupation in the acute care setting and (4) Personal skills needed and organisation factors affecting acute care practice. The current literature has highlighted the challenges occupational therapists face in practicing within an acute setting. Findings from this review enhance understanding of how occupational therapy department managers and educators can best support staff that practise in acute hospital settings. © 2015 Occupational Therapy Australia.

Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function.

PubMed

Bonnefoy-Cudraz, Eric; Bueno, Hector; Casella, Gianni; De Maria, Elia; Fitzsimons, Donna; Halvorsen, Sigrun; Hassager, Christian; Iakobishvili, Zaza; Magdy, Ahmed; Marandi, Toomas; Mimoso, Jorge; Parkhomenko, Alexander; Price, Susana; Rokyta, Richard; Roubille, Francois; Serpytis, Pranas; Shimony, Avi; Stepinska, Janina; Tint, Diana; Trendafilova, Elina; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zima, Endre; Zukermann, Robert; Lettino, Maddalena

2018-02-01

Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.

Characteristics and respiratory risk profile of children aged less than 5 years presenting to an urban, Aboriginal-friendly, comprehensive primary health practice in Australia.

PubMed

Hall, Kerry K; Chang, Anne B; Anderson, Jennie; Dunbar, Melissa; Arnold, Daniel; O'Grady, Kerry-Ann F

2017-07-01

There are no published data on factors impacting on acute respiratory illness (ARI) among urban Indigenous children. We describe the characteristics and respiratory risk profile of young urban Indigenous children attending an Aboriginal-friendly primary health-care practice. We conducted a cross-sectional analysis of data collected at baseline in a cohort study investigating ARI in urban Indigenous children aged less than 5 years registered with an Aboriginal primary health-care service. Descriptive analyses of epidemiological, clinical, environmental and cultural factors were performed. Logistic regression was undertaken to examine associations between child characteristics and the presence of ARI at baseline. Between February 2013 and October 2015, 180 Indigenous children were enrolled; the median age was 18.4 months (7.7-35), 51% were male. A total of 40 (22%) children presented for a cough-related illness; however, ARI was identified in 33% of all children at the time of enrolment. A total of 72% of children were exposed to environmental tobacco smoke. ARI at baseline was associated with low birthweight (adjusted odds ratio (aOR) 2.54, 95% confidence interval (CI) 1.08-5.94), a history of eczema (aOR 2.67, 95% CI 1.00-7.15) and either having a family member from the Stolen Generation (aOR 3.47, 95% CI 1.33-9.03) or not knowing this family history (aOR 3.35, 95% CI 1.21-9.26). We identified an urban community of children of high socio-economic disadvantage and who have excessive exposure to environmental tobacco smoke. Connection to the Stolen Generation or not knowing the family history may be directly impacting on child health in this community. Further research is needed to understand the relationship between cultural factors and ARI. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Meanings and expressions of care and caring for elders in urban Namibian families: a transcultural nursing study.

PubMed

Leuning, C J; Small, L F; van Dyk, A

2000-09-01

Since Namibia's Independence in 1990, the population of elders--persons 65 years old and older--in urban communities is growing steadily. As such, requests for home health care, health counselling, respite care and residential care for aging members of society are overwhelming nurses and the health care system. This study expands transcultural nursing knowledge by increasing understanding of generic (home-based) patterns of elder care that are practised and lived by urban Namibian families. Guided by Madeleine Leininger's theory of culture care diversity and universality and the ethnonursing research method, emic (insider) meanings and expressions of care and caring for elders in selected urban households have been transposed into five substantive themes. The themes, which depict what carring for elders means to urban families, include: 1 nurturing the health of the family, 2 trusting in the benevolence of life as lived, 3 honouring one's elders, 4 sustaining security and purpose for life amid uncertainty, and 5 living with rapidly changing cultural and social structures. These findings add a voice from the developing world to the evolving body of transcultural nursing knowledge. Synthesis of findings with professional care practices facilitates the creation of community-focussed models for provisioning culturally congruent nursing care to elders and their families in urban Namibia.

Post-acute referral patterns for hospitals and implications for bundled payment initiatives.

PubMed

Lau, Christopher; Alpert, Abby; Huckfeldt, Peter; Hussey, Peter; Auerbach, David; Liu, Hangsheng; Sood, Neeraj; Mehrotra, Ateev

2014-09-01

Under new bundled payment models, hospitals are financially responsible for post-acute care delivered by providers such as skilled nursing facilities (SNFs) and home health agencies (HHAs). The hope is that hospitals will use post-acute care more prudently and better coordinate care with post-acute providers. However, little is known about existing patterns in hospitals׳ referrals to post-acute providers. Post-acute provider referrals were identified using SNF and HHA claims within 14 days following hospital discharge. Hospital post-acute care network size and concentration were estimated across hospital types and regions. The 2008 Medicare Provider Analysis and Review claims for acute hospitals and SNFs, and the 100% HHA Standard Analytic Files were used. The mean post-acute care network size for U.S. hospitals included 57.9 providers with 37.5 SNFs and 23.4 HHAs. The majority of these providers (65.7% of SNFs, 60.9% of HHAs) accounted for 1 percent or less of a hospital׳s referrals and classified as "low-volume". Other post-acute providers we classified as routine. The mean network size for routine providers was greater for larger hospitals, teaching hospitals and in regions with higher per capita post-acute care spending. The average hospital works with over 50 different post-acute providers. Moreover, the size of post-acute care networks varies considerably geographically and by hospital characteristics. These results provide context on the complex task hospitals will face in coordinating care with post-acute providers and cutting costs under new bundled payment models. Copyright © 2014 Elsevier Inc. All rights reserved.

Medicare's post-acute care payment: a review of the issues and policy proposals.

PubMed

Linehan, Kathryn

2012-12-07

Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

Facilitators and barriers to doing workplace mental health research: Case study of acute psychological trauma in a public transit system.

PubMed

Links, Paul S; Bender, Ash; Eynan, Rahel; O'Grady, John; Shah, Ravi

2016-03-10

The Acute Psychological Trauma (APT) Study was a collaboration between an acute care hospital, a specialized multidisciplinary program designed to meet the mental health needs of injured workers, and a large urban public transit system. The overall purpose was to evaluate a Best Practices Intervention (BPI) for employees affected by acute psychological trauma compared to a Treatment as Usual (TAU) group. The specific purpose is to discuss facilitators and barriers that were recognized in implementing and carrying out mental health research in a workplace setting. Over the course of the APT study, a joint implementation committee was responsible for day-to-day study operations and made regular observations on the facilitators and barriers that arose throughout the study. The facilitators to this study included the longstanding relationships among the partners, increased recognition for the need of mental health research in the workplace, and the existence of a community advisory committee. The significant barriers to doing this study of mental health research in the workplace included differences in organizational culture, inconsistent union support, co-interventions, and stigma. Researchers and funding agencies need to be flexible and provide additional resources in order to overcome the barriers that can exist doing workplace mental health research.

Examination of the Use of Healing Touch by Registered Nurses in the Acute Care Setting.

PubMed

Anderson, Joel G; Friesen, Mary Ann; Swengros, Diane; Herbst, Anna; Mangione, Lucrezia

2017-03-01

Acute care nursing is currently undergoing unprecedented change, with health systems becoming more open to nonpharmacological approaches to patient care. Healing Touch (HT) may be a valuable intervention for acute care patients. Research has shown that HT helps both the patient and the caregiver; however, no study to date has examined the impact that the education of nurses in and their use of HT have on daily care delivery in the acute care setting. The purpose of the current qualitative study was to examine the use of HT by registered nurses in the acute care setting during their delivery of patient care, as well as the impact of education in and use of HT on the nurses themselves. Five themes were identified: (1) use of HT techniques, processes, and sequence; (2) outcomes related to HT; (3) integration of HT into acute care nursing practice; (4) perceptions of HT, from skepticism to openness; and (5) transformation through HT. Education in HT and delivery of this modality by nurses in the acute care setting provide nurses with a transformative tool to improve patient outcomes.

Smartphone Use by Nurses in Acute Care Settings.

PubMed

Flynn, Greir Ander Huck; Polivka, Barbara; Behr, Jodi Herron

2018-03-01

The use of smartphones in acute care settings remains controversial due to security concerns and personal use. The purposes of this study were to determine (1) the current rates of personal smartphone use by nurses in acute care settings, (2) nurses' preferences regarding the use of smartphone functionality at work, and (3) nurse perceptions of the benefits and drawbacks of smartphone use at work. An online survey of nurses from six acute care facilities within one healthcare system assessed the use of personal smartphones in acute care settings and perceptions of the benefits and drawbacks of smartphone use at work. Participants (N = 735) were primarily point-of-care nurses older than 31 years. Most participants (98%) used a smartphone in the acute care setting. Respondents perceived the most common useful and beneficial smartphone functions in acute care settings as allowing them to access information on medications, procedures, and diseases. Participants older than 50 years were less likely to use a smartphone in acute care settings and to agree with the benefits of smartphones. There is a critical need for recognition that smartphones are used by point-of-care nurses for a variety of functions and that realistic policies for smartphone use are needed to enhance patient care and minimize distractions.

Recommended care adherence: improved by patient reminder letters but with potential attenuation by the healthcare process complexity.

PubMed

Zhang, Zhou; Fish, Jason

2012-01-01

American adults receive the recommended care just over half of the time for all recommended services. Many patient reminder strategies have attempted to increase the adherence rates for preventative and chronic disease management. However, there is a lack of data available in relation to adherence rates for symptom-specific recommended services and a lack of data identifying any contributions from the organisational structures to these adherence rates. To identify the efficacy and differences in patient reminder letter strategies on various categories of recommended services, as well as to analyse the relationship between a novel quantification of a healthcare system's process complexity with adherence rates. Retrospective cohort study analysing pilot data collected from an urban, academic healthcare provider utilising patient reminder letters. Adults attending one academic medical centre's outpatient practice from 2008 to 2009. Two reminder letters sent chronologically if the recommended care was not completed in the appropriate time frame. Adherence rates of each recommended service at baseline, after first and second reminder letters, and non-adherence rates despite the reminder letter intervention. Process flow complexity was calculated as a composite score combining elements of fastest time to complete routine order, number of different steps in routine order, number of departments involved, and number of sites patients visit. Patient adherence rates increased for all the recommended services after the first reminder letter. Preventative and Chronic Disease Management recommendations demonstrated additional moderate increases after the second reminder letter. Referrals and Radiologogy and Diagnostic Testing (acute, symptom specific) and Labs (acute and nonacute) demonstrated additional minimal adherence rate increases after the second reminder letter. Comparison of the process flow complexity demonstrated an inverse relationship between process complexity and adherence rates, particularly for non-acute orders. One reminder letter seemed to be sufficient for most recommended care. The complexity of the healthcare process may be an important predictive factor for patient adherence.

78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-10

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment... [CMS-1599-P] RIN 0938-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute... capital-related costs of acute care hospitals to implement changes arising from our continuing experience...

Effects of payment changes on trends in post-acute care.

PubMed

Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J

2009-08-01

To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.

Cardiovascular genomics: implications for acute and critical care nurses.

PubMed

Quinn Griffin, Mary T; Klein, Deborah; Winkelman, Chris

2013-01-01

As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.

Acute care surgery: impact on practice and economics of elective surgeons.

PubMed

Miller, Preston R; Wildman, Elizabeth A; Chang, Michael C; Meredith, J Wayne

2012-04-01

The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution. Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons. The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation. Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Differences in health care seeking behaviour between rural and urban communities in South Africa

PubMed Central

2012-01-01

Objective The aim of this study was to explore possible differences in health care seeking behaviour among a rural and urban African population. Design A cross sectional design was followed using the infrastructure of the PURE-SA study. Four rural and urban Setswana communities which represented different strata of urbanisation in the North West Province, South Africa, were selected. Structured interviews were held with 206 participants. Data on general demographic and socio-economic characteristics, health status, beliefs about health and (access to) health care was collected. Results The results clearly illustrated differences in socio-economic characteristics, health status, beliefs about health, and health care utilisation. In general, inhabitants of urban communities rated their health significantly better than rural participants. Although most urban and rural participants consider their access to health care as sufficient, they still experienced difficulties in receiving the requested care. The difference in employment rate between urban and rural communities in this study indicated that participants of urban communities were more likely to be employed. Consequently, participants from rural communities had a significantly lower available weekly budget, not only for health care itself, but also for transport to the health care facility. Urban participants were more than 5 times more likely to prefer a medical doctor in private practice (OR:5.29, 95% CI 2.83-988). Conclusion Recommendations are formulated for infrastructure investments in rural communities, quality of health care and its perception, improvement of household socio-economical status and further research on the consequences of delay in health care seeking behaviour. PMID:22691443

A Conceptual Model for Episodes of Acute, Unscheduled Care.

PubMed

Pines, Jesse M; Lotrecchiano, Gaetano R; Zocchi, Mark S; Lazar, Danielle; Leedekerken, Jacob B; Margolis, Gregg S; Carr, Brendan G

2016-10-01

We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Urban poverty and utilization of maternal and child health care services in India.

PubMed

Prakash, Ravi; Kumar, Abhishek

2013-07-01

Drawing upon data from the third round of the National Family Health Survey (NFHS-3) conducted in India during 2005-06, this study compares the utilization of selected maternal and child health care services between the urban poor and non-poor in India and across selected Indian states. A wealth index was created, separately for urban areas, using Principal Component Analysis to identify the urban poor. The findings suggest that the indicators of maternal and child health care are worse among the urban poor than in their non-poor counterparts. For instance, the levels of antenatal care, safe delivery and childhood vaccinations are much lower among the urban poor than non-poor, especially in socioeconomically disadvantageous states. Among all the maternal and child health care indicators, the non-poor/poor difference is most pronounced for delivery care in the country and across the states. Other than poverty status, utilization of antenatal services by mothers increases the chances of safe delivery and child immunization at both national and sub-national levels. The poverty status of the household emerged as a significant barrier to utilization of health care services in urban India.

Patient dissatisfaction with acute stroke care.

PubMed

Asplund, Kjell; Jonsson, Fredrik; Eriksson, Marie; Stegmayr, Birgitta; Appelros, Peter; Norrving, Bo; Terént, Andreas; Asberg, Kerstin Hulter

2009-12-01

Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

Rural-urban migration in Nigeria: consequences on housing, health-care and employment.

PubMed

Johnnie, P B

1988-01-01

This article explores the results of an on-going longitudinal study in selected high-density areas of Port Harcourt metropolis involving 240 respondents from 4 groups. When respondents in the 1st cohort (watchnights, laborers, and messengers) were asked what motivated them to move from rural areas to the city, 94% said to get better jobs and increase their earnings. 98% of the clerks migrated to Port Harcourt for better jobs and to find employment. All 40 school leavers confirmed that they had moved to the city to find jobs. In spite of the various statutory provisions and policy statements relating to housing in Nigeria there still exists an acute and noticeable shortage both in rural and urban housing. There not only exists a dearth of residential accommodation in these urban centers, but there is also a seemingly atrocious disparity in housing conditions between a large majority of poor urban dwellers and a negligible number of urban residents who are reasonably wealthy. With the growing number of persons migrating from the rural areas to the urban centers, there are also likely to be problems of overcrowding which would exacerbate the problems of communicable diseases and pollution. In terms of the allocation of medical personnel, equipment, and drugs, there is a disproportionately skewed distribution in favor of urban dwellers. 1 important cause of urban employment problems is the phenomenal growth in urbanization and the inability of these urban centers to be able to utilize or absorb the urban labor that was created through the process of urbanization. The other problem is the extremely slow pace of industrialization as compared to urbanization . A serious malady responsible for urban unemployment is the staggering rate at which young school leavers migrate to the city. Nigeria as a nation state has assumed the most dangerous dimensions of capitalism by deliberately erecting inequality and poverty in society. 1 way by which the state, controlled by the bourgeosie, has institutionalized poverty is through the process of generating unemployment. Recently, the government has attempted to create jobs by establishing the Directorate of Employment, but most of its schemes have already existed under other names.

Determinants of Medical and Health Care Expenditure Growth for Urban Residents in China: A Systematic Review Article.

PubMed

Zhu, Xiaolong; Cai, Qiong; Wang, Jin; Liu, Yun

2014-12-01

In recent years, medical and health care consumption has risen, making health risk an important determinant of household spending and welfare. We aimed to examine the determinants of medical and health care expenditure to help policy-makers in the improvement of China's health care system, benefiting the country, society and every household. This paper employs panel data from China's provinces from 2001 to 2011 with all possible economic variations and studies the determinants of medical and healthcare expenditure for urban residents. CPI (consumer price index) of medical services and the resident consumption level of urban residents have positive influence on medical and health care expenditures for urban residents, while the local medical budget, the number of health institutions, the incidence of infectious diseases, the year-end population and the savings of urban residents will not have effect on medical and health care expenditure for urban residents. This paper proposed three relevant policy suggestions for Chinese governments based on the findings of the research.

Timely access to specialist medical oncology services closer to home for rural patients: experience from the Townsville Teleoncology Model.

PubMed

Sabesan, Sabe; Roberts, Lynden J; Aiken, Peter; Joshi, Abhishek; Larkins, Sarah

2014-08-01

Prior to 2009, the teleoncology model of the Townsville Cancer Centre (TCC) did not achieve its aims of equal waiting times for rural and urban patients and the provision of reliable, local acute cancer care. From 2007-2009, 60 new patients from Mt Isa travelled to TCC for their first consultation and their first dose of chemotherapy. Six of these patients required inter-hospital transfers and eight required urgent flights to attend outpatient clinics. Only 50% these rural patients (n = 30) were reviewed within one week of their referral, compared with 90% of Townsville patients. A descriptive study. TCC provides teleoncology services to 21 rural towns; the largest is Mt Isa, Qld. Specialist review of 90% of urgent cases within 24 hours, and 90% of non-urgent cases within one week of referral via videoconferencing. A 50% reduction in inpatient inter-hospital transfers from Mt Isa to Townsville. Employment of a half-time medical officer and a half-time cancer care coordinator, and implementation of new policies. Between 2009 and 2011, TCC provided cancer care to 70 new patients from Mt Isa. Of these new patients, 93% (65/70) were seen within one week of referral. All 17 patients requiring urgent reviews were seen within 24 hours of referral and managed locally thus eliminating the need for inpatient inter-hospital transfers. Provision of timely acute cancer care closer to home requires an increase in the rural case complexity and human resources. © 2014 National Rural Health Alliance Inc.

Delayed Hospital Presentation in Acute Decompensated Heart Failure: Clinical and Patient Reported Factors

PubMed Central

Darling, Chad; Saczynski, Jane S.; McManus, David D.; Lessard, Darleen; Spencer, Frederick A.; Goldberg, Robert J.

2013-01-01

Background Patients with acute decompensated heart failure (ADHF) often wait a considerable amount of time before going to the hospital. Prior studies have examined the reasons why such delays may occur, but additional studies are needed to identify modifiable factors contributing to these delays. Purpose To describe care-seeking delay times, factors associated with prolonged delay, and patient's thoughts and actions in adult men and women hospitalized with ADHF. Methods We surveyed 1,271 patients hospitalized with ADHF at 8 urban medical centers between 2007 and 2010. Results The average age of our study population was 73 years, 47% were female, and 72% had prior heart failure. The median duration of pre-hospital delay prior to hospital presentation was 5.3 hours. Patients who delayed longer than the median were older, more likely to have diabetes, peripheral edema, to have symptoms that began in the afternoon, and to have contacted their medical provider(s) about their symptoms. Prolonged care seekers were less likely to have attributed their symptoms to ADHF, less likely to want to have bothered their doctor or family, and were more likely to be concerned about missing work due to their illness (all p values<0.05). Conclusions Care-seeking delays are common among patients with ADHF. A variety of factors contribute to these delays which in some cases may represent efforts to manage ADHF symptoms at home. More research is needed to better understand the detrimental effects of these delays and how best to encourage timely care-seeking behavior in the setting of ADHF. PMID:23474108

Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit.

PubMed

Fu, Jack B; Lee, Jay; Shin, Ben C; Silver, Julie K; Smith, Dennis W; Shah, Jatin J; Bruera, Eduardo

2017-06-01

Pancytopenia, immunosuppression, and other factors may place patients with multiple myeloma at risk for medical complications. These patients often require inpatient rehabilitation. No previous studies have looked at risk factors for return to the primary acute care service of this patient population. To determine the percentage of and factors associated with return to the primary acute care service of multiple myeloma rehabilitation inpatients. Retrospective review. Acute inpatient rehabilitation unit within a National Cancer Institute Comprehensive Cancer Center. All patients with multiple myeloma admitted to the inpatient rehabilitation unit between March 1, 2004, and February 28, 2015. Return to the primary acute care service was analyzed with demographic information, multiple myeloma characteristics, medications, laboratory values, and hospital admission characteristics. One hundred forty-three inpatient rehabilitation admissions were found during the study period. After we removed multiple admissions of the same patients and planned transfers to the primary acute care service, 122 admissions were analyzed. Thirty-two (26%) patients transferred back to the primary acute care service for unplanned reasons. Multivariate analysis revealed male gender and thrombocytopenia as significantly associated with return to the primary acute care service. The median survival of patients who transferred back to the inpatient primary acute care service was 180 days versus 550 days for those who did not (P < .001). Because of their medical fragility, clinicians caring for rehabilitation inpatients with multiple myeloma should maintain close contact with the primary oncology service. Factors associated with an increased risk of transfer back to the primary acute care service include male gender and thrombocytopenia. IV. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

76 FR 53137 - Bundled Payments for Care Improvement Initiative: Request for Applications

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-25

... (RFA) will test episode-based payment for acute care and associated post-acute care, using both retrospective and prospective bundled payment methods. The RFA requests applications to test models centered around acute care; these models will inform the design of future models, including care improvement for...

Occupational therapy in Australian acute hospitals: A modified practice.

PubMed

Britton, Lauren; Rosenwax, Lorna; McNamara, Beverley

2016-08-01

Ongoing changes to health-care funding Australia wide continue to influence how occupational therapists practise in acute hospitals. This study describes the practice challenges experienced by Western Australian acute care occupational therapists. Then, it explores if and how acute care occupational therapists are modifying their practice in response to these practice changes. This study used a qualitative grounded theory approach. Semi-structured interviews were completed with 13 purposively selected acute care occupational therapists from four Western Australian metropolitan hospitals. Data were analysed using a constant comparative method to provide detailed descriptions of acute care occupational therapy practice and to generate theory. Five conceptual categories were developed. The first two addressed practice challenges: pragmatic organisational influences on client care and establishing a professional identity within the multidisciplinary team. Three categories related to therapist responses are as follows: becoming the client advocate, being the facilitator and applying clinical reasoning. Finally, modified practice was identified as the core category which explains the process whereby acute care occupational therapists are ensuring they remain relevant and authentic in the acute care context. Western Australian acute care occupational therapists are practising in a highly complex health context that presents many challenges. They are responding by using a modified form of practice that ensures occupational therapy skills remain relevant within the narrow confines of this health setting. © 2016 Occupational Therapy Australia.

Effects of Payment Changes on Trends in Post-Acute Care

PubMed Central

Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J

2009-01-01

Objective To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Data Sources Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. Study Design We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. Data Extraction Methods A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Principal Findings Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Conclusions Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites. PMID:19490159

The "leap forward" in nursing home development in urban China: future policy directions.

PubMed

Shum, Michelle H Y; Lou, Vivian W Q; He, Kelly Z J; Chen, Coco C H; Wang, Junfang

2015-09-01

In the past decade, the number of nursing beds in China has increased annually by an average of 10%, reaching 4.3 million in 2013. Although the State Council pushed for further increases to a ratio of 30 nursing home beds per 1000 persons by 2015, service utilization, quality assurance, and regulatory oversight are the inherent challenges in developing an equitable long-term care (LTC) system that can safeguard older persons' rights. We review and analyze both laws and policies in light of demographic and socioeconomic changes and advocate 3 policy directions for LTC development in China: allocating LTC resources with comprehensive eligibility criteria, with particular consideration of family needs; establishing viable quality standards for outcome-driven evaluation; and highlighting standardized monitoring mechanisms in both institutional and home LTC settings. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Model for equitable care and outcomes for remote full care hemodialysis units.

PubMed

Bernstein, Keevin; Zacharias, James; Blanchard, James F; Yu, B Nancy; Shaw, Souradet Y

2010-04-01

Remotely located patients not living close to a nephrologist present major challenges for providing care. Various models of remotely delivered care have been developed, with a gap in knowledge regarding the outcomes of these heterogeneous models. This report describes a satellite care model for remote full-care hemodialysis units managed homogenously in the province of Manitoba, Canada, without onsite nephrologists. Survival in remotely located full-care units is compared with a large, urban full-care center with onsite nephrologists. Data from a Canadian provincial dialysis registry were extracted on 2663 patients between 1990 and 2005. All-cause mortality after initiation of chronic hemodialysis was assessed with Cox proportional hazards regression. Both short-term (1 year) and long-term (2 to 5 years) survival were analyzed. Survival for patients receiving remotely delivered care was shown to be better than for those receiving care in the urban care center with this particular Canadian model of care. Furthermore, there was no difference when assessing short- and long-term survival. This was independent of distance from the urban center. Chronic hemodialysis patients receiving remotely delivered care in a specialized facility attain comparable, if not better survival outcomes than their urban counterparts with direct onsite nephrology care. This model can potentially be adapted to other underserviced areas, including increasingly larger urban centers.

Urban College Student Self-Report of Hookah Use with Health Care Providers

ERIC Educational Resources Information Center

Jani, Samir Ranjit; Brown, Darryl; Berhane, Zekarias; Peter, Nadja; Solecki, Susan; Turchi, Renee

2018-01-01

Objective: This study's purpose was to describe urban college students' communication about hookah with health care providers. Participants: Participants included a random sample of undergraduate urban college students and health care providers. Methods: Students surveyed determined the epidemiology of hookah use in this population, how many…

[Comparison of Patients and their Care in Urban and Rural Specialised Palliative Home Care - A Single Service Analysis].

PubMed

Heckel, M; Stiel, S; Frauendorf, T; Hanke, R M; Ostgathe, C

2016-07-01

Specialised outpatient palliative care teams (in Germany called SAPV) aim to ensure best possible end-of-life care for outpatients with complex needs. Information on the influence of living areas (rural vs. urban) on patient and care related aspects is rare. This study aims to explore differences between palliative care patients in urban and rural dwellings concerning their nursing and service characteristics. A retrospective data analysis of documentary data for 502 patients supplied by SAPV team from December 2009 to June 2012 was conducted. Patients and care characteristics were investigated by frequency analysis and were compared for both groups of urban and rural dwelling patients (T test, Chi², Fisher's exact test p < 0.05). 387 complete data sets could be included. Urban (n=197) and rural (n=190) dwelling patients were almost equally sized groups. The mean age of the whole sample was 74.5 years, 55.3% were female. Most patients were diagnosed with cancer (76.8%). No significant differences in urban and rural dwelling patients concerning most demographics, care, disease and service related aspects of palliative home care could be detected. An exception is that the rate of re-admittance to hospital is higher for rural dwelling patients (Fisher's exact test p=0.022). Although predominantly presumed, the single service analysis shows - except for the re-admittance rate to hospital - no considerable differences between palliative care patients regarding their living area. Our findings indicate that patients cared for in rural and urban settings have similar needs and impose similar requirements on palliative care teams. © Georg Thieme Verlag KG Stuttgart · New York.

Pediatric acute gastroenteritis: understanding caregivers' experiences and information needs.

PubMed

Albrecht, Lauren; Hartling, Lisa; Scott, Shannon D

2017-05-01

Pediatric acute gastroenteritis (AGE) is a common condition with high health care utilization, persistent practice variation, and substantial family burden. An initial approach to resolve these issues is to understand the patient/caregiver experience of this illness. The objective of this study was to describe caregivers' experiences of pediatric AGE and identify their information needs, preferences, and priorities. A qualitative, descriptive study was conducted. Caregivers of a child with AGE were recruited for this study in the pediatric emergency department (ED) at a tertiary hospital in a major urban centre. Individual interviews were conducted (n=15), and a thematic analysis of interview transcripts was completed using a hybrid inductive/deductive approach. Five major themes were identified and described: 1) caregiver management strategies; 2) reasons for going to the ED; 3) treatment and management of AGE in the ED; 4) caregivers' information needs; and 5) additional factors influencing caregivers' experiences and decision-making. A number of subthemes within each major theme were identified and described. This qualitative descriptive study has identified caregiver information needs, preferences, and priorities regarding pediatric AGE. This study also identified inconsistencies in the treatment and management of pediatric AGE at home and in the ED that influence health care utilization and patient outcomes related to pediatric AGE.

Healthcare-seeking behaviors for acute respiratory illness in two communities of Java, Indonesia: a cross-sectional survey

PubMed Central

Praptiningsih, Catharina Y.; Lafond, Kathryn E.; Wahyuningrum, Yunita; Storms, Aaron D.; Mangiri, Amalya; Iuliano, Angela D.; Samaan, Gina; Titaley, Christiana R.; Yelda, Fitra; Kreslake, Jennifer; Storey, Douglas; Uyeki, Timothy M.

2017-01-01

Understanding healthcare-seeking patterns for respiratory illness can help improve estimations of disease burden and inform public health interventions to control acute respiratory disease in Indonesia. The objectives of this study were to describe healthcare-seeking behaviors for respiratory illnesses in one rural and one urban community in Western Java, and to explore the factors that affect care seeking. From February 8, 2012 to March 1, 2012, a survey was conducted in 2520 households in the East Jakarta and Bogor districts to identify reported recent respiratory illnesses, as well as all hospitalizations from the previous 12-month period. We found that 4% (10% of those less than 5 years) of people had respiratory disease resulting in a visit to a healthcare provider in the past 2 weeks; these episodes were most commonly treated at government (33%) or private (44%) clinics. Forty-five people (0.4% of those surveyed) had respiratory hospitalizations in the past year, and just over half of these (24/45, 53%) occurred at a public hospital. Public health programs targeting respiratory disease in this region should account for care at private hospitals and clinics, as well as illnesses that are treated at home, in order to capture the true burden of illness in these communities. PMID:26930154

Healthcare-seeking behaviors for acute respiratory illness in two communities of Java, Indonesia: a cross-sectional survey.

PubMed

Praptiningsih, Catharina Y; Lafond, Kathryn E; Wahyuningrum, Yunita; Storms, Aaron D; Mangiri, Amalya; Iuliano, Angela D; Samaan, Gina; Titaley, Christiana R; Yelda, Fitra; Kreslake, Jennifer; Storey, Douglas; Uyeki, Timothy M

2016-06-01

Understanding healthcare-seeking patterns for respiratory illness can help improve estimations of disease burden and inform public health interventions to control acute respiratory disease in Indonesia. The objectives of this study were to describe healthcare-seeking behaviors for respiratory illnesses in one rural and one urban community in Western Java, and to explore the factors that affect care seeking. From February 8, 2012 to March 1, 2012, a survey was conducted in 2520 households in the East Jakarta and Bogor districts to identify reported recent respiratory illnesses, as well as all hospitalizations from the previous 12-month period. We found that 4% (10% of those less than 5years) of people had respiratory disease resulting in a visit to a healthcare provider in the past 2weeks; these episodes were most commonly treated at government (33%) or private (44%) clinics. Forty-five people (0.4% of those surveyed) had respiratory hospitalizations in the past year, and just over half of these (24/45, 53%) occurred at a public hospital. Public health programs targeting respiratory disease in this region should account for care at private hospitals and clinics, as well as illnesses that are treated at home, in order to capture the true burden of illness in these communities. Published by Elsevier Ltd.

Reconfiguration of acute care hospitals in post-socialist Serbia: spatial distribution of hospital beds.

PubMed

Matejic, Marko

2017-04-01

In the context of healthcare reforms in post-socialist Serbia, this research analyses the reconfiguration of acute care hospitals from the aspect of the spatial distribution of hospital beds among and within state-owned hospitals. The research builds a relationship between the macro or national level and the micro or hospital level of the spatial distribution of hospital beds. The aim of the study is to point out that a high level of efficiency in hospital functionality is difficult to achieve within the current hospital network and architectural-urban patterns of hospitals, and to draw attention to the necessity of a strategically planned hospital spatial reconfiguration, conducted simultaneously with other segments of the healthcare system reform. The research analyses published and unpublished data presented in tables and diagrams. The theoretical platform of the research covers earlier discussions of the Yugoslav healthcare system, its post-socialist reforms and the experiences of developed countries. The results show that the hospital bed distribution has not undergone significant changes, while the hospital spatial reconfiguration has either not been carried out at all or, if it has, only on a small scale. All this has contributed to overall inadequate, inflexible, inefficient, defragmented and unequal bed distribution. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Costs of terminal patients who receive palliative care or usual care in different hospital wards.

PubMed

Simoens, Steven; Kutten, Betty; Keirse, Emmanuel; Berghe, Paul Vanden; Beguin, Claire; Desmedt, Marianne; Deveugele, Myriam; Léonard, Christian; Paulus, Dominique; Menten, Johan

2010-11-01

In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards. A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data. Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward. This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.

Acute Respiratory Failure in Cardiac Transplant Recipients.

PubMed

Komurcu, Ozgur; Ozdemirkan, Aycan; Camkiran Firat, Aynur; Zeyneloglu, Pinar; Sezgin, Atilla; Pirat, Arash

2015-11-01

This study sought to evaluate the incidence, risk factors, and outcomes of acute respiratory failure in cardiac transplant recipients. Cardiac transplant recipients >15 years of age and readmitted to the intensive care unit after cardiac transplant between 2005 and 2015 were included. Thirty-nine patients were included in the final analyses. Patients with acute respiratory failure and without acute respiratory failure were compared. The most frequent causes of readmission were routine intensive care unit follow-up after endomyocardial biopsy, heart failure, sepsis, and pneumonia. Patients who were readmitted to the intensive care unit were further divided into 2 groups based on presence of acute respiratory failure. Patients' ages and body weights did not differ between groups. The groups were not different in terms of comorbidities. The admission sequential organ failure assessment scores were higher in patients with acute respiratory failure. Patients with acute respiratory failure were more likely to use bronchodilators and n-acetylcysteine before readmission. Mean peak inspiratory pressures were higher in patients in acute respiratory failure. Patients with acute respiratory failure developed sepsis more frequently and they were more likely to have hypotension. Patients with acute respiratory failure had higher values of serum creatinine before admission to intensive care unit and in the first day of intensive care unit. Patients with acute respiratory failure had more frequent bilateral opacities on chest radiographs and positive blood and urine cultures. Duration of intensive care unit and hospital stays were not statistically different between groups. Mortality in patients with acute respiratory failure was 76.5% compared with 0% in patients without acute respiratory failure. A significant number of cardiac transplant recipients were readmitted to the intensive care unit. Patients presenting with acute respiratory failure on readmission more frequently developed sepsis and hypotension, suggesting a poorer prognosis.

The choice and preference for public-private health care among urban residents in China: evidence from a discrete choice experiment.

PubMed

Tang, Chengxiang; Xu, Judy; Zhang, Meng

2016-10-18

Public health care dominated the services provision in China before 1980s. However, the number of private health care providers in China has been increasing since then. The growth of private hospitals escalated after a market-oriented reform was implemented in 2001. Through an experimental approach, this study aims to a better understanding of the dynamic change in preference of health care utilisation among the residents in urban China. Based on a discrete choice experiment (DCE) from a random sample of respondents in urban China, the study evaluated preference over health care attributes affecting individuals' choice for the utilisation of hospital health care. The marginal willingness-to-pay for five health care attributes was estimated, including public/private provision of health care, by analysing mixed logit and latent class models. The results indicated a significantly negative marginal willingness-to-pay for private health care, which was interpreted as representing people's previous interactions with the health care system. The latent class model further suggested preference heterogeneity across our sample. We found that Hukou type, a typical indicator of socioeconomic background, was significantly related to respondents' preference for health care utilisation. Permanent urban residents (urban Hukou) valued private health care less; in contrast rural migrants (rural Hukou) were more likely to be indifferent between public/private provision. Urban residents in China showed a high disposition to obtain health care from the public providers of health care. Our results have implications in the context of the Chinese government attempts to expand the private health care sector in the short term. Policy makers need to consider residents' preference for health care in health policy development as the preference can only change in the long term.

The Australian National Sub-Acute and Non-Acute Patient casemix classification.

PubMed

Eagar, K

1999-01-01

The Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) Version 1 casemix classification was completed in 1997. AN-SNAP is designed for the classification of sub-acute and non-acute care provided in both inpatient and ambulatory settings and is intended to be useful for both funding and clinical management purposes. The National Sub-Acute and Non-Acute Casemix Classification study has produced the first version of a national classification of sub-acute and non-acute care. Ongoing refinement (leading to Version 2) will be possible through further analysis of the existing data set in combination with analysis of the results of a carefully planned and phased implementation.

Hypodermoclysis therapy. In a chronic care hospital setting.

PubMed

Worobec, G; Brown, M K

1997-06-01

Occasionally, elderly patients experience acute, episodic incidents of illness that result in dehydration or a high potential for dehydration (e.g., flu, diarrhea). At times, patients may be unable, or refuse, to take fluids orally. Enteral routes via a nasogastric tube or enteral stomach tube may also not be available. In the past, these patients often had to be transferred from home or long-term care facilities to an acute care hospital for intravenous therapy. A transfer of the acutely ill elderly patient to an acute care hospital is often very stressful to the patient and his/her family and is costly to the health care delivery system. Hypodermoclysis, the process of rehydrating a patient by providing isotonic fluids into the subcutaneous tissues over a short time period, provides an alternative method to deal with acute, short-term fluid deficit problems in the elderly. Hypodermoclysis therapy can be administered in a chronic care setting thus potentially decreasing the need to transfer the elderly client to an acute care hospital. The purpose of this study was to investigate the use of hypodermoclysis therapy in solving acute, or potentially acute fluid deficit problems, that were anticipated to be both reversible and short term in nature. This was carried out in an elderly population that resided in a 284-bed chronic care hospital in southern Ontario.

Determinants of Medical and Health Care Expenditure Growth for Urban Residents in China: A Systematic Review Article

PubMed Central

ZHU, Xiaolong; CAI, Qiong; WANG, Jin; LIU, Yun

2014-01-01

In recent years, medical and health care consumption has risen, making health risk an important determinant of household spending and welfare. We aimed to examine the determinants of medical and health care expenditure to help policy-makers in the improvement of China’s health care system, benefiting the country, society and every household. This paper employs panel data from China’s provinces from 2001 to 2011 with all possible economic variations and studies the determinants of medical and healthcare expenditure for urban residents. CPI (consumer price index) of medical services and the resident consumption level of urban residents have positive influence on medical and health care expenditures for urban residents, while the local medical budget, the number of health institutions, the incidence of infectious diseases, the year-end population and the savings of urban residents will not have effect on medical and health care expenditure for urban residents. This paper proposed three relevant policy suggestions for Chinese governments based on the findings of the research. PMID:26171351

Differential effectiveness of depression disease management for rural and urban primary care patients.

PubMed

Adams, Scott J; Xu, Stanley; Dong, Fran; Fortney, John; Rost, Kathryn

2006-01-01

Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations. To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling). A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study. Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients. Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.

Stress among nurses working in emergency, anesthesiology and intensive care units depends on qualification: a Job Demand-Control survey.

PubMed

Trousselard, Marion; Dutheil, Frédéric; Naughton, Geraldine; Cosserant, Sylvie; Amadon, Sylvie; Dualé, Christian; Schoeffler, Pierre

2016-02-01

The nurse stress literature reports an overwhelming culture of acceptance and expectation of work stressors, ironically linked to the control of the workplace to effectively and proactively manage stress. The stressors involved in delivering "stress management" have been well studied in nursing-related workplaces, especially in acute care settings in accordance with the Karasek Job Demand-Control-Support (JDCS) model. However, little is known about the effects of specificity of an acute care unit and the level of qualifications on stress experienced by nurses. A survey using the JDCS model was conducted among 385 nurses working in three different acute care units (anesthesiology, emergency and intensive care unit) from a university hospital. Specific questions explored variables such as gender, acute care units, level of qualification and working experience. Two hundred questionnaires were returned. A high level of job strain was highlighted without a gender effect and in the absence of isostrain. Nurses from acute care units were located in the high stress quadrant of the JDCS model. Conversely, other nurses were commonly located in the "active" quadrant. Independent of acute care settings, the highest level of education was associated with the highest job strain and the lowest level of control. In an acute care setting, a high level of education was a key factor for high job stress and was associated with a perception of a low control in the workplace, both of which may be predictors of adverse mental health. In particular, the lack of control has been associated with moral distress, a frequently reported characteristic of acute care settings. To enhance the personal and professional outcomes of the advanced registered nurses, strategies for supporting nurses manage daily stressors in acute care are urgently required.

An Empirical Analysis of Rural-Urban Differences in Out-Of-Pocket Health Expenditures in a Low-Income Society of China.

PubMed

Wang, Lidan; Wang, Anjue; Zhou, Detong; FitzGerald, Gerry; Ye, Dongqing; Jiang, Qicheng

2016-01-01

The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China.

An Empirical Analysis of Rural-Urban Differences in Out-Of-Pocket Health Expenditures in a Low-Income Society of China

PubMed Central

Wang, Lidan; Wang, Anjue; Zhou, Detong; FitzGerald, Gerry; Ye, Dongqing; Jiang, Qicheng

2016-01-01

Objective The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. Method Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. Result Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. Conclusion A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China. PMID:27223811

Modeling the Urban Boundary and Canopy Layers

EPA Science Inventory

Today, we are confronted with increasingly more sophisticated application requirements for urban modeling. These include those that address emergency response to acute exposures from toxic releases, health exposure assessments from adverse air quality, energy usage, and character...

77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-03

... Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality... entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

Interprofessional communication failures in acute care chains: How can we identify the causes?

PubMed

van Leijen-Zeelenberg, Janneke E; van Raak, Arno J A; Duimel-Peeters, Inge G P; Kroese, Mariëlle E A L; Brink, Peter R G; Vrijhoef, Hubertus J M

2015-01-01

Although communication failures between professionals in acute care delivery occur, explanations for these failures remain unclear. We aim to gain a deeper understanding of interprofessional communication failures by assessing two different explanations for them. A multiple case study containing six cases (i.e. acute care chains) was carried out in which semi-structured interviews, physical artifacts and archival records were used for data collection. Data were entered into matrices and the pattern-matching technique was used to examine the two complementary propositions. Based on the level of standardization and integration present in the acute care chains, the six acute care chains could be divided into two categories of care processes, with the care chains equally distributed among the categories. Failures in communication occurred in both groups. Communication routines were embedded within organizations and descriptions of communication routines in the entire acute care chain could not be found. Based on the results, failures in communication could not exclusively be explained by literature on process typology. Literature on organizational routines was useful to explain the occurrence of communication failures in the acute care chains. Organizational routines can be seen as repetitive action patterns and play an important role in organizations, as most processes are carried out by means of routines. The results of this study imply that it is useful to further explore the role of organizational routines on interprofessional communication in acute care chains to develop a solution for failures in handover practices.

Acute care nurse practitioners in trauma care: results of a role survey and implications for the future of health care delivery.

PubMed

Noffsinger, Dana L

2014-01-01

The role of acute care nurse practitioners (ACNPs) in trauma care has evolved over time. A survey was performed with the aim of describing the role across the United States. There were 68 respondents who depicted the typical trauma ACNP as being a 42-year-old woman who works full-time at a level I American College of Surgeons verified trauma center. Trauma ACNPs typically practice with 80% of their time for clinical care and are based on a trauma and acute care surgery service. They are acute care certified and hold several advanced certifications to supplement their nursing license.

Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study.

PubMed

Hincapié, Cesar A; Tomlinson, George A; Côté, Pierre; Rampersaud, Y Raja; Jadad, Alejandro R; Cassidy, J David

2017-10-16

Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery. Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits. 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.

The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition.

PubMed

Chavez, Laura J; Liu, Chuan-Fen; Tefft, Nathan; Hebert, Paul L; Devine, Beth; Bradley, Katharine A

2017-10-01

Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.

Patients' view of retail clinics as a source of primary care: boon for nurse practitioners?

PubMed

Ahmed, Arif; Fincham, Jack E

2011-04-01

To estimate consumer utilities associated with major attributes of retail clinics (RCs). A discrete choice experiment (DCE) with 383 adult residents of the metropolitan statistical areas in Georgia conducted via Random Digit Dial survey of households. The DCE had two levels each of four attributes: price ($59; $75), appointment wait time (same day; 1 day or more), care setting-provider combination (nurse practitioner [NP]-RC; physician-private office), and acute illness (urinary tract infection; influenza), resulting in 16 choice scenarios. The respondents indicated whether they would seek care under each scenario. Cost savings and convenience offered by RCs are attractive to urban patients, and given sufficient cost savings they are likely to seek care there. All else equal, one would require cost savings of at least $30.21 to seek care from an NP at RC rather than a physician at private office, and $83.20 to wait one day or more. Appointment wait time is a major determinant of care-seeking decisions for minor illnesses. The size of the consumer utility associated with the convenience feature of RCs indicates that there is likely to be further growth and employment opportunities for NPs in these clinics. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.

Quality geriatric care as perceived by nurses in long-term and acute care settings.

PubMed

Barba, Beth Ellen; Hu, Jie; Efird, Jimmy

2012-03-01

This study focused on differences in nurses' satisfaction with the quality of care of older people and with organisational characteristics and work environment in acute care and long-term care settings. Numerous studies have explored links between nurses' satisfaction with care and work environments on the one hand and a variety of physical, behavioural and psychological reactions of nurses on the other. One key to keeping nurses in the workplace is a better understanding of nurses' satisfaction with the quality of care they provide. Descriptive design. The self-selected sample included 298 registered nurses and licensed practical nurses who provide care to minority, underserved and disadvantaged older populations in 89 long-term care and <100 bed hospitals in 38 rural counties and eight metropolitan areas in a Southern state. All completed the Agency Geriatric Nursing Care survey, which consisted of a 13-item scale measuring nurses' satisfaction with the quality of geriatric care in their practice settings and an 11-item scale examining obstacles to providing quality geriatric care. Demographic variables were compared with chi-square. Independent t-tests were used to examine differences between nurses in long-term care and acute care settings. Significant differences were found in level of satisfaction and perceived obstacles to providing quality care to older adults between participants from acute and long-term care. Participants in long-term care had greater satisfaction with the quality of geriatric care than those in acute facilities. Nurses in long-term care were more satisfied that care was evidence-based; specialised to individual needs of older adults; promoted autonomy and independence of elders; and was continuous across settings. Participants in acute facilities perceived more obstacles to providing quality geriatric care than nurses in long-term care facilities. Modification of hospital geriatric practice environments and leadership commitment to evidence-based practice guidelines that promote autonomy and independence of patients and staff could improve acute care nurses' perceptions of quality of geriatric care. © 2011 Blackwell Publishing Ltd.

Patients with acute abdominal pain describe their experiences of fundamental care across the acute care episode: a multi-stage qualitative case study.

PubMed

Jangland, Eva; Kitson, Alison; Muntlin Athlin, Åsa

2016-04-01

To explore how patients with acute abdominal pain describe their experiences of fundamental care across the acute care episode. Acute abdominal pain is one of the most common conditions to present in the acute care setting. Little is known about how patients' fundamental care needs are managed from presentation to post discharge. A multi-stage qualitative case study using the Fundamentals of Care framework as the overarching theoretical and explanatory mechanism. Repeated reflective interviews were conducted with five adult patients over a 6-month period in 2013 at a university hospital in Sweden. The interviews (n = 14) were analysed using directed content analysis. Patients' experiences across the acute care episode are presented as five patient narratives and synthesized into five descriptions of the entire hospital journey. The patients talked about the fundamentals of care and had vivid accounts of what they meant to them. The experiences of each of the patients were influenced by the extent to which they felt engaged with the health professionals. The ability to engage or build a rapport was identified as a central component across the fundamental care elements, but it varied in visibility. Consistent pain management, comfort, timely and accurate information, choice and dignity and relationships were identified as essential fundamental care needs of patients experiencing acute abdominal pain regardless of setting, diagnosis, or demographic variables. These were variously achieved and the patients' narratives raised areas for improvement in several areas. © 2016 John Wiley & Sons Ltd.

Length of stay and medical stability for spinal cord-injured patients on admission to an inpatient rehabilitation hospital: a comparison between a model SCI trauma center and non-SCI trauma center.

PubMed

Ploumis, A; Kolli, S; Patrick, M; Owens, M; Beris, A; Marino, R J

2011-03-01

Retrospective database review. To compare lengths of stay (LOS), pressure ulcers and readmissions to the acute care hospital of patients admitted to the inpatient rehabilitation facility (IRF) from a model spinal cord injury (SCI) trauma center or from a non-SCI acute hospital. Only sparse data exist comparing the status of patients admitted to IRF from a model SCI trauma center or from a non-SCI acute hospital. Acute care, IRF and total LOS were compared between patients transferred to IRF from the SCI center (n=78) and from non-SCI centers (n=131). The percentages of pressure ulcers on admission to IRF and transfer back to acute care were also compared. Patients admitted to IRF from the SCI trauma center (SCI TC) had significantly shorter (P=0.01) acute care LOS and total LOS compared with patients admitted from non-SCI TCs. By neurological category, acute-care LOS was less for all groups admitted from the SCI center, but statistically significant only for tetraplegia. There was no significant difference in the incidence of readmissions to acute care from IRF. More patients from non-SCI centers (34%) than SCI centers (12%) had pressure ulcers (P<0.001). Acute care in organized SCI TCs before transfer to IRF can significantly lower acute-care LOS or total LOS and incidence of pressure ulcers compared with non-SCI TCs. Patients admitted to IRF from SCI TCs are no more likely to be sent back to an acute hospital than those from non-SCI TCs.

Health and Health Care Access of Rural Women Veterans: Findings From the National Survey of Women Veterans.

PubMed

Cordasco, Kristina M; Mengeling, Michelle A; Yano, Elizabeth M; Washington, Donna L

2016-09-01

Disparities in health and health care access between rural and urban Americans are well documented. There is evidence that these disparities are mirrored within the US veteran population. However, there are few studies assessing this issue among women veterans (WVs). Using the 2008-2009 National Survey of Women Veterans, a population-based cross-sectional national telephone survey, we examined rural WVs' health and health care access compared to urban WVs. We measured health using the Medical Outcomes Study Short-Form (SF-12); access using measures of regular source of care (RSOC), health care utilization, and unmet needs; and barriers to getting needed care. Rural WVs have significantly worse physical health functioning compared to urban WVs (mean physical component score of 43.6 for rural WVs versus 47.2 for urban WVs; P = .007). Rural WVs were more likely to have a VA RSOC (16.4% versus 10.6%; P = .009) and use VA health care (21.7% versus 12.9%; P < .001), and had fewer non-VA health care visits compared with urban WVs (mean 4.2 versus 5.9; P = .021). They had similar overall numbers of health care visits (mean 5.8 versus 7.1; P = .11 ). Access barriers were affordability for rural WVs and work release time for urban WVs. Rural WVs additionally reported that transportation was a major factor affecting health care decisions. Our findings demonstrate VA's crucial role in addressing disparities in health and health care access for rural WVs. As VA continues to strive to optimally meet the needs of all WVs, innovative care models need to account for their high health care needs and persistent barriers to care. © 2016 National Rural Health Association.

Urban-Rural Differences in Health-Care-Seeking Pattern of Residents of Abia State, Nigeria, and the Implication in the Control of NCDs.

PubMed

Onyeonoro, Ugochukwu U; Ogah, Okechukwu S; Ukegbu, Andrew U; Chukwuonye, Innocent I; Madukwe, Okechukwu O; Moses, Akhimiem O

2016-01-01

Understanding the differences in care-seeking pattern is key in designing interventions aimed at improving health-care service delivery, including prevention and control of noncommunicable diseases. The aim of this study was to identify the differences and determinants of care-seeking patterns of urban and rural residents in Abia State in southeast Nigeria. This was a cross-sectional, community-based, study involving 2999 respondents aged 18 years and above. Data were collected using the modified World Health Organization's STEPS questionnaire, including data on care seeking following the onset of illness. Descriptive statistics and logistic regressions were used to analyze care-seeking behavior and to identify differences among those seeking care in urban and rural areas. In both urban and rural areas, patent medicine vendors (73.0%) were the most common sources of primary care following the onset of illness, while only 20.0% of the participants used formal care. Significant predictors of difference in care-seeking practices between residents in urban and rural communities were educational status, income, occupation, and body mass index. Efforts should be made to reduce barriers to formal health-care service utilization in the state by increasing health insurance coverage, strengthening the health-care system, and increasing the role of patent medicine vendors in the formal health-care delivery system.

Comparative characteristics of the home care nursing services used by community-dwelling older people from urban and rural environments.

PubMed

Borowiak, Ewa; Kostka, Tomasz

2013-06-01

To compare home care nursing services use by community-dwelling older people from urban and rural environments in Poland. In the current literature, there is a lack of data based on multidimensional geriatric assessment concerning the provision of care delivered by nurses for older people from urban and rural environments. Cross-sectional random survey. Between 2006-2010, a random sample of 935 older people (over 65 years of age) from an urban environment and 812 from a neighbouring rural environment were interviewed in a cross-sectional survey. The rural dwellers (82·8%) nominated their family members as care providers more often than the city inhabitants (51·2%). Home nursing care was provided to 4·1% of people in the city and 6·5% in the county. Poststroke condition, poor nutritional status, and low physical activity level, as well as low scores for activities of daily living, instrumental activities of daily living, and Mini-Mental State Examination values, were all determinants of nursing care, both in urban and rural areas. In the urban environment, additional predictors of nursing care use were age, presence of ischaemic heart disease, diabetes and respiratory disorders, number of medications taken, and a high depression score. Poor functional status is the most important determinant of nursing care use in both environments. In the urban environment, a considerable proportion of community-dwelling elders live alone. In the rural environment, older people usually have someone available for potential care services. The main problem seems to be seeking nursing care only in advanced deterioration of functional status. © 2012 Blackwell Publishing Ltd.

Creating learning momentum through overt teaching interactions during real acute care episodes.

PubMed

Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R

2015-10-01

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Effect of residence on mothers' health care seeking behavior for common childhood illness in Northwest Ethiopia: a community based comparative cross--sectional study.

PubMed

Gelaw, Yalemzewod Assefa; Biks, Gashaw Andargie; Alene, Kefyalew Addis

2014-10-08

Children are at higher risk of acquiring infections and developing severe disease. This study assessed the health care seeking behavior and associated factors of urban and rural mothers for common childhood illness in Northwest Ethiopia. A comparative community based cross-sectional study was conducted among urban and rural mothers living in the district. A multistage sampling technique was used to select the study participants. A pre-tested and structured questioner via interview was used to collect the data. Binary logistic regression analysis was used to identify associated factors. Odds ratio with 95% CI was computed to assess the strength of the associations. A total of 827 (274 urban and 553 rural) mothers were interviewed. Among these, 79.3% (95% CI: (76.5%, 82.06%)) of the mothers were sought health care in the district. Health care seeking behavior was higher among urban mothers (84.6%) than rural mothers (76.7%). Marital status, completion health extension package, and sex of child were significantly associated with health care seeking behavior of urban mothers. Whereas age of child, age and occupation of mothers, educational level of fathers, wealth quintile, and type of reported illness were significantly associated with rural mothers. Perceived severity of illness was significantly associated with both urban and rural mothers for health care seeking behavior. The overall health seeking behaviors of mothers for common childhood illness was high. However, urban mothers seek health care more than rural. Socio Economic position and types of reported illness has an effect for health seeking behavior of rural mothers. Whereas child sex preference and graduation status for health extension package has an effect for health care seeking behavior of urban mothers. Work on strengthen accessibility of health care services in the rural mothers and increase awareness of mothers about the disadvantage of sex preferences will improve the health care seek behavior of families regardless of the severity of illness and types of illnesses.

Rural Implications of Medicare's Post-Acute-Care Transfer Payment Policy

ERIC Educational Resources Information Center

Schoenman, Julie A.; Mueller, Curt D.

2005-01-01

Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the…

75 FR 23851 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-04

... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... operating and capital-related costs of acute care hospitals to implement changes arising from our continuing... changes to the amounts and factors used to determine the rates for Medicare acute care hospital inpatient...

Urinary NGAL in patients with and without acute kidney injury in a cardiology intensive care unit

PubMed Central

Watanabe, Mirian; Silva, Gabriela Fulan e; da Fonseca, Cassiane Dezoti; Vattimo, Maria de Fatima Fernandes

2014-01-01

Objective To assess the diagnostic and prognostic efficacy of urine neutrophil gelatinase-associated lipocalin in patients admitted to an intensive care unit. Methods Longitudinal, prospective cohort study conducted in a cardiology intensive care unit. The participants were divided into groups with and without acute kidney injury and were followed from admission to the intensive care unit until hospital discharge or death. Serum creatinine, urine output and urine neutrophil gelatinase-associated lipocalin were measured 24 and 48 hours after admission. Results A total of 83 patients admitted to the intensive care unit for clinical reasons were assessed, most being male (57.8%). The participants were divided into groups without acute kidney injury (N=18), with acute kidney injury (N=28) and with severe acute kidney injury (N=37). Chronic diseases, mechanical ventilation and renal replacement therapy were more common in the groups with acute kidney injury and severe acute kidney injury, and those groups exhibited longer intensive care unit stay and hospital stay and higher mortality. Serum creatinine did not change significantly in the group with acute kidney injury within the first 24 hours of admission to the intensive care unit, although, urine neutrophil gelatinase-associated lipocalin was high in the groups with acute kidney injury and severe acute kidney injury (p<0.001). Increased urine neutrophil gelatinase-associated lipocalin was associated with death. Conclusion An increase in urine neutrophil gelatinase-associated lipocalin precedes variations in serum creatinine in patients with acute kidney injury and may be associated with death. PMID:25607262

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.

PubMed

Hall, Rasheeda K; Toles, Mark; Massing, Mark; Jackson, Eric; Peacock-Hinton, Sharon; O'Hare, Ann M; Colón-Emeric, Cathleen

2015-03-06

Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home. This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome. Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use. Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed. Copyright © 2015 by the American Society of Nephrology.

Acute care teaching in the undergraduate nursing curriculum.

PubMed

McGaughey, Jennifer

2009-01-01

To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards. Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum. PRACTICE DEVELOPMENT INITIATIVE: An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module. Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care. The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.

Medicare's bundling pilot: including post-acute care services.

PubMed

Dummit, Laura A

2011-03-28

Fee-for-service Medicare, in which a separate payment is made for each service, rewards health care providers for delivering more services, but not necessarily coordinating those services over time or across settings. To help address these concerns, the Patient Protection and Affordable Care Act of 2010 requires Medicare to experiment with making a bundled payment for a hospitalization plus post-acute care, that is, the recuperative or rehabilitative care following a hospital discharge. This bundled payment approach is intended to promote more efficient care across the acute/post-acute episode because the entity that receives the payment has financial incentives to keep episode costs below the payment. Although the entity is expected to control costs through improved care coordination and efficiency, it could stint on care or avoid expensive patients instead. This issue brief focuses on the unique challenges posed by the inclusion of post-acute care services in a payment bundle and special considerations in implementing and evaluating the episode payment approach.

Getting Out of Silos: An Innovative Transitional Care Curriculum for Internal Medicine Residents Through Experiential Interdisciplinary Learning

PubMed Central

Schoenborn, Nancy L.; Christmas, Colleen

2013-01-01

Background Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines. Intervention We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions. Setting/Participants Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics. Program Description The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises. Program Evaluation The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum. Conclusions Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior. PMID:24455024

Acute respiratory distress syndrome: an audit of incidence and outcome in Scottish intensive care units.

PubMed

Hughes, M; MacKirdy, F N; Ross, J; Norrie, J; Grant, I S

2003-09-01

This prospective audit of incidence and outcome of the acute respiratory distress syndrome was conducted as part of the national audit of intensive care practice in Scotland. All patients with acute respiratory distress syndrome in 23 adult intensive care units were identified using the diagnostic criteria defined by the American-European Consensus Conference. Daily data collection was continued until death or intensive care unit discharge. Three hundred and sixty-nine patients were diagnosed with acute respiratory distress syndrome over the 8-month study period. The frequency of acute respiratory distress syndrome in the intensive care unit population was 8.1%; the incidence in the Scottish population was estimated at 16.0 cases.100,000(-1).year(-1). Intensive care unit mortality for acute respiratory distress syndrome was 53.1%, with a hospital mortality of 60.9%. In our national unselected population of critically ill patients, the overall outcome is comparable with published series (Acute Physiology and Chronic Health Evaluation II standardised mortality ratio = 0.99). However, mortality from acute respiratory distress syndrome in Scotland is substantially higher than in recent other series suggesting an improvement in outcome in this condition.

Delayed emergency department presentation in critically ill patients.

PubMed

Rodriguez, R M; Passanante, M; Phelps, M A; Dresden, G; Kriza, K; Carrasco, M; Franklin, J

2001-12-01

To determine the frequency and causes of delayed emergency department presentation in critically ill patients who did not have acute myocardial infarction and to evaluate whether factors such as age, gender, prior medical advice, lack of insurance, or low educational level are associated with delayed presentation. Prospective, descriptive analysis. Emergency department and medical intensive care unit of an urban county hospital. All adult patients admitted from the emergency department to the medical intensive care unit for reasons other than unstable angina, acute myocardial infarction, or stroke over two 9-wk blocks. Within 72 hrs of intensive care unit admission, patients or their families were interviewed to determine time elapsed between the onset of symptoms and patient emergency department presentation and to elicit reasons for delays in seeking medical treatment. We interviewed 155 of 173 (90%) of eligible patients and found that 58% waited >24 hrs before presenting to the emergency department. The most commonly cited primary reason for delays were beliefs that symptoms were not serious enough for emergency care (31%) and that symptoms would resolve spontaneously (29%). Most (55%) sought medical treatment only at the urging of family members or other advocates. Although variables such as lack of insurance and low educational level were not associated with delayed presentation, male gender and having sought medical advice before presenting to the emergency department were significantly associated with delay (p =.036 for each). Because of poor understanding of the gravity and natural progression of their symptoms, most critically ill patients waited >24 hrs to present to our emergency department. Education on warning symptom recognition for serious illnesses may be warranted not only for patients themselves but also for family members and caregivers.

Regionalization of surgical services in central Florida: the next step in acute care surgery.

PubMed

Block, Ernest F J; Rudloff, Beth; Noon, Charles; Behn, Bruce

2010-09-01

There is a national loss of access to surgeons for emergencies. Contributing factors include reduced numbers of practicing general surgeons, superspecialization, reimbursement issues, emphasis on work and life balance, and medical liability. Regionalizing acute care surgery (ACS), as exists for trauma care, represents a potential solution. The purpose of this study is to assess the financial and resources impact of transferring all nontrauma ACS cases from a community hospital (CH) to a trauma center (TC). We performed a case mix and financial analysis of patient records with ACS for a rural CH located near an urban Level I TC. ACS patients were analyzed for diagnosis, insurance status, procedures, and length of stay. We estimated physician reimbursement based on evaluation and management codes and procedural CPT codes. Hospital revenues were based on regional diagnosis-related group rates. All third-party remuneration was set at published Medicare rates; self-pay was set at nil. Nine hundred ninety patients were treated in the CH emergency department with 188 potential surgical diseases. ACS was necessary in 62 cases; 25.4% were uninsured. Extrapolated to 12 months, 248 patients would generate new TC physician revenue of >$155,000 and hospital profits of >$1.5 million. CH savings for call pay and other variable costs are >$100,000. TC operating room volume would only increase by 1%. Regionalization of ACS to TCs is a viable option from a business perspective. Access to care is preserved during an approaching crisis in emergency general surgical coverage. The referring hospital is relieved of an unfavorable payer mix and surgeon call problems. The TC receives a new revenue stream with limited impact on resources by absorbing these patients under its fixed costs, saving the CH variable costs.

Health Care Seeking Behavior of Persons with Acute Chagas Disease in Rural Argentina: A Qualitative View.

PubMed

Llovet, Ignacio; Dinardi, Graciela; Canevari, Cecilia; Torabi, Nahal

2016-01-01

Chagas disease (CD) is a tropical parasitic disease largely underdiagnosed and mostly asymptomatic affecting marginalized rural populations. Argentina regularly reports acute cases of CD, mostly young individuals under 14 years old. There is a void of knowledge of health care seeking behavior in subjects experiencing a CD acute condition. Early treatment of the acute case is crucial to limit subsequent development of disease. The article explores how the health outcome of persons with acute CD may be conditioned by their health care seeking behavior. The study, with a qualitative approach, was carried out in rural areas of Santiago del Estero Province, a high risk endemic region for vector transmission of CD. Narratives of 25 in-depth interviews carried out in 2005 and 2006 are analyzed identifying patterns of health care seeking behavior followed by acute cases. Through the retrospective recall of paths for diagnoses, weaknesses of disease information, knowledge at the household level, and underperformance at the provincial health care system level are detected. The misdiagnoses were a major factor in delaying a health care response. The study results expose lost opportunities for the health care system to effectively record CD acute cases.

Health Care Seeking Behavior of Persons with Acute Chagas Disease in Rural Argentina: A Qualitative View

PubMed Central

Dinardi, Graciela; Canevari, Cecilia; Torabi, Nahal

2016-01-01

Chagas disease (CD) is a tropical parasitic disease largely underdiagnosed and mostly asymptomatic affecting marginalized rural populations. Argentina regularly reports acute cases of CD, mostly young individuals under 14 years old. There is a void of knowledge of health care seeking behavior in subjects experiencing a CD acute condition. Early treatment of the acute case is crucial to limit subsequent development of disease. The article explores how the health outcome of persons with acute CD may be conditioned by their health care seeking behavior. The study, with a qualitative approach, was carried out in rural areas of Santiago del Estero Province, a high risk endemic region for vector transmission of CD. Narratives of 25 in-depth interviews carried out in 2005 and 2006 are analyzed identifying patterns of health care seeking behavior followed by acute cases. Through the retrospective recall of paths for diagnoses, weaknesses of disease information, knowledge at the household level, and underperformance at the provincial health care system level are detected. The misdiagnoses were a major factor in delaying a health care response. The study results expose lost opportunities for the health care system to effectively record CD acute cases. PMID:27829843

Urban American Indian/Alaskan Natives Compared to Non-Indians in Out-of-Home Care

ERIC Educational Resources Information Center

Carter, Vernon B.

2011-01-01

Historically, American Indian/Alaskan Native (AI/AN) children have been disproportionately represented in the foster care system. In this study, nationally representative child welfare data from October 1999 was used to compare urban AI/AN children to non-Indian children placed into out-of-home care. Compared to non-Indian children, urban AI/AN…

Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States.

PubMed

Caldwell, Julia T; Ford, Chandra L; Wallace, Steven P; Wang, May C; Takahashi, Lois M

2016-08-01

To examine whether living in a rural versus urban area differentially exposes populations to social conditions associated with disparities in access to health care. We linked Medical Expenditure Panel Survey (2005-2010) data to geographic data from the American Community Survey (2005-2009) and Area Health Resource File (2010). We categorized census tracts as rural and urban by using the Rural-Urban Commuting Area Codes. Respondent sample sizes ranged from 49 839 to 105 306. Outcomes were access to a usual source of health care, cholesterol screening, cervical screening, dental visit within recommended intervals, and health care needs met. African Americans in rural areas had lower odds of cholesterol screening (odds ratio[OR] = 0.37; 95% confidence interval[CI] = 0.25, 0.57) and cervical screening (OR = 0.48; 95% CI = 0.29, 0.80) than African Americans in urban areas. Whites had fewer screenings and dental visits in rural versus urban areas. There were mixed results for which racial/ethnic group had better access. Rural status confers additional disadvantage for most of the health care use measures, independently of poverty and health care supply.

Acute care research: is it ethical?

PubMed

Iserson, K V; Mahowald, M B

1992-07-01

Research in acute care is a troubling area for Institutional Review Board (IRB) approval and informed consent. Confusion about ethical and legal requirements has hampered research efforts and subsequent patient benefits. Acute care patients are the relatively few critical care patients who have suffered unexpected events that carry a high probability of mortality or severe morbidity unless immediate medical intervention is provided. We argue that acute care research is justified if the usual ethical requirements for research are modified to reflect the uniqueness of the situation. Our recommendations are to: a) use an explicit definition of acute care as distinct from other modes of critical care; b) eliminate the requirement for informed consent (as it is usually understood); and c) require stringent IRB oversight, regarding the unique ethical problems raised by this area of research. We further suggest that IRB oversight includes review of the protocol by a panel of individuals who represent possible enrollees in the proposed study.

Burn unit care of Stevens Johnson syndrome/toxic epidermal necrolysis: A survey.

PubMed

Le, Hong-Gam; Saeed, Hajirah; Mantagos, Iason S; Mitchell, Caroline M; Goverman, Jeremy; Chodosh, James

2016-06-01

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a systemic disease that can be associated with debilitating acute and chronic complications across multiple organ systems. As patients with acute SJS/TEN are often treated in a burn intensive care unit (BICU), we surveyed burn centers across the United States to determine their approach to the care of these patients. The goal of our study was to identify best practices and possible variations in the care of patients with acute SJS/TEN. We demonstrate that the method of diagnosis, use of systemic therapies, and involvement of subspecialists varied significantly between burn centers. Beyond supportive care provided to every patient, our data highlights a lack of standardization in the acute care of patients with SJS/TEN. A comprehensive guideline for the care of patients with acute SJS/TEN is indicated. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings.

PubMed

Pian, Linping; Gillman, Lawrence M; McBeth, Paul B; Xiao, Zhengwen; Ball, Chad G; Blaivas, Michael; Hamilton, Douglas R; Kirkpatrick, Andrew W

2013-01-01

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, "nontraditional" providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

Comparative analysis of the expected demands for nursing care services among older people from urban, rural, and institutional environments

PubMed Central

Borowiak, Ewa; Kostka, Joanna; Kostka, Tomasz

2015-01-01

Background Demand for nursing and social services may vary depending on the socio-demographic variables, health status, receipt of formal and informal care provided, and place of residence. Objectives To conduct a comparative analysis of the expectations of older people from urban, rural, and institutional environments concerning nursing care with respect to the care provided and elements of a comprehensive geriatric assessment. Material and methods The study comprised 2,627 individuals above the age of 65 years living in urban (n=935) and rural (n=812) areas as well as nursing homes (n=880). Results Family care was most often expected both in urban (56.6%) and rural (54.7%) environments, followed by care provided simultaneously by a family and nurse (urban – 18.8%; rural – 26.1%) and realized only by a nurse (urban – 24.6%; rural – 19.2%). Not surprisingly, nursing home residents most commonly expected nursing care (57.5%) but 33.1% preferred care provided by family or friends and neighbors. In the whole cohort of people living in the home environment (n=1,718), those living with family demonstrated willingness to use primarily care implemented by the family (62.0%), while respondents living alone more often expected nursing services (30.3%). In the logistic regression model, among the respondents living in the city, only the form of care already received determined the expectations for nursing care. Among the respondents living in the county, the presence of musculoskeletal disorders, better nutritional status, and current care provided by family decreased expectations for nursing care. Higher cognitive functioning, symptoms of depression, and living alone increased the willingness to obtain nursing care. Conclusion Older inhabitants of urban areas, rural areas, and those residing in institutions have different expectations for individual nursing care. Nearly 45% of seniors living in the community expect to obtain nursing care, while only 1.6% do not expect any social or nursing help. While the expectations for the provision of nursing care are significantly increased by living alone, they are decreased by having access to care provided by family. Support for families to take care of elderly relatives would appear to be essential for an effective nursing and social care system. PMID:25673980

Late Intensive Care Unit Admission in Liver Transplant Recipients: 10-Year Experience.

PubMed

Atar, Funda; Gedik, Ender; Kaplan, Şerife; Zeyneloğlu, Pınar; Pirat, Arash; Haberal, Mehmet

2015-11-01

We evaluated late intensive care unit admission in liver transplant recipients to identify incidences and causes of acute respiratory failure in the postoperative period and to compare these results with results in patients who did not have acute respiratory failure. We retrospectively screened the data of 173 consecutive adult liver transplant recipients from January 2005 through March 2015 to identify patients with late admission (> 30 d posttransplant) to an intensive care unit. Patients were divided into 2 groups: patients with and without acute respiratory failure. Acute respiratory failure was defined as severe dyspnea, respiratory distress, decreased oxygen saturation, hypoxemia or hypercapnia on room air, or need for noninvasive or invasive mechanical ventilation. Demographic, laboratory, clinical, and respiratory data were collected. Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Sequential Organ Failure Assessment scores; lengths of intensive care unit and hospital stays; and hospital mortality were assessed. Among 173 patients, 37 (21.4%) were admitted to an intensive care unit, including 22 (59.5%) with acute respiratory failure. The leading cause of acute respiratory failure was pneumonia (n = 19, 86.4%). Patients with acute respiratory failure had significantly lower levels of albumin before intensive care unit admission (P = .003). In patients with acute respiratory failure, severe sepsis and septic shock were more frequently observed and tracheotomy was more frequently performed (P = .041). Acute respiratory failure developed in 59.5% of liver transplant recipients with late intensive care unit admission. The leading cause was pneumonia, with this group of patients having higher requirements for invasive mechanical ventilation and tracheotomy, longer stays in an intensive care unit, and higher mortality.

The Relative Importance of Post-Acute Care and Readmissions for Post-Discharge Spending.

PubMed

Huckfeldt, Peter J; Mehrotra, Ateev; Hussey, Peter S

2016-10-01

To understand what patterns of health care use are associated with higher post-hospitalization spending. Medicare hospital, skilled nursing, inpatient rehabilitation, and home health agency claims, and Medicare enrollment data from 2007 and 2008. For 10 common inpatient conditions, we calculated variation across hospitals in price-standardized and case mix-adjusted Medicare spending in the 30 days following hospital discharge. We estimated the fraction of spending differences between low- and high-spending hospitals attributable to readmissions versus post-acute care, and within post-acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use. We identified index hospital claims and examined hospital and post-acute care occurring within a 30-day period following hospital discharge. For each Medicare Severity Diagnosis-Related Group (MS-DRG) at each hospital, we calculated average price-standardized Medicare payments for readmissions, SNFs, IRFs, and post-acute care overall (also including home health agencies and long-term care hospitals). There was extensive variation across hospitals in Medicare spending in the 30 days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS-DRGs. The proportion of differences attributable to readmissions versus post-acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post-acute care spending. There was also variation in the relative importance of the type of post-acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in post-acute care spending In contrast, for pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post-acute spending. Through initiatives such as bundled payment, hospitals are financially responsible for spending in the post-hospitalization period. The key driver of variation in post-hospitalization spending varied greatly across conditions. For some conditions, the key driver was having a readmission, for others it was whether patients receive any post-acute care, and for others the key driver was the type of post-acute care. These findings may help hospitals implement strategies to reduce post-discharge spending. © Health Research and Educational Trust.

Appropriateness of bed usage for inpatients admitted as emergencies to internal medicine services.

PubMed

Armstrong, S H; Peden, N R; Nimmo, S; Alcorn, M

2001-11-01

To establish the appropriateness of bed usage for acute care within the medical directorates of two district general hospitals using a validated assessment tool, the Emergency Admission Review (EAR). This tool assesses the appropriateness of day of care against strict criteria and allows classification of care as either acute or non-acute. Prospectively, 200 medical emergency admissions, 100 in each of the hospitals, were selected. Following identification patients were assessed every two days during the first fortnight of admission or until discharge. Those patients staying longer than two weeks were then assessed weekly until conclusion of the audit period or discharge whichever was reached first. The medical directorates of two District General Hospitals within one acute NHS trust. All patients admitted as medical emergencies, who were 14 years or older and had a length of stay of 24 hours or more. A total of 787 acute in-patient bed days were analysed in Hospital A of which 363 (46%) were deemed inappropriate for acute care. In Hospital B 810 bed days were analysed and 44% (363) were deemed inappropriate. In Hospital A the most common reason for bed-days not meeting the acute care criteria was short-term waiting, accounting for 60% (217 days) of the total bed days deemed non-acute. In Hospital B the most common reason for patients receiving non-acute care was that they were having active rehabilitation. This accounted for 29% (105 days) of the total number of non-acute care days. In Hospital B three patients accounted for 28% of the total occupied bed days. The use of the EAR is a systematic and objective approach to the assessment of appropriateness of acute care. It applies strict criteria to determine the reason for a patient's continued hospital stay. From the results it is clear that a significant proportion of medical emergency admissions in both Hospital A and B remain in hospital for care that is deemed non-acute and therefore in theory could be performed in another setting. This information has significant potential in identifying the opportunities for streamlining services within hospitals to reduce short-term delays and also to inform the development of intermediate care services both within and outwith the acute hospital setting.

Short-term outcomes of seniors aged 80 years and older with acute illness: hospitalist care by geriatricians and other internists compared.

PubMed

Ding, Yew Yoong; Sun, Yan; Tay, Jam Chin; Chong, Wai Fung

2014-10-01

Although acute geriatric units have improved the outcomes of hospitalized seniors, it is uncertain as to whether hospitalist care by geriatricians outside of these units confers similar benefit. To determine whether hospitalist care by geriatricians reduces short-term mortality and readmission, and length of stay (LOS) for seniors aged 80 years and older with acute medical illnesses compared with care by other internists. Retrospective cohort study using administrative and chart review data on demographic, admission-related, and clinical information of hospital episodes. General internal medicine department of an acute-care hospital in Singapore from 2005 to 2008. Seniors aged 80 years and older with specific focus on 2 subgroups with premorbid functional impairment and acute geriatric syndromes. Hospitalist care by geriatricians compared with care by other internists. Hospital mortality, 30-day mortality or readmission, and LOS. For 1944 hospital episodes (intervention: 968, control: 976), there was a nonsignificant trend toward lower hospital mortality (15.5% vs 16.9%) but not 30-day mortality or readmission, or LOS for care by geriatricians compared with care by other internists. A marginally stronger trend toward lower hospital mortality for care by geriatricians among those with acute geriatric syndromes (20.2% vs 23.1%) was observed. Similar treatment effects were found after adjustment for demographic, admission-related, and clinical factors. For seniors aged 80 years and over with acute medical illness, hospitalist care by geriatricians did not significantly reduce short-term mortality, readmission, or LOS, compared with care by other internists. © 2014 Society of Hospital Medicine.

Key stakeholder perceptions regarding acute care psychiatry in distressed publicly funded mental health care markets.

PubMed

Frueh, B Christopher; Grubaugh, Anouk L; Lo Sasso, Anthony T; Jones, Walter J; Oldham, John M; Lindrooth, Richard C

2012-01-01

The role of acute care inpatient psychiatry, public and private, has changed dramatically since the 1960s, especially as recent market forces affecting the private sector have had ripple effects on publicly funded mental health care. Key stakeholders' experiences, perceptions, and opinions regarding the role of acute care psychiatry in distressed markets of publicly funded mental health care were examined. A qualitative research study was conducted using semi-structured thematic interviews with 52 senior mental health system administrators, clinical directors and managers, and nonclinical policy specialists. Participants were selected from markets in six regions of the United States that experienced recent significant closures of acute care psychiatric beds. Qualitative data analyses yielded findings that clustered around three sets of higher order themes: structure of care, service delivery barriers, and outcomes. Structure of care suggests that acute care psychiatry is seen as part of a continuum of services; service delivery barriers inhibit effective delivery of services and are perceived to include economic, regulatory, and political factors; outcomes include fragmentation of mental health care services across the continuum, the shift of mental health care to the criminal justice system, and market-specific issues affecting mental health care. Findings delineate key stakeholders' perceptions regarding the role acute care psychiatry plays in the continuum of care for publicly funded mental health and suggest that public mental health care is inefficacious. Results carry implications for policy makers regarding strategies/policies to improve optimal utilization of scarce resources for mental health care, including greater focus on psychotherapy.

Key stakeholder perceptions regarding acute care psychiatry in distressed publicly funded mental health care markets

PubMed Central

Frueh, B. Christopher; Grubaugh, Anouk L.; Lo Sasso, Anthony T.; Jones, Walter J.; Oldham, John M.; Lindrooth, Richard C.

2017-01-01

The role of acute care inpatient psychiatry, public and private, has changed dramatically since the 1960s, especially as recent market forces affecting the private sector have had ripple effects on publicly funded mental health care. Key stakeholders’ experiences, perceptions, and opinions regarding the role of acute care psychiatry in distressed markets of publicly funded mental health care were examined. A qualitative research study was conducted using semi-structured thematic interviews with 52 senior mental health system administrators, clinical directors and managers, and nonclinical policy specialists. Participants were selected from markets in six regions of the United States that experienced recent significant closures of acute care psychiatric beds. Qualitative data analyses yielded findings that clustered around three sets of higher order themes: structure of care, service delivery barriers, and outcomes. Structure of care suggests that acute care psychiatry is seen as part of a continuum of services; service delivery barriers inhibit effective delivery of services and are perceived to include economic, regulatory, and political factors; outcomes include fragmentation of mental health care services across the continuum, the shift of mental health care to the criminal justice system, and market-specific issues affecting mental health care. Findings delineate key stakeholders’ perceptions regarding the role acute care psychiatry plays in the continuum of care for publicly funded mental health and suggest that public mental health care is inefficacious. Results carry implications for policy makers regarding strategies/policies to improve optimal utilization of scarce resources for mental health care, including greater focus on psychotherapy. PMID:22409204

The Sepsis Early Recognition and Response Initiative (SERRI)

PubMed Central

Jones, Stephen L.; Ashton, Carol M.; Kiehne, Lisa; Gigliotti, Elizabeth; Bell-Gordon, Charyl; Pinn, Teresa T.; Tran, Shirley K.; Nicolas, Juan C.; Rose, Alexis L.; Shirkey, Beverly A.; Disbot, Maureen; Masud, Faisal; Wray, Nelda P.

2016-01-01

Duration of Initiative 48 months and currently ongoing. Setting The Houston Methodist Hospital System and affiliated hospitals (3 facilities with 2 hospital-run skilled nursing facilities in and around Houston), St. Joseph’s Regional Health Center (1 acute care hospital and 2 skilled nursing facilities in Bryan, Texas), Hospital Corporation of America (2 acute care facilities in Houston, 1 acute care facility in McAllen, Texas [Rio Grande Valley]), Kindred Healthcare (2 long term acute care facilities in Houston), Select Medical Specialty Hospitals (2 long term acute care facilities in Houston). Whom This Should Concern Hospital administrators, quality and safety officers, performance improvement and patient safety professionals, clinic managers, infection control and prevention staff, and other physicians, nurses, and clinical staff. PMID:26892701

Delays in accessing electroconvulsive therapy: a comparison between two urban and two rural populations in Australia.

PubMed

Johnston, Natalie E

2015-10-01

A comparison of the timing, rates and characteristics of electroconvulsive therapy use between urban and rural populations. The medical records of patients who received an acute course of electroconvulsive therapy at two rural and two urban psychiatric hospitals in New South Wales (NSW), Australia, in 2010 were reviewed retrospectively. Main outcome measures were the time from symptom onset, diagnosis and admission to commencing electroconvulsive therapy. Rates of use of electroconvulsive therapy were also compared between rural and urban hospitals using NSW statewide data. There was a significant delay in the time it took for rural patients to receive electroconvulsive therapy compared with urban patients when measured both from the time of symptom onset and from when they received a diagnosis. There were corresponding delays in the time taken for rural patients to be admitted to hospital compared with urban patients. There was no difference in the time it took to commence electroconvulsive therapy once a patient was admitted to hospital. NSW statewide urban-rural comparisons showed rates of electroconvulsive therapy treatment were significantly higher in urban hospitals. Patients in rural areas receive electroconvulsive therapy later in their acute illness due to delays in being admitted to hospital. The rate of use of electroconvulsive therapy also differs geographically. © The Royal Australian and New Zealand College of Psychiatrists 2015.

An evidence-based approach to case management model selection for an acute care facility: is there really a preferred model?

PubMed

Terra, Sandra M

2007-01-01

This research seeks to determine whether there is adequate evidence-based justification for selection of one acute care case management model over another. Acute Inpatient Hospital. This article presents a systematic review of published case management literature, resulting in classification specific to terms of level of evidence. This review examines the best available evidence in an effort to select an acute care case management model. Although no single case management model can be identified as preferred, it is clear that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and to form a foundation for the efficacy of hospital case management practice. Although no single case management model can be identified as preferred, this systematic review demonstrates that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and forming a foundation for the efficacy of hospital case management practice. Distinctive aspects of case management frameworks can be used to guide the development of an acute care case management model. The study illustrates: * The effectiveness of case management when there is direct patient contact by the case manager regardless of disease condition: not only does the quality of care increase but also length of stay (LOS) decreases, care is defragmented, and both patient and physician satisfaction can increase. * The preferred case management models result in measurable outcomes that can directly relate to, and demonstrate alignment with, organizational strategy. * Acute care management programs reduce cost and LOS, and improve outcomes. * An integrated case management program that includes social workers, as well as nursing, is the most effective acute care management model. * The successful case management model will recognize physicians, as well as patients, as valued customers with whom partnership can positively affect financial outcomes in terms of reduction in LOS, improvement in quality, and delivery of care.

Newborn care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study.

PubMed

Moran, Allisyn C; Choudhury, Nuzhat; Uz Zaman Khan, Nazib; Ahsan Karar, Zunaid; Wahed, Tasnuva; Faiz Rashid, Sabina; Alam, M Ashraful

2009-11-17

Urbanization is occurring at a rapid pace, especially in low-income countries. Dhaka, Bangladesh, is estimated to grow to 50 million by 2015, with 21 million living in urban slums. Although health services are available, neonatal mortality is higher in slum areas than in urban non-slum areas. The Manoshi program works to improve maternal, newborn, and child health in urban slums in Bangladesh. This paper describes newborn care practices in urban slums in Dhaka and provides program recommendations. A quantitative baseline survey was conducted in six urban slum areas to measure newborn care practices among recently delivered women (n = 1,256). Thirty-six in-depth semi-structured interviews were conducted to explore newborn care practices among currently pregnant women (n = 18) and women who had at least one delivery (n = 18). In the baseline survey, the majority of women gave birth at home (84%). Most women reported having knowledge about drying the baby (64%), wrapping the baby after birth (59%), and cord care (46%). In the in-depth interviews, almost all women reported using sterilized instruments to cut the cord. Babies are typically bathed soon after birth to purify them from the birth process. There was extensive care given to the umbilical cord including massage and/or applying substances, as well as a variety of practices to keep the baby warm. Exclusive breastfeeding was rare; most women reported first giving their babies sweet water, honey and/or other foods. These reported newborn care practices are similar to those in rural areas of Bangladesh and to urban and rural areas in the South Asia region. There are several program implications. Educational messages to promote providing newborn care immediately after birth, using sterile thread, delaying bathing, and ensuring dry cord care and exclusive breastfeeding are needed. Programs in urban slum areas should also consider interventions to improve social support for women, especially first time mothers. These interventions may improve newborn survival and help achieve MDG4.

Access to Expert Stroke Care with Telemedicine: REACH MUSC

PubMed Central

Kazley, Abby Swanson; Wilkerson, Rebecca C.; Jauch, Edward; Adams, Robert J.

2012-01-01

Stroke is a leading cause of death and disability, and recombinant tissue plasminogen activator (rtPA) can significantly reduce the long-term impact of acute ischemic stroke (AIS) if given within 3 h of symptom onset. South Carolina is located in the “stroke belt” and has a high rate of stroke and stroke mortality. Many small rural SC hospitals do not maintain the expertise needed to treat AIS patients with rtPA. MUSC is an academic medical center using REACH MUSC telemedicine to deliver stroke care to 15 hospitals in the state, increasing the likelihood of timely treatment with rtPA. The purpose of this study is to determine the increase in access to rtPA through the use of telemedicine for AIS in the general population and in specific segments of the population based on age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. We used a retrospective cross-sectional design examining Census data from 2000 and geographic information systems analysis to identify South Carolina residents that live within 30 or 60 min of a primary stroke center (PSC) or a REACH MUSC site. We include all South Carolina citizens in our analysis and specifically examine the population’s age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. Our sample includes 4,012,012 South Carolinians. The main measure is access to expert stroke care at a PSC or a REACH MUSC hospital within 30 or 60 min. We find that without REACH MUSC, only 38% of the population has potential access to expert stroke care in SC within 60 min given that most PSCs will maintain expert stroke coverage. REACH MUSC allows 76% of the population to be within 60 min of expert stroke care, and 43% of the population to be within 30 min drive time of expert stroke care. These increases in access are especially significant for groups that have faced disparities in care and high rates of AIS. The use of telemedicine can greatly increase access to care for residents throughout South Carolina. PMID:22461780

Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components: A Systematic Review and Meta-Analysis

PubMed Central

Fox, Mary T; Persaud, Malini; Maimets, Ilo; O'Brien, Kelly; Brooks, Dina; Tregunno, Deborah; Schraa, Ellen

2012-01-01

Objectives To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care. Design Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources. Setting Acute care geriatric and nongeriatric hospital units. Participants Acutely ill or injured adults (N = 6,839) with an average age of 81. Interventions Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment. Measurements Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions. Results Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29–0.88), less delirium (RR = 0.73, 95% CI = 0.61–0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78–0.97), shorter length of hospital stay (weighted mean difference (WMD) = −0.61, 95% CI = −1.16 to −0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68–0.99), lower costs (WMD = −$245.80, 95% CI = −$446.23 to −$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01–1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions. Conclusion Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system-level outcomes. PMID:23176020

Teleneurology applications

PubMed Central

Wechsler, Lawrence R.; Tsao, Jack W.; Levine, Steven R.; Swain-Eng, Rebecca J.; Adams, Robert J.; Demaerschalk, Bart M.; Hess, David C.; Moro, Elena; Schwamm, Lee H.; Steffensen, Steve; Stern, Barney J.; Zuckerman, Steven J.; Bhattacharya, Pratik; Davis, Larry E.; Yurkiewicz, Ilana R.; Alphonso, Aimee L.

2013-01-01

Objective: To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. Methods: Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. Results: Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. Conclusions: Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology. PMID:23400317

Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology.

PubMed

Wechsler, Lawrence R; Tsao, Jack W; Levine, Steven R; Swain-Eng, Rebecca J; Adams, Robert J; Demaerschalk, Bart M; Hess, David C; Moro, Elena; Schwamm, Lee H; Steffensen, Steve; Stern, Barney J; Zuckerman, Steven J; Bhattacharya, Pratik; Davis, Larry E; Yurkiewicz, Ilana R; Alphonso, Aimee L

2013-02-12

To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.

Post-acute care and vertical integration after the Patient Protection and Affordable Care Act.

PubMed

Shay, Patrick D; Mick, Stephen S

2013-01-01

The anticipated changes resulting from the passage of the Patient Protection and Affordable Care Act-including the proposed adoption of bundled payment systems and the promotion of accountable care organizations-have generated considerable controversy as U.S. healthcare industry observers debate whether such changes will motivate vertical integration activity. Using examples of accountable care organizations and bundled payment systems in the American post-acute healthcare sector, this article applies economic and sociological perspectives from organization theory to predict that as acute care organizations vary in the degree to which they experience environmental uncertainty, asset specificity, and network embeddedness, their motivation to integrate post-acute care services will also vary, resulting in a spectrum of integrative behavior.

Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.

PubMed

Beaudoin, Francesca L; Lin, Charlie; Guan, Wentao; Merchant, Roland C

2014-11-01

Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients. A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration < 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured. Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p < 0.02). The SPIDs for the ketamine groups were similar (p < 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness. Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations. © 2014 by the Society for Academic Emergency Medicine.

Childhood urinary tract infection in primary care: a prospective observational study of prevalence, diagnosis, treatment, and recovery.

PubMed

Butler, Christopher C; O'Brien, Kathryn; Pickles, Timothy; Hood, Kerenza; Wootton, Mandy; Howe, Robin; Waldron, Cherry-Ann; Thomas-Jones, Emma; Hollingworth, William; Little, Paul; Van Der Voort, Judith; Dudley, Jan; Rumsby, Kate; Downing, Harriet; Harman, Kim; Hay, Alastair D

2015-04-01

The prevalence of targeted and serendipitous treatment for, and associated recovery from, urinary tract infection (UTI) in pre-school children is unknown. To determine the frequency and suspicion of UTI in children who are acutely ill, along with details of antibiotic prescribing, its appropriateness, and whether that appropriateness impacted on symptom improvement and recovery. Prospective observational cohort study in primary care sites in urban and rural areas in England and Wales. Systematic urine sampling from children aged <5 years presenting in primary care with acute illness with culture in NHS laboratories. Of 6079 children's urine samples, 339 (5.6%) met laboratory criteria for UTI and 162 (47.9%) were prescribed antibiotics at the initial consultation. In total, 576/7101 (8.1%) children were suspected of having a UTI prior to urine sampling, including 107 of the 338 with a UTI (clinician sensitivity 31.7%). Children with a laboratory-diagnosed UTI were more likely to be prescribed antibiotics when UTI was clinically suspected than when it was not (86.0% versus 30.3%, P<0.001). Of 231 children with unsuspected UTI, 70 (30.3%) received serendipitous antibiotics (that is, antibiotics prescribed for a different reason). Overall, 176 (52.1%) children with confirmed UTI did not receive any initial antibiotic. Organism sensitivity to the prescribed antibiotic was higher when UTI was suspected than when treated serendipitously (77.1% versus 26.0%; P<0.001). Children with UTI prescribed appropriate antibiotics at the initial consultation improved a little sooner than those with a UTI who were not prescribed appropriate antibiotics initially (3.5 days versus 4.0 days; P = 0.005). Over half of children with UTI on culture were not prescribed antibiotics at first presentation. Serendipitous UTI treatment was relatively common, but often inappropriate to the organism's sensitivity. Methods for improved targeting of antibiotic treatment in children who are acutely unwell are urgently needed. © British Journal of General Practice 2015.

Childhood urinary tract infection in primary care: a prospective observational study of prevalence, diagnosis, treatment, and recovery

PubMed Central

Butler, Christopher C; O’Brien, Kathryn; Pickles, Timothy; Hood, Kerenza; Wootton, Mandy; Howe, Robin; Waldron, Cherry-Ann; Thomas-Jones, Emma; Hollingworth, William; Little, Paul; Van Der Voort, Judith; Dudley, Jan; Rumsby, Kate; Downing, Harriet; Harman, Kim; Hay, Alastair D

2015-01-01

Background The prevalence of targeted and serendipitous treatment for, and associated recovery from, urinary tract infection (UTI) in pre-school children is unknown. Aim To determine the frequency and suspicion of UTI in children who are acutely ill, along with details of antibiotic prescribing, its appropriateness, and whether that appropriateness impacted on symptom improvement and recovery. Design and setting Prospective observational cohort study in primary care sites in urban and rural areas in England and Wales. Method Systematic urine sampling from children aged <5years presenting in primary care with acute illness with culture in NHS laboratories. Results Of 6079 children’s urine samples, 339 (5.6%) met laboratory criteria for UTI and 162 (47.9%) were prescribed antibiotics at the initial consultation. In total, 576/7101 (8.1%) children were suspected of having a UTI prior to urine sampling, including 107 of the 338 with a UTI (clinician sensitivity 31.7%). Children with a laboratory-diagnosed UTI were more likely to be prescribed antibiotics when UTI was clinically suspected than when it was not (86.0% versus 30.3%, P<0.001). Of 231 children with unsuspected UTI, 70 (30.3%) received serendipitous antibiotics (that is, antibiotics prescribed for a different reason). Overall, 176 (52.1%) children with confirmed UTI did not receive any initial antibiotic. Organism sensitivity to the prescribed antibiotic was higher when UTI was suspected than when treated serendipitously (77.1% versus 26.0%; P<0.001). Children with UTI prescribed appropriate antibiotics at the initial consultation improved a little sooner than those with a UTI who were not prescribed appropriate antibiotics initially (3.5 days versus 4.0 days; P = 0.005). Conclusion Over half of children with UTI on culture were not prescribed antibiotics at first presentation. Serendipitous UTI treatment was relatively common, but often inappropriate to the organism’s sensitivity. Methods for improved targeting of antibiotic treatment in children who are acutely unwell are urgently needed. PMID:25824181

Nontechnical skills performance and care processes in the management of the acute trauma patient.

PubMed

Pucher, Philip H; Aggarwal, Rajesh; Batrick, Nicola; Jenkins, Michael; Darzi, Ara

2014-05-01

Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5-25); duration of stay 1 (IQR, 1-8) days; T-NOTECHS, 20.5 (IQR, 18-23); time to disposition, 24 minutes (IQR, 18-42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23-53) versus 20 (IQR, 16-25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P < .001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between "in-hours" and "out-of-hours" trauma calls for T-NOTECHS scores (21 [IQR, 18-22] vs 20 [IQR, 20-23]; P = .361), or time to disposition (34 minutes [IQR, 24-52] vs 17 [IQR, 15-27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06-0.95). Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes. Copyright © 2014 Mosby, Inc. All rights reserved.

Gender differences in burns: A study from emergency centres in the Western Cape, South Africa.

PubMed

Blom, Lisa; Klingberg, Anders; Laflamme, Lucie; Wallis, Lee; Hasselberg, Marie

2016-11-01

Little is known about gender differences in aetiology and management of acute burns in resource-constrained settings in South Africa. This cross-sectional study is based on burn case reports (n=1915) from eight emergency centres in Western Cape, South Africa (June 2012-May 2013). Male/female rate ratios by age group and age-specific incidence rates were compiled for urban and rural areas along with gender differences in proportions between children and adults for injury aetiology, burn severity, length of stay and patient disposition. Children 0-4 years in urban areas had the highest burn incidence but only among adults did male rates surpass females, with fire burns more common among men 20-39 years and hot liquid burns among men 55+ years. Men had a higher proportion of burns during weekends, from interpersonal violence and suspected use of alcohol/other substances, with more pronounced differences for hot liquid burns. Despite similar Abbreviated Injury Scale (AIS) scores, men were more often transferred to higher levels of care and women more often treated and discharged. Burns were far more common among children although gender differences arose only among adults. Men sustained more injuries of somewhat different aetiology and were referred to higher levels of care more often for comparable wound severity. The results suggest different disposition between men and women despite similar AIS scores. However, further studies with more comprehensive information on severity level and other care- and patient-related factors are needed to explore these results further. Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Frontline staff motivation levels and health care quality in rural and urban primary health facilities: a baseline study in the Greater Accra and Western regions of Ghana.

PubMed

Alhassan, Robert Kaba; Nketiah-Amponsah, Edward

2016-12-01

The population of Ghana is increasingly becoming urbanized with about 70 % of the estimated 26.9 million people living in urban and peri-urban areas. Nonetheless, eight out of the ten regions in Ghana remain predominantly rural where only 32.1 % of the national health sector workforce works. Doctor-patient ratio in a predominantly rural region is about 1:18,257 compared to 1:4,099 in an urban region. These rural-urban inequities significantly account for the inability of Ghana to attain the health related Millennium Development Goals (MDGs) before the end of 2015. To ascertain whether or not rural-urban differences exist in health worker motivation levels and quality of health care in health facilities accredited by the National Health Insurance Authority in Ghana. This is a baseline quantitative study conducted in 2012 among 324 health workers in 64 accredited clinics located in 9 rural and 7 urban districts in Ghana. Ordered logistic regression was performed to determine the relationship between facility geographic location (rural/urban) and staff motivation levels, and quality health care standards. Quality health care and patient safety standards were averagely low in the sampled health facilities. Even though health workers in rural facilities were more de-motivated by poor availability of resources and drugs than their counterparts in urban facilities (p < 0.05), quality of health care and patient safety standards were relatively better in rural facilities. For Ghana to attain the newly formulated sustainable development goals on health, there is the need for health authorities to address the existing rural-urban imbalances in health worker motivation and quality health care standards in primary healthcare facilities. Future studies should compare staff motivation levels and quality standards in accredited and non-accredited health facilities since the current study was limited to health facilities accredited by the National Health Insurance Authority.

The health encounter as a treatable moment for homeless substance-using adults: the role of homelessness, health seeking behavior, readiness for behavior change and motivation for treatment.

PubMed

O'Toole, Thomas P; Pollini, Robin A; Ford, Daniel E; Bigelow, George

2008-09-01

Substance-using homeless persons frequent emergency departments and hospitals often. However, little is known about how homelessness affects when they seek care and their motivation for substance abuse treatment (SAT). We surveyed homeless (N=266) and non-homeless (N=104) substance-using adults sequentially admitted to an urban hospital medicine service, comparing demographics, readiness for change (URICA), and motivating reasons for SAT. Homeless respondents were more likely to be younger, uninsured, have hepatitis B/C, and <12th grade education. The majority in both groups were in either a precontemplative or contemplative stage of change, although more homeless respondents were in an action stage. They also had similar motivating reasons for wanting SAT, although being homeless was an additional motivator for the majority of homeless respondents. Almost half reported that being homeless caused them to delay seeking health care; paradoxically those citing physical health as a SAT motivator were 3.4 times more likely to have delayed care. While acutely ill homeless persons were at least as motivated for SAT, these data suggest the challenge is getting them to care in a timely manner and tailoring interventions during the care episode to avail of this motivation.

[Role of community pharmacist in the management of patients in ophthalmology].

PubMed

Delolme, M-P; Law-Ki, A; Belon, J-P; Creuzot-Garcher, C; Bron, A

2011-03-01

To assess the role of community pharmacists in ophthalmology, to evaluate the frequency of giving patients advice, and to report their difficulties in daily practice. An anonymous questionnaire consisting of 13 questions was sent to 620 community pharmacists of Burgundy (France). Pharmacists were asked about their ophthalmic products, their ophthalmic activity in giving patients advice on ocular symptoms, and patients' expectations. For analysis, community pharmacies were separated into three groups: pharmacies in rural areas (under 2000 inhabitants), pharmacies in an urban zone with fewer than 10,000 inhabitants, and pharmacies in an urban zone with more than 10,000 inhabitants. The response rate was 46.9%. Ophthalmic products were mainly glasses for presbyopia (84.5%), eye care hygiene products (76.0%), and contact lens solutions (55.3%). Ophthalmic vitamin supplements were sold by 36.8% of pharmacists, mainly in urban areas. On average, the pharmacist was consulted for ocular problems seven times a week. Acute benign symptoms were most frequent. Advice on prescriptions came next. Then, information on contact lenses and chronic ocular disease were given (cataract, glaucoma, visual acuity loss, age-related maculopathy). Finally, the pharmacist either sold the patient an ocular treatment or oriented the patient to an ophthalmologist when needed. The pharmacist and his staff are active players in providing advice on ocular diseases and taking care of patients. Moreover, pharmacists have to manage ocular therapeutics, urgent symptoms, and chronic diseases. However, in our study, 46.0% of pharmacists felt confident with their knowledge on ophthalmology, 36.4% did not give their opinion, and 7.0% were uncomfortable with some questions. Most community pharmacists mentioned a lack of continuing education from pharmaceutical companies and postgraduate education on ocular diseases and treatment, mainly for age-related maculopathy. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

Increased ICU resource needs for an academic emergency general surgery service*.

PubMed

Lissauer, Matthew E; Galvagno, Samuel M; Rock, Peter; Narayan, Mayur; Shah, Paulesh; Spencer, Heather; Hong, Caron; Diaz, Jose J

2014-04-01

ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Retrospective database review. Academic, tertiary care, nontrauma surgical ICU. All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. None. Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access.

PubMed

Patterson, Brendan M; Draeger, Reid W; Olsson, Erik C; Spang, Jeffrey T; Lin, Feng-Chang; Kamath, Ganesh V

2014-09-17

Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals. Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded. Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005). Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals. This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review.

PubMed

Luu, Ngoc-Phuong; Pitts, Samantha; Petty, Brent; Sawyer, Melinda D; Dennison-Himmelfarb, Cheryl; Boonyasai, Romsai Tony; Maruthur, Nisa M

2016-04-01

Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care. We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool. Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65%), conducted in the US (55%), and studied communication between primary care and inpatient providers (62%). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95% CI 0.92-1.26). The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.

Overcoming the hurdles to providing urban health care in the 21st century.

PubMed

Guerra, Fernando A; Crockett, Susan A

2004-12-01

The delivery of health care services to urban populations in the United States is a system of rapidly increasing complexity. With the emergence of superspecialized physicians, a scientific approach to disease management has received great emphasis. Those providing health care at the population level may also apply this evidence-based approach. Analysis of the process of health care delivery in its entirety is complicated, confusing, and may be fraught with bias. In this article, a powerful instrument for providing a scientific approach to urban health care health policy development is introduced. This tool allows for analysis and assessment of hurdles to health care delivery to urban populations by dividing the process into elements of "administration," "provision," and "utilization" (APU). This APU triangle model, while intuitive, also allows a more definitive analysis by parts than would be possible to make of the whole. Using this model, the authors explore some of the hurdles faced by each element as well as some potential solutions. Although this model is presented in the context of urban hurdles to health care, it is equally applicable to rural environments or other service-delivery systems. In conclusion, this article discusses the emergence of the role of the public health department as the facilitator and manager between sectors of the community not traditionally connected in a collaborative health care model. Thus, the urban public health department coordinates efforts to surmount the hurdles and provides the venue for analysis, development, and employment of successful strategies.

A systematic review of randomized control trials evaluating the effectiveness of interactive computerized asthma patient education programs.

PubMed

Bussey-Smith, Kristin L; Rossen, Roger D

2007-06-01

Educating patients with asthma about the pathophysiology and treatment of their disease is recommended. In recent years, several computer programs have been developed to provide this education. These programs take advantage of the population's increasing skill with computers and the growth of the Internet as a source of health care information. To evaluate the effectiveness of published interactive computerized asthma patient education programs (CAPEPs) that have been subjected to randomized controlled trials (RCTs). The PubMed, ERIC, CINAHL, Psychinfo, and Clinicaltrials.gov databases were searched (through October 3, 2005) using the following terms: asthma, patient, education, interactive, and computer. RCTs in English that evaluated the effect of an interactive CAPEP on the following primary end points were included in the study: hospitalizations, acute care visits, rescue inhaler use, or lung function. Secondary end points included asthma knowledge and symptoms. Trials were screened by title and abstract before full text review. Two independent investigators used a standardized data extraction form to identify the articles chosen for full review. Nine of 406 citations met inclusion criteria. Four CAPEPs were computer games, 7 only studied children, and 4 focused on urban populations. One study each showed that the intervention reduced the number of hospitalizations, acute care visits, or rescue inhaler use. Two studies reported lung function improvements. Four studies showed improvement in asthma knowledge, and 5 studies reported improvements in symptoms. Although interactive CAPEPs may improve patient asthma knowledge and symptoms, their effect on objective clinical outcomes is less consistent.

Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States

PubMed Central

Ford, Chandra L.; Wallace, Steven P.; Wang, May C.; Takahashi, Lois M.

2016-01-01

Objectives. To examine whether living in a rural versus urban area differentially exposes populations to social conditions associated with disparities in access to health care. Methods. We linked Medical Expenditure Panel Survey (2005–2010) data to geographic data from the American Community Survey (2005–2009) and Area Health Resource File (2010). We categorized census tracts as rural and urban by using the Rural–Urban Commuting Area Codes. Respondent sample sizes ranged from 49 839 to 105 306. Outcomes were access to a usual source of health care, cholesterol screening, cervical screening, dental visit within recommended intervals, and health care needs met. Results. African Americans in rural areas had lower odds of cholesterol screening (odds ratio[OR] = 0.37; 95% confidence interval[CI] = 0.25, 0.57) and cervical screening (OR = 0.48; 95% CI = 0.29, 0.80) than African Americans in urban areas. Whites had fewer screenings and dental visits in rural versus urban areas. There were mixed results for which racial/ethnic group had better access. Conclusions. Rural status confers additional disadvantage for most of the health care use measures, independently of poverty and health care supply. PMID:27310341

Utilization of Maternal and Child Health Care Services by Primigravida Females in Urban and Rural Areas of India

PubMed Central

2014-01-01

Maternal complications and poor perinatal outcome are highly associated with nonutilisation of antenatal and delivery care services and poor socioeconomic conditions of the patient. It is essential that all pregnant women have access to high quality obstetric care throughout their pregnancies. Present longitudinal study was carried out to compare utilization of maternal and child health care services by urban and rural primigravida females. A total of 240 study participants were enrolled in this study. More illiteracy and less mean age at the time of marriage were observed in rural population. Poor knowledge about prelacteal feed, colostrums, tetanus injection and iron-follic acid tablet consumption was noted in both urban and rural areas. Very few study participants from both areas were counselled for HIV testing before pregnancy. More numbers of abortions (19.2%) were noted in urban study participants compared to rural area. Thus utilization of maternal and child health care (MCH) services was poor in both urban and rural areas. A sustained and focussed IEC campaign to improve the awareness amongst community on MCH will help in improving community participation. This may improve the quality, accessibility, and utilization of maternal health care services provided by the government agencies in both rural and urban areas. PMID:24977099

Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial.

PubMed

Rwabihama, Jean Paul; Audureau, Etienne; Laurent, Marie; Rakotoarisoa, Lalaina; Jegou, Marc; Saddedine, Sofiane; Krypciak, Sébastien; Herbaud, Stéphane; Benzengli, Hind; Segaux, Lauriane; Guery, Esther; Ambime, Gabin; Rabus, Marie-Thérèse; Perilliat, Jean-Guy; David, Jean-Philippe; Paillaud, Elena

2018-06-01

To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention. A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use. Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively. Patients hospitalized between January 1 and May 31, 2015, in participating departments. The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome. We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group. This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Opioid vs nonopioid prescribers: Variations in care for a standardized acute back pain case.

PubMed

Hanley, Kathleen; Zabar, Sondra; Altshuler, Lisa; Lee, Hillary; Ross, Jasmine; Rivera, Nicomedes; Marvilli, Christian; Gillespie, Colleen

2017-01-01

Opioid analgesics are effective and appropriate therapy for many types of acute pain. Epidemiologic evidence supports a direct relationship between increased opioid prescribing and increases in opioid use disorders and overdoses. To tailor our residency curriculum, we designed and fielded an unannounced standardized patient (USP) case involving a patient with acute back pain who is requesting Vicodin (5/325 mg). We describe residents' case management and examine whether their management decisions, including opioid prescribing, were related to their core clinical skills. Results are based on 50 (USP) visits with residents in 2 urban primary care clinics. Highly trained USPs portrayed a patient with acute lower back pain who was taking leftover Vicodin with effective pain relief but was running out. We describe how residents managed this case, using both USP report and chart review data, and compare summary clinical skills scores between those who prescribed Vicodin and those who did not. Of the 50 residents, 18 prescribed Vicodin (10-60 pills). Among those who did not prescribe (32/50), most (50%) prescribed ibuprofen. Eighty-three percent of the prescribers and 72% of nonprescribers ordered physical therapy (nonsignificant). Of the 18 prescribers, 13 documented checking the prescription monitoring database. Prescribers had significantly better communication scores than nonprescribers (relationship development: 80% vs. 58% well done, P = .029; patient education: 59% vs. 31% well done, P = .018). Assessment summary scores were also higher (60% vs. 46%) but not significantly (P = .060). Patient satisfaction and activation scores were higher in the prescribers than nonprescribers (71% vs. 39%, P = .004 and 48% vs. 26%, P = .034, respectively). Most Vicodin prescribers did not follow prescribing guidelines, and they demonstrated better communication and assessment skills than the nonprescribers. Results suggest the need to guide residents in using a systematic approach to prescribing opioids safely and to develop an acceptable alternative pain management plan when they decide against prescribing.

Urban and rural differences in risk of admission to a care home: a census-based follow-up study.

PubMed

McCann, Mark; Grundy, Emily; O'Reilly, Dermot

2014-11-01

Research on admissions to care homes for older people has paid more attention to individual and social characteristics than to geographical factors. This paper considers rural-urban differences in household composition and admission rates. 51,619 people aged 65 years or older at the time of the 2001 Census and not living in a care home, drawn from a data linkage study based on c.28% of the Northern Ireland population. Living alone was less common in rural areas; 25% of older people in rural areas lived with children compared to 18% in urban areas. Care home admission was more common in urban (4.7%) and intermediate (4.3%) areas than in rural areas (3.2%). Even after adjusting for age, sex, health and living arrangements, the rate of care home admission in rural areas was still only 75% of that in urban areas. People in rural areas experience better family support by living as part of two or three generation households. Even after accounting for this difference, older rural dwellers are less likely to enter care homes; suggesting that neighbours and relatives in rural areas provide more informal care; or that there may be differential deployment of formal home care services. Copyright © 2014 Elsevier Ltd. All rights reserved.

County-level poverty is equally associated with unmet health care needs in rural and urban settings.

PubMed

Peterson, Lars E; Litaker, David G

2010-01-01

Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care. © 2010 National Rural Health Association.

The business of palliative medicine--part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center.

PubMed

Walsh, Declan

2004-01-01

In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.

Rural-urban differences in cancer care: results from the Lake Superior Rural Cancer Care Project.

PubMed

Elliott, Thomas E; Elliott, Barbara A; Renier, Colleen M; Haller, Irina V

2004-09-01

Past studies have shown significant differences between rural and urban cancer patients in many measures of cancer care. There is little recent information about this disparity, which generally has shown disadvantages in rural populations. This study reports the rural and urban differences in cancer care using data from the Lake Superior Rural Cancer Care Project. The study used a prospective, population-based design that included all incident cases of breast, colorectal, lung, and prostate cancers diagnosed in northeastern Minnesota, northwestern Wisconsin, and the western portion of Michigan's Upper Peninsula from 1992 to 1997. The outcome measures were 9 endpoints that represented state-of-the-art cancer care during the study. Rural cancer patients as compared with their urban counterparts were disadvantaged in proportion staged, stage at diagnosis, initial management procedures, post-treatment surveillance testing, and participation in cancer clinical trials. These findings are similar to previously published studies. Further research is needed to determine more clearly the barriers in rural cancer care and to find more effective strategies.

Urban college student self-report of hookah use with health care providers.

PubMed

Jani, Samir Ranjit; Brown, Darryl; Berhane, Zekarias; Peter, Nadja; Solecki, Susan; Turchi, Renee

2018-07-01

This study's purpose was to describe urban college students' communication about hookah with health care providers. Participants included a random sample of undergraduate urban college students and health care providers. Students surveyed determined the epidemiology of hookah use in this population, how many health care providers asked about hookah, and how many students admitted hookah use to a physician. Of 375 students surveyed, 78 (20.8%) had never tried it, 284 (75.7%) had smoked hookah at least once, and 64 students (22.6%) were classified as frequent hookah smokers. Only 15 (4.7%) reported a health care provider asking about hookah during visits, whereas 36 (12.7%) admitted their hookah use to a health care provider. Hookah use was found to be highly prevalent among students in one urban university. This study supports the hypothesis that few health care providers broach the topic with patients. Additional research on health consequences of hookah use, education, and improved screening is warranted.

Associations between job demands, work-related strain and perceived quality of care: a longitudinal study among hospital physicians.

PubMed

Krämer, Tanya; Schneider, Anna; Spieß, Erika; Angerer, Peter; Weigl, Matthias

2016-12-01

Drawing on a sample of hospital physicians, we attempted to determine prospective associations between three job demands, work-related strain and perceived quality of care. Longitudinal follow-up study with with a 1-year time lag. Physicians of two acute-care hospitals in Germany (one general urban and one children's hospital). Ninety-five physicians filled out a standardized questionnaire. Physicians' evaluations of quality of care at both waves. Our results support the hypothesis that job demands directly influence quality of care irrespective of strain. Specifically, high social stressors (β = -0.15, P = 0.036) and time pressure (β = -0.19, P = 0.031) were associated with decreased quality of care over time. We additionally observed reversed effects from quality of care at baseline to time pressure at follow-up (β = -0.35, P = 0.006). Contrary to expectations, physicians' work-related strain did not mediate the job demands-quality of care-relationship, nor were strain-to-stressor effects observed. Our results corroborate that hospital work environments with high demands have a direct impact on physician-perceived quality of care. In turn, poor care practices contribute to increased job demands. Our findings also emphasize that further understanding is required of how physicians' workplace conditions affect job demands, well-being, and quality of care, respectively. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Rural/Urban Differences in Barriers to and Burden of Care for Children with Special Health Care Needs

ERIC Educational Resources Information Center

Skinner, Asheley Cockrell; Slifkin, Rebecca T.

2007-01-01

Purpose: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children. Methods: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs,…

Intentional injuries in young Ohio children: is there urban/rural variation?

PubMed

Anderson, Brit L; Pomerantz, Wendy J; Gittelman, Michael A

2014-09-01

Intentional injuries are the third leading cause of death in children 1 year to 4 years of age. The epidemiology of these injuries based on urban/rural geography and economic variables has not been clearly established. The study purposes are (1) to determine the rate of severe intentional injuries in children younger than 5 years in urban versus rural Ohio counties and (2) to determine if poverty within counties is associated with intentional injury rate. Demographic and injury data on children younger than 5 years who experienced intentional injuries, from January 1, 2003, to December 31, 2011, were extracted retrospectively from the Ohio Trauma Acute Care Registry. We calculated injury rates using the county of residence and US census data. We assigned each county to an urbanization level based on population density (A, most urban; D, most rural). Mean income and percentage of families with children younger than 5 years living below poverty in Ohio counties were obtained from the US census. Rates are per 100,000 children younger than 5 years per year. A total of 984 patients were included; the overall injury rate was 15.9. The mean age was 0.66 years (SD, 1.02 years); 583 (59.2%) were male and 655 (66.6%) were white. One hundred twenty-nine (13.1%) died. Injury rates by urbanization level were as follows: A, 16.5; B, 10.7; C, 18.7; and D, 15.2 (p = 0.285). There were significant associations between county injury rate and mean income (p = 0.05) and percentage of families with children younger than 5 years living below poverty (p = 0.04). We found no association between intentional injury rate and urbanization level in young Ohio children. However, we did find an association between county mean income and percentage of families living below poverty, with intentional injury rate suggesting that financial hardship may be an important risk factor of these injuries.

An acute interprofessional simulation experience for occupational and physical therapy students: Key findings from a survey study.

PubMed

Thomas, Erin M; Rybski, Melinda F; Apke, Tonya L; Kegelmeyer, Deb A; Kloos, Anne D

2017-05-01

Due to the fast pace and high complexity of managing patients in intensive and acute care units (ICUs), healthcare students often feel challenged and unprepared to practice in this environment. Simulations and standardised patients provide "hands-on" learning experiences that are realistic and help students to gain competence and confidence. This study examined the impact of an intensive case simulation laboratory using a patient simulator and standardised patients on students' perceptions of their confidence and preparedness to work in acute care settings. Second-year Masters of Occupational Therapy (MOT; n = 127) and Doctor of Physical Therapy (DPT; n = 105) students participated in a three-hour intensive care simulation laboratory comprised of four stations that were designed to simulate common ICU patient care scenarios. Data analysed were student pre- and post-simulation surveys and written comments, and clinical instructors' (CIs; n = 51) ratings on DPT students' preparedness and confidence within the first two weeks of their acute care internships obtained after the laboratory. There was a significant increase for DPT (p < 0.0001) and MOT (p < 0.10) students in median ratings of how prepared they felt to practice in acute care settings following the ICU simulation compared to before the laboratory. CIs rated the DPT students as either prepared or very prepared for and moderately confident or very confident in the acute care setting. The use of simulation training using standardised patients and patient simulators was beneficial in increasing student confidence and preparing OT and PT students to practice in the acute care setting. Health professional educators should consider using an interprofessional simulation experience to improve their students' confidence and preparedness to provide appropriate care in the acute setting.

Evaluating the Impact of EBP Education: Development of a Modified Fresno Test for Acute Care Nursing.

PubMed

Halm, Margo A

2018-05-14

Proficiency in evidence-based practice (EBP) is essential for relevant research findings to be integrated into clinical care when congruent with patient preferences. Few valid and reliable tools are available to evaluate the effectiveness of educational programs in advancing EBP attitudes, knowledge, skills, or behaviors, and ongoing competency. The Fresno test is one objective method to evaluate EBP knowledge and skills; however, the original and modified versions were validated with family physicians, physical therapists, and speech and language therapists. To adapt the Modified Fresno-Acute Care Nursing test and develop a psychometrically sound tool for use in academic and practice settings. In Phase 1, modified Fresno (Tilson, 2010) items were adapted for acute care nursing. In Phase 2, content validity was established with an expert panel. Content validity indices (I-CVI) ranged from .75 to 1.0. Scale CVI was .95%. A cross-sectional convenience sample of acute care nurses (n = 90) in novice, master, and expert cohorts completed the Modified Fresno-Acute Care Nursing test administered electronically via SurveyMonkey. Total scores were significantly different between training levels (p < .0001). Novice nurses scored significantly lower than master or expert nurses, but differences were not found between the latter cohorts. Total score reliability was acceptable: (interrater [ICC (2, 1)]) = .88. Cronbach's alpha was 0.70. Psychometric properties of most modified items were satisfactory; however, six require further revision and testing to meet acceptable standards. The Modified Fresno-Acute Care Nursing test is a 14-item test for objectively assessing EBP knowledge and skills of acute care nurses. While preliminary psychometric properties for this new EBP knowledge measure for acute care nursing are promising, further validation of some of the items and scoring rubric is needed. © 2018 Sigma Theta Tau International.

Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans.

PubMed

Loftus, John; Allen, Elizabeth M; Call, Kathleen Thiede; Everson-Rose, Susan A

2018-02-01

Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota. This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities. Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees. Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence. © 2017 National Rural Health Association.

Functional Outcomes of Persons Undergoing Dysvascular Lower Extremity Amputations

PubMed Central

Sauter, Carley N.; Pezzin, Liliana E.; Dillingham, Timothy R.

2012-01-01

Objective To examine the effect of post-acute rehabilitation setting on functional outcomes among patients undergoing major lower extremity dysvascular amputations. Design A population-based, prospective cohort study conducted in Maryland and Wisconsin. Data collected from medical records and patient interviews conducted during acute hospitalization following amputation and at six-month following the acute care discharge were analyzed using multivariate models and instrumental variable techniques. Results A total of 297 patients were analyzed based on post-acute care rehabilitation setting: acute inpatient rehabilitation (IRF), skilled nursing facility (SNF) or home. The majority (43.4%) received care in IRF, 32% in SNF, and 24.6% at home. On SF-36 subscales, significantly improved outcomes were observed for patients receiving post-acute care at an IRF relative to those cared for at a SNF in physical function (PF), role physical (RF) and physical component score (PCS). Patients receiving post-acute care in IRFs also experienced better RF and PCS outcomes compared to those discharged directly home. In addition, patients receiving post-acute care at an IRF were significantly more likely to score in the top quartile for general health in IRF compared to SNF or home, and less likely to score in the lowest quartile for PF, RF and PCS in IRF compared to SNF. Lower ADL impairment was observed in IRF compared to SNF. Conclusions Among this large and diverse cohort of patients undergoing major dysvascular lower limb amputations, receipt of interdisciplinary rehabilitation services at an IRF yielded improved functional outcomes six months after amputation relative to care received at SNFs or home. PMID:23291599

Identifying patient-level health and social care costs for older adults discharged from acute medical units in England.

PubMed

Franklin, Matthew; Berdunov, Vladislav; Edmans, Judi; Conroy, Simon; Gladman, John; Tanajewski, Lukasz; Gkountouras, Georgios; Elliott, Rachel A

2014-09-01

acute medical units allow for those who need admission to be correctly identified, and for those who could be managed in ambulatory settings to be discharged. However, re-admission rates for older people following discharge from acute medical units are high and may be associated with substantial health and social care costs. identifying patient-level health and social care costs for older people discharged from acute medical units in England. a prospective cohort study of health and social care resource use. an acute medical unit in Nottingham, England. four hundred and fifty-six people aged over 70 who were discharged from an acute medical unit within 72 h of admission. hospitalisation and social care data were collected for 3 months post-recruitment. In Nottingham, further approvals were gained to obtain data from general practices, ambulance services, intermediate care and mental healthcare. Resource use was combined with national unit costs. costs from all sectors were available for 250 participants. The mean (95% CI, median, range) total cost was £1926 (1579-2383, 659, 0-23,612). Contribution was: secondary care (76.1%), primary care (10.9%), ambulance service (0.7%), intermediate care (0.2%), mental healthcare (2.1%) and social care (10.0%). The costliest 10% of participants accounted for 50% of the cost. this study highlights the costs accrued by older people discharged from acute medical units (AMUs): they are mainly (76%) in secondary care and half of all costs were incurred by a minority of participants (10%). © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

[Analysis of characteristics of acute poisoning caused by various poisons in Guangxi, China].

PubMed

Hu, De-hong; Zhang, Zhen-ming; Liu, Qing-hua; Jiang, Dong-fang

2013-11-01

To investigate the characteristics of acute poisonings caused by various poisons in Guangxi, China. A retrospective investigation was performed in 5859 cases of acute poisonings who were admitted to 63 hospitals in 11 cities, as well as 531 types of poisons involved. The poisons were categorized into 6 groups; each group of cases was stratified by the rural or urban settings, frequency of poisoning, and cause of poisoning to analyze the numbers of cases and constituent ratios. Most types of poisons (68.74%) belonged to drugs (217 types) and pesticides (148 types). Most cases of poisonings (61.63%) were caused by pesticides (n = 2547) and chemicals (n = 1064). Pesticides, poisons of plant origins, and poisons of animal origins were responsible for most of the cases in rural settings; 88.46%, 79.10%, and 66.74% of the cases of these poison categories happened in rural settings. Chemicals, drugs, and other poisons were responsible for most of the cases in urban settings; 70.20%, 61.74%, and 63.73% of the cases of these poison categories happened in urban settings. The numbers of cases in 5-year-poisoning groups were the highest in all categories of poisons, accounting for 85.24%, 88.57%, 55.16%, 70.79%, 68.36%, and 66.44%of cases of respective categories. Most cases of poisonings by chemicals, poisons of animal origin, and other poisons were accident-related (86.24%, 72.66%, and 46.71%of the poison categories). Most cases of poisonings by pesticides and drugs were suicide-related (59.39% and 33.52% of the poison categories). Most cases by poisons of plant origin were caused by accidental ingestion (70.36% of the poison category). Most of the acute poisonings in Guangxi area are caused by pesticides and chemicals; the most common causes of poisoning are accidents, accidental ingestion, and suicide. There are significant differences in the causes of acute poisonings between the urban and rural settings.

Urban women's use of rural-based health care services: the case of Igbo women in Aba City, Nigeria.

PubMed

Izugbara, C Otutubikey; Afangideh, A Isong

2005-03-01

This study addresses the quest for rural-based health care services among women in urban Nigeria relying on a large qualitative database obtained from 63 Igbo women living in Aba, Nigeria. Results indicate that urban Igbo women of different socioeconomic and demographic characteristics utilize the services of different rural-based health care providers-indigenous healers, traditional birth attendants (TBAs), faith/spiritual, western-trained doctors and nurses as well as chemist shopkeepers-for conditions ranging from infertility, through child birthing and abortions, to swollen body, epilepsy, bone setting, and stubborn skin diseases. Major attractions to rural-based therapists were the failure of urban-based health services to provide cure, perceived mystical nature of conditions, need to conceal information on therapeutic progress and/or the nature of specific disease conditions, belief in rural-based therapists' ability to cure condition, and affordability of the services of rural-based health care providers. Findings underscore the critical implications of service characteristics, cultural beliefs, and the symbolic content of place(s) for care seekers' patterns of resort. We suggest that need exists for policies and programs aimed at making health care services in urban Nigeria more responsive to care seekers' socioeconomic and cultural sensitivities, integrating informal health care providers into Nigeria's health care system, and strengthening public health education in Nigeria.

Too Costly To Be Ill: Health Care Access and Health Seeking Behaviors among Rural-to-urban Migrants in China

PubMed Central

Hong, Yan; Li, Xiaoming; Stanton, Bonita; Lin, Danhua; Fang, Xiaoyi; Rong, Mao; Wang, Jing

2007-01-01

Of the 114 million rural-to-urban migrants in China, most have only temporary employment in the cities. Because of their non-urban residence, they are not entitled to many benefits and services accorded to most urban dwellers. Only limited research has been conducted on the health care access and health seeking behaviors of this population. This study, based on qualitative data from in-depth interviews with 90 rural-to-urban migrants, found that migrants had limited access to regular medical services. Lack of insurance coverage, high cost, and exacting work schedules have resulted in use of unsupervised self-treatment or substandard care. Their health seeking behaviors have led to suboptimal health consequences including delayed treatment of illnesses. Findings from this study underscore the importance of reducing institutional barriers to health services and providing affordable health care to this population. PMID:18277099

Intra-facility linkage of HIV-positive mothers and HIV-exposed babies into HIV chronic care: rural and urban experience in a resource limited setting.

PubMed

Mugasha, Christine; Kigozi, Joanita; Kiragga, Agnes; Muganzi, Alex; Sewankambo, Nelson; Coutinho, Alex; Nakanjako, Damalie

2014-01-01

Linkage of HIV-infected pregnant women to HIV care remains critical for improvement of maternal and child outcomes through prevention of maternal-to-child transmission of HIV (PMTCT) and subsequent chronic HIV care. This study determined proportions and factors associated with intra-facility linkage to HIV care and Early Infant Diagnosis care (EID) to inform strategic scale up of PMTCT programs. A cross-sectional review of records was done at 2 urban and 3 rural public health care facilities supported by the Infectious Diseases Institute (IDI). HIV-infected pregnant mothers, identified through routine antenatal care (ANC) and HIV-exposed babies were evaluated for enrollment in HIV clinics by 6 weeks post-delivery. Overall, 1,025 HIV-infected pregnant mothers were identified during ANC between January and June, 2012; 267/1,025 (26%) in rural and 743/1,025 (74%) in urban facilities. Of these 375/1,025 (37%) were linked to HIV clinics [67/267(25%) rural and 308/758(41%) urban]. Of 636 HIV-exposed babies, 193 (30%) were linked to EID. Linkage of mother-baby pairs to HIV chronic care and EID was 16% (101/636); 8/179 (4.5%)] in rural and 93/457(20.3%) in urban health facilities. Within rural facilities, ANC registration <28 weeks-of-gestation was associated with mothers' linkage to HIV chronic care [AoR, 2.0 95% CI, 1.1-3.7, p = 0.019] and mothers' multi-parity was associated with baby's linkage to EID; AoR 4.4 (1.3-15.1), p = 0.023. Stigma, long distance to health facilities and vertical PMTCT services affected linkage in rural facilities, while peer mothers, infant feeding services, long patient queues and limited privacy hindered linkage to HIV care in urban settings. Post-natal linkage of HIV-infected mothers to chronic HIV care and HIV-exposed babies to EID programs was low. Barriers to linkage to HIV care vary in urban and rural settings. We recommend targeted interventions to rapidly improve linkage to antiretroviral therapy for elimination of MTCT.

Intra-Facility Linkage of HIV-Positive Mothers and HIV-Exposed Babies into HIV Chronic Care: Rural and Urban Experience in a Resource Limited Setting

PubMed Central

Mugasha, Christine; Kigozi, Joanita; Kiragga, Agnes; Muganzi, Alex; Sewankambo, Nelson; Coutinho, Alex; Nakanjako, Damalie

2014-01-01

Introduction Linkage of HIV-infected pregnant women to HIV care remains critical for improvement of maternal and child outcomes through prevention of maternal-to-child transmission of HIV (PMTCT) and subsequent chronic HIV care. This study determined proportions and factors associated with intra-facility linkage to HIV care and Early Infant Diagnosis care (EID) to inform strategic scale up of PMTCT programs. Methods A cross-sectional review of records was done at 2 urban and 3 rural public health care facilities supported by the Infectious Diseases Institute (IDI). HIV-infected pregnant mothers, identified through routine antenatal care (ANC) and HIV-exposed babies were evaluated for enrollment in HIV clinics by 6 weeks post-delivery. Results Overall, 1,025 HIV-infected pregnant mothers were identified during ANC between January and June, 2012; 267/1,025 (26%) in rural and 743/1,025 (74%) in urban facilities. Of these 375/1,025 (37%) were linked to HIV clinics [67/267(25%) rural and 308/758(41%) urban]. Of 636 HIV-exposed babies, 193 (30%) were linked to EID. Linkage of mother-baby pairs to HIV chronic care and EID was 16% (101/636); 8/179 (4.5%)] in rural and 93/457(20.3%) in urban health facilities. Within rural facilities, ANC registration <28 weeks-of-gestation was associated with mothers' linkage to HIV chronic care [AoR, 2.0 95% CI, 1.1–3.7, p = 0.019] and mothers' multi-parity was associated with baby's linkage to EID; AoR 4.4 (1.3–15.1), p = 0.023. Stigma, long distance to health facilities and vertical PMTCT services affected linkage in rural facilities, while peer mothers, infant feeding services, long patient queues and limited privacy hindered linkage to HIV care in urban settings. Conclusion Post-natal linkage of HIV-infected mothers to chronic HIV care and HIV-exposed babies to EID programs was low. Barriers to linkage to HIV care vary in urban and rural settings. We recommend targeted interventions to rapidly improve linkage to antiretroviral therapy for elimination of MTCT. PMID:25546453

Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review.

PubMed

Williams, Allison; Botti, Mari

2002-10-01

Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions. To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge. A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge. Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people. Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.

Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial.

PubMed

Huffman, Jeff C; Mastromauro, Carol A; Beach, Scott R; Celano, Christopher M; DuBois, Christina M; Healy, Brian C; Suarez, Laura; Rollman, Bruce L; Januzzi, James L

2014-06-01

Depression and anxiety are associated with adverse cardiovascular outcomes in patients with recent acute cardiac events. There has been minimal study of collaborative care (CC) management models for mental health disorders in high-risk cardiac inpatients, and no prior CC intervention has simultaneously managed depression and anxiety disorders. To determine the impact of a low-intensity CC intervention for depression, generalized anxiety disorder, and panic disorder among patients hospitalized for an acute cardiac illness. Single-blind randomized clinical trial, with study assessors blind to group assignment, from September 2010 through July 2013 of 183 patients admitted to inpatient cardiac units in an urban academic general hospital for acute coronary syndrome, arrhythmia, or heart failure and found to have clinical depression, generalized anxiety disorder, or panic disorder on structured assessment. Participants were randomized to 24 weeks of a low-intensity telephone-based multicomponent CC intervention targeting depression and anxiety disorders (n = 92) or to enhanced usual care (serial notification of primary medical providers; n = 91). The CC intervention used a social work care manager to coordinate assessment and stepped care of psychiatric conditions and to provide support and therapeutic interventions as appropriate. Improvement in mental health-related quality of life (Short Form-12 Mental Component Score [SF-12 MCS]) at 24 weeks, compared between groups using a random-effects model in an intent-to-treat analysis. Patients randomized to CC had significantly greater estimated mean improvements in SF-12 MCS at 24 weeks (11.21 points [from 34.21 to 45.42] in the CC group vs 5.53 points [from 36.30 to 41.83] in the control group; estimated mean difference, 5.68 points [95% CI, 2.14-9.22]; P = .002; effect size, 0.61). Patients receiving CC also had significant improvements in depressive symptoms and general functioning, and higher rates of treatment of a mental health disorder; anxiety scores, rates of disorder response, and adherence did not differ between groups. A novel telephone-based, low-intensity model to concurrently manage cardiac patients with depression and/or anxiety disorders was effective for improving mental health-related quality of life in a 24-week trial. clinicaltrials.gov Identifier: NCT01201967.

Effects of Teaching Health Care Workers on Diagnosis and Treatment of Pesticide Poisonings in Uganda.

PubMed

Sibani, Claudia; Jessen, Kristian Kjaer; Tekin, Bircan; Nabankema, Victoria; Jørs, Erik

2017-01-01

Acute pesticide poisoning in developing countries is a considerable problem, requiring diagnosis and treatment. This study describes how training of health care workers in Uganda affects their ability to diagnose and manage acute pesticide poisoning. A postintervention cross-sectional study was conducted using a standardized questionnaire. A total of 326 health care workers in Uganda were interviewed on knowledge and handling of acute pesticide poisoning. Of those, 173 health care workers had received training, whereas 153 untrained health care workers from neighboring regions served as controls. Trained health care workers scored higher on knowledge of pesticide toxicity and handling of acute pesticide poisoning. Stratification by sex, profession, experience, and health center level did not have any influence on the outcome. Training health care workers can improve their knowledge and treatment of pesticide poisonings. Knowledge of the subject is still insufficient among health care workers and further training is needed.

The influence of health policy and market factors on the hospital safety net.

PubMed

Bazzoli, Gloria J; Lindrooth, Richard C; Kang, Ray; Hasnain-Wynia, Romana

2006-08-01

To examine how the financial pressures resulting from the Balanced Budget Act (BBA) of 1997 interacted with private sector pressures to affect indigent care provision. American Hospital Association Annual Survey, Area Resource File, InterStudy Health Maintenance Organization files, Current Population Survey, and Bureau of Primary Health Care data. We distinguished core and voluntary safety net hospitals in our analysis. Core safety net hospitals provide a large share of uncompensated care in their markets and have large indigent care patient mix. Voluntary safety net hospitals provide substantial indigent care but less so than core hospitals. We examined the effect of financial pressure in the initial year of the 1997 BBA on uncompensated care for three hospital groups. Data for 1996-2000 were analyzed using approaches that control for hospital and market heterogeneity. All urban U.S. general acute care hospitals with complete data for at least 2 years between 1996 and 2000, which totaled 1,693 institutions. Core safety net hospitals reduced their uncompensated care in response to Medicaid financial pressure. Voluntary safety net hospitals also responded in this way but only when faced with the combined forces of Medicaid and private sector payment pressures. Nonsafety net hospitals did not exhibit similar responses. Our results are consistent with theories of hospital behavior when institutions face reductions in payment. They raise concern given continuing state budget crises plus the focus of recent federal deficit reduction legislation intended to cut Medicaid expenditures.

Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma

PubMed Central

Zatzick, Douglas; Rivara, Frederick; Jurkovich, Gregory; Russo, Joan; Trusz, Sarah Geiss; Wang, Jin; Wagner, Amy; Stephens, Kari; Dunn, Chris; Uehara, Edwina; Petrie, Megan; Engel, Charles; Davydow, Dimitri; Katon, Wayne

2011-01-01

Objective To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions. Method We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. Results Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers. Conclusions Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts. PMID:21596205

The Burden of Common Infectious Disease Syndromes at the Clinic and Household Level from Population-Based Surveillance in Rural and Urban Kenya

PubMed Central

Feikin, Daniel R.; Olack, Beatrice; Bigogo, Godfrey M.; Audi, Allan; Cosmas, Leonard; Aura, Barrack; Burke, Heather; Njenga, M. Kariuki; Williamson, John; Breiman, Robert F.

2011-01-01

Background Characterizing infectious disease burden in Africa is important for prioritizing and targeting limited resources for curative and preventive services and monitoring the impact of interventions. Methods From June 1, 2006 to May 31, 2008, we estimated rates of acute lower respiratory tract illness (ALRI), diarrhea and acute febrile illness (AFI) among >50,000 persons participating in population-based surveillance in impoverished, rural western Kenya (Asembo) and an informal settlement in Nairobi, Kenya (Kibera). Field workers visited households every two weeks, collecting recent illness information and performing limited exams. Participants could access free high-quality care in a designated referral clinic in each site. Incidence and longitudinal prevalence were calculated and compared using Poisson regression. Results Incidence rates resulting in clinic visitation were the following: ALRI — 0.36 and 0.51 episodes per year for children <5 years and 0.067 and 0.026 for persons ≥5 years in Asembo and Kibera, respectively; diarrhea — 0.40 and 0.71 episodes per year for children <5 years and 0.09 and 0.062 for persons ≥5 years in Asembo and Kibera, respectively; AFI — 0.17 and 0.09 episodes per year for children <5 years and 0.03 and 0.015 for persons ≥5 years in Asembo and Kibera, respectively. Annually, based on household visits, children <5 years in Asembo and Kibera had 60 and 27 cough days, 10 and 8 diarrhea days, and 37 and 11 fever days, respectively. Household-based rates were higher than clinic rates for diarrhea and AFI, this difference being several-fold greater in the rural than urban site. Conclusions Individuals in poor Kenyan communities still suffer from a high burden of infectious diseases, which likely hampers their development. Urban slum and rural disease incidence and clinic utilization are sufficiently disparate in Africa to warrant data from both settings for estimating burden and focusing interventions. PMID:21267459

The burden of common infectious disease syndromes at the clinic and household level from population-based surveillance in rural and urban Kenya.

PubMed

Feikin, Daniel R; Olack, Beatrice; Bigogo, Godfrey M; Audi, Allan; Cosmas, Leonard; Aura, Barrack; Burke, Heather; Njenga, M Kariuki; Williamson, John; Breiman, Robert F

2011-01-18

Characterizing infectious disease burden in Africa is important for prioritizing and targeting limited resources for curative and preventive services and monitoring the impact of interventions. From June 1, 2006 to May 31, 2008, we estimated rates of acute lower respiratory tract illness (ALRI), diarrhea and acute febrile illness (AFI) among >50,000 persons participating in population-based surveillance in impoverished, rural western Kenya (Asembo) and an informal settlement in Nairobi, Kenya (Kibera). Field workers visited households every two weeks, collecting recent illness information and performing limited exams. Participants could access free high-quality care in a designated referral clinic in each site. Incidence and longitudinal prevalence were calculated and compared using Poisson regression. INCIDENCE RATES RESULTING IN CLINIC VISITATION WERE THE FOLLOWING: ALRI--0.36 and 0.51 episodes per year for children <5 years and 0.067 and 0.026 for persons ≥ 5 years in Asembo and Kibera, respectively; diarrhea--0.40 and 0.71 episodes per year for children <5 years and 0.09 and 0.062 for persons ≥ 5 years in Asembo and Kibera, respectively; AFI--0.17 and 0.09 episodes per year for children <5 years and 0.03 and 0.015 for persons ≥ 5 years in Asembo and Kibera, respectively. Annually, based on household visits, children <5 years in Asembo and Kibera had 60 and 27 cough days, 10 and 8 diarrhea days, and 37 and 11 fever days, respectively. Household-based rates were higher than clinic rates for diarrhea and AFI, this difference being several-fold greater in the rural than urban site. Individuals in poor Kenyan communities still suffer from a high burden of infectious diseases, which likely hampers their development. Urban slum and rural disease incidence and clinic utilization are sufficiently disparate in Africa to warrant data from both settings for estimating burden and focusing interventions.

Monte-Carlo Modeling of the Prompt Radiation Emitted by a Nuclear Device in the National Capital Region, Revision 1

DTIC Science & Technology

2016-08-10

Anno, et al. 2003). The asymptomatic level (0.75 Gy) is considered the lower dose threshold of the presence of symptoms from acute radiation ...high probability of acute injury due to prompt radiation (shown in yellow, > 0.75-Gy equivalent dose) and low probability of acute injury from prompt...of an urban nuclear-weapon detonation as associated with the possibility of acute , deterministic radiation effects. Equivalent-dose calculations for

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

PubMed

Napoles, Tessa M; Burke, Nancy J; Shim, Janet K; Davis, Elizabeth; Moskowitz, David; Yen, Irene H

2017-12-01

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

Vital Signs: Preventing Antibiotic-Resistant Infections in Hospitals - United States, 2014.

PubMed

Weiner, Lindsey M; Fridkin, Scott K; Aponte-Torres, Zuleika; Avery, Lacey; Coffin, Nicole; Dudeck, Margaret A; Edwards, Jonathan R; Jernigan, John A; Konnor, Rebecca; Soe, Minn M; Peterson, Kelly; McDonald, L Clifford

2016-03-11

Health care-associated antibiotic-resistant (AR) infections increase patient morbidity and mortality and might be impossible to successfully treat with any antibiotic. CDC assessed health care-associated infections (HAI), including Clostridium difficile infections (CDI), and the role of six AR bacteria of highest concern nationwide in several types of health care facilities. During 2014, approximately 4,000 short-term acute care hospitals, 501 long-term acute care hospitals, and 1,135 inpatient rehabilitation facilities in all 50 states reported data on specific infections to the National Healthcare Safety Network. National standardized infection ratios and their percentage reduction from a baseline year for each HAI type, by facility type, were calculated. The proportions of AR pathogens and HAIs caused by any of six resistant bacteria highlighted by CDC in 2013 as urgent or serious threats were determined. In 2014, the reductions in incidence in short-term acute care hospitals and long-term acute care hospitals were 50% and 9%, respectively, for central line-associated bloodstream infection; 0% (short-term acute care hospitals), 11% (long-term acute care hospitals), and 14% (inpatient rehabilitation facilities) for catheter-associated urinary tract infection; 17% (short-term acute care hospitals) for surgical site infection, and 8% (short-term acute care hospitals) for CDI. Combining HAIs other than CDI across all settings, 47.9% of Staphylococcus aureus isolates were methicillin resistant, 29.5% of enterococci were vancomycin-resistant, 17.8% of Enterobacteriaceae were extended-spectrum beta-lactamase phenotype, 3.6% of Enterobacteriaceae were carbapenem resistant, 15.9% of Pseudomonas aeruginosa isolates were multidrug resistant, and 52.6% of Acinetobacter species were multidrug resistant. The likelihood of HAIs caused by any of the six resistant bacteria ranged from 12% in inpatient rehabilitation facilities to 29% in long-term acute care hospitals. Although there has been considerable progress in preventing some HAIs, many remaining infections could be prevented with implementation of existing recommended practices. Depending upon the setting, more than one in four of HAIs excluding CDI are caused by AR bacteria. Physicians, nurses, and health care leaders need to consistently and comprehensively follow all recommendations to prevent catheter- and procedure-related infections and reduce the impact of AR bacteria through antimicrobial stewardship and measures to prevent spread.

Motor and Cognitive Functional Status Are Associated with 30-day Unplanned Rehospitalization Following Post-Acute Care in Medicare Fee-for-Service Beneficiaries.

PubMed

Middleton, Addie; Graham, James E; Lin, Yu-Li; Goodwin, James S; Bettger, Janet Prvu; Deutsch, Anne; Ottenbacher, Kenneth J

2016-12-01

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. This was a retrospective cohort study. Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). Not applicable. Thirty-day unplanned rehospitalization following post-acute rehabilitation. The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

Parent Perceptions of How Nurse Encounters Can Provide Caring Support for the Family in Early Acute Care Following Children’s Severe Traumatic Brain Injury

PubMed Central

Roscigno, Cecelia I.

2016-01-01

Objective A child’s severe traumatic brain injury (TBI) creates a family crisis requiring extensive cultural, informational, psychological, and environmental support. Nurses need to understand parents’ expectations of caring in early acute care so they can tailor their attitudes, beliefs, and behaviors appropriately to accommodate the family’s needs. Methods In a previous qualitative study of 42 parents or caregivers from 37 families of children with moderate to severe TBI, parents of children with severe TBI (n = 25) described their appraisals of nurse caring and uncaring behaviors in early acute care. Swanson’s theory of caring was used to categorize parents’ descriptions in order to inform nursing early acute care practices and family-centered care. Results Caring nurse encounters included: (a) involving parents in the care of their child and reflecting on all socio-cultural factors shaping family resources and responses (knowing); (b) respecting that family grief can be co-mingled with resilience, and that parents are typically competent to be involved in decision-making (maintaining belief); (d) actively listening and engaging parents in order to fully understand family values and needs (being with); (e) decreasing parents’ workload to get information, emotional support, and providing a safe cultural, psychological, and physical environment for the family (doing for), and; (f) providing anticipatory guidance to navigate the early acute care system and giving assistance to learn and adjust to their situation (enabling). Conclusion Application of Swanson’s caring theory is prescriptive in helping individual nurses and early acute care systems to meet important family needs following children’s severe TBI. PMID:26871242

Factors contributing to the process of intensive care patient discharge: an ethnographic study informed by activity theory.

PubMed

Lin, Frances; Chaboyer, Wendy; Wallis, Marianne; Miller, Anne

2013-08-01

Patient flow from intensive care to acute care units is often problematic and many discharges from intensive care to acute care are unsuccessful on the first attempt. The aim of this study was to explore the factors that influence intensive care patient discharge. This ethnographic study was undertaken in an Australian metropolitan tertiary hospital that had a 14-bed level 3 intensive care unit. Intensive care and acute care unit medical and nursing staff, and other hospital staff who were involved in the intensive care patient discharge process participated in this study. A total of 28 discharges were observed, and 56 one on one interviews were conducted. Data collection techniques including direct observations, semi-structured interviews, and collection of existing documents were used. Activity theory was the theoretical framework that underpinned this study. Three patient activity systems were identified: intensive care patient discharge activity, acute care unit accepting patient activity, and hospital bed management activity. Analysis of the interactions among these activity systems revealed conflicting objects (goals), communication breakdowns, and teamwork issues. Discharge delay was found to be a significant problem, which was associated with limited acute care unit bed availability. Strategies to improve acute care unit bed availability are needed. Routine after-hours ICU discharge could raise patient safety concerns which need to be considered. All team members' input in discharge decision making should be encouraged. Problems identified in clinical handover call for actions to change the handover practice. Activity theory successfully guided the study by providing a practical and descriptive framework for the study, facilitating the understanding of the interrelationships among the activity systems. Copyright © 2012 Elsevier Ltd. All rights reserved.

Transitioning from acute to primary health care nursing: an integrative review of the literature.

PubMed

Ashley, Christine; Halcomb, Elizabeth; Brown, Angela

2016-08-01

This paper seeks to explore the transition experiences of acute care nurses entering employment in primary health care settings. Internationally the provision of care in primary health care settings is increasing. Nurses are moving from acute care settings to meet the growing demand for a primary health care workforce. While there is significant research relating to new graduate transition experiences, little is known about the transition experience from acute care into primary health care employment. An integrative review, guided by Whittemore and Knafl's (2005) approach, was undertaken. Following a systematic literature search eight studies met the inclusion criteria. Papers which met the study criteria were identified and assessed against the inclusion and exclusion criteria. Papers were then subjected to methodological quality appraisal. Thematic analysis was undertaken to identify key themes within the data. Eight papers met the selection criteria. All described nurses transitioning to either community or home nursing settings. Three themes were identified: (1) a conceptual understanding of transition, (2) role losses and gains and (3) barriers and enablers. There is a lack of research specifically exploring the transitioning of acute care nurses to primary health care settings. To better understand this process, and to support the growth of the primary health care workforce there is an urgent need for further well-designed research. There is an increasing demand for the employment of nurses in primary health care settings. To recruit experienced nurses it is logical that many nurses will transition into primary health care from employment in the acute sector. To optimise retention and enhance the transition experience of these nurses it is important to understand the transition experience. © 2016 John Wiley & Sons Ltd.

Prevalence of Sarcopenia and Associated Factors in Chinese Community-Dwelling Elderly: Comparison Between Rural and Urban Areas.

PubMed

Gao, Langli; Jiang, Jiaojiao; Yang, Ming; Hao, Qiukui; Luo, Li; Dong, Birong

2015-11-01

To compare the prevalence of sarcopenia in urban and rural Chinese elderly adults and to identify the risk factors related to sarcopenia. A cross-sectional study. Urban and rural communities in western China. A total of 887 community-dwelling elderly adults aged 60 years or older. Sarcopenia was defined according to the recommended algorithm of the Asian Working Group for Sarcopenia (AWGS). Cognitive function, depression, and nutrition status were assessed using the Chinese version of the Mini-Mental Status Examination (MMSE), the Chinese version of the 30-item Geriatric Depression Scale (GDS-30), and the revised Mini Nutritional Assessment short-form (MNA-SF), respectively. A total of 612 individuals aged 70.6 ± 6.7 years (range, 60-91 years) were included in this study. The prevalence of sarcopenia in the study population was 9.8% (women, 12.0%; men, 6.7%; P = .031). The prevalence of sarcopenia was 13.1% in rural elders and 7.0% in urban elders (P = .012). Age (odds ratio [OR] 1.22; 95% confidence interval [CI] 1.15-1.29), women (OR 1.71; 95% CI 1.20-5.65), malnutrition or at risk for malnutrition (OR 3.53; 95% CI 1.68-7.41), rural residence (OR 2.15; 95% CI 1.33-4.51), and the number of medications (OR 1.23; 95% CI 1.06-1.44) were independently associated with sarcopenia. Rural elders are more vulnerable to sarcopenia than urban elders in a sample of western China's elderly population. More attention should focus on rural populations in future sarcopenia studies. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need

PubMed Central

2014-01-01

With the increasing trend in refugee urbanisation, growing numbers of refugees are diagnosed with chronic noncommunicable diseases (NCDs). However, with few exceptions, the local and international communities prioritise communicable diseases. The aim of this study is to review the literature to determine the prevalence and distribution of chronic NCDs among urban refugees living in developing countries, to report refugee access to health care for NCDs and to compare the prevalence of NCDs among urban refugees with the prevalence in their home countries. Major search engines and refugee agency websites were systematically searched between June and July 2012 for articles and reports on NCD prevalence among urban refugees. Most studies were conducted in the Middle East and indicated a high prevalence of NCDs among urban refugees in this region, but in general, the prevalence varied by refugees’ region or country of origin. Hypertension, musculoskeletal disease, diabetes and chronic respiratory disease were the major diseases observed. In general, most urban refugees in developing countries have adequate access to primary health care services. Further investigations are needed to document the burden of NCDs among urban refugees and to identify their need for health care in developing countries. PMID:24708876

Issues experienced while administering care to patients with dementia in acute care hospitals: A study based on focus group interviews

PubMed Central

Fukuda, Risa; Shimizu, Yasuko

2015-01-01

Objective Dementia is a major public health problem. More and more patients with dementia are being admitted to acute care hospitals for treatment of comorbidities. Issues associated with care of patients with dementia in acute care hospitals have not been adequately clarified. This study aimed to explore the challenges nurses face in providing care to patients with dementia in acute care hospitals in Japan. Methods This was a qualitative study using focus group interviews (FGIs). The setting was six acute hospitals with surgical and medical wards in the western region of Japan. Participants were nurses in surgical and internal medicine wards, excluding intensive care units. Nurses with less than 3 years working experience, those without experience in dementia patient care in their currently assigned ward, and head nurses were excluded from participation. FGIs were used to collect data from February to December 2008. Interviews were scheduled for 1–1.5 h. The qualitative synthesis method was used for data analysis. Results In total, 50 nurses with an average experience of 9.8 years participated. Eight focus groups were formed. Issues in administering care to patients with dementia at acute care hospitals were divided into seven groups. Three of these groups, that is, problematic patient behaviors, recurrent problem, and problems affecting many people equally, interact to result in a burdensome cycle. This cycle is exacerbated by lack of nursing experience and lack of organization in hospitals. In coping with this cycle, the nurses develop protection plans for themselves and for the hospital. Conclusions The two main issues experienced by nurses while administering care to patients with dementia in acute care hospitals were as follows: (a) the various problems and difficulties faced by nurses were interactive and caused a burdensome cycle, and (b) nurses do their best to adapt to these conditions despite feeling conflicted. PMID:25716983

The Experience of Witnessing Patients' Trauma and Suffering among Acute Care Nurses

ERIC Educational Resources Information Center

Walsh, Mary E.; Buchanan, Marla J.

2011-01-01

A large body of research provides evidence of workplace injuries to those in the nursing profession. Research on workplace stress and burnout among medical professionals is also well known; however, the profession of acute care nursing has not been examined with regards to work-related stress. This qualitative study focused on acute care nurses'…

Pressure Injuries in Inpatient Care Facilities in the Czech Republic: Analysis of a National Electronic Database.

PubMed

Pokorná, Andrea; Benešová, Klára; Jarkovský, Jirˇí; Mužík, Jan; Beeckman, Dimitri

The purpose of this study was to analyze pressure injury (PI) occurrence upon admission and at any time during the hospital course inpatients care facilities in the Czech Republic. Secondary aims were to evaluate demographic and clinical data of patients with PI and the impact of a PI on length of stay (LOS) in the hospital. Retrospective, cross-sectional analysis. The sample comprised data of hospitalized patients entered into the National Register of Hospitalized Patients (NRHOSP) database of the Czech Republic between 2007 and 2014 with a diagnosis L89 (pressure ulcer of unspecified site based on the International Classification of Diseases, Tenth Revision, ICD-10). Electronic records of 17,762,854 hospitalizations were reviewed. Data from the NRHOSP from all acute and non-acute care hospitals in the Czech Republic were analyzed. Specifically, we analyzed patients admitted to acute and non-acute care facilities with a primary or secondary diagnosis of PI. The NRHOSP database included 17,762,854 cases, of which 46,224 cases (33,342 cases in acute care hospitals; 12,882 in non-acute care hospitals) had the L89 diagnosis (0.3%). The mean age of patients admitted with a PI was 73.8 ± 15.3 years (mean ± SD), and their average LOS was 33.2 ± 76.9 days. The mean LOS of patients hospitalized with L89 code as a primary diagnosis (n = 6877) was significantly longer compared to those patients for whom L89 code was a secondary diagnosis (25.8 vs 20.2 days, P < .001) in acute care facilities. In contrast, we found no difference in the mean LOS for patients hospitalized in non-acute care facility (58.7 days vs 65.1 days; P = .146) with ICD code L89. Pressure injuries were associated with significant LOS in both acute and non-acute care settings in the Czech Republic. Despite the valuable insights we obtained from the analysis of NRHOSP data, we advocate creation of a more valid and reliable electronic reporting system that enables policy makers to evaluate the quality and safety concerning PI and its impact on patients and the healthcare system.

Factors associated with emergency medical services scope of practice for acute cardiovascular events.

PubMed

Williams, Ishmael; Valderrama, Amy L; Bolton, Patricia; Greek, April; Greer, Sophia; Patterson, Davis G; Zhang, Zefeng

2012-01-01

To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department-based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department-based/non-fire department-based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.

An analysis of clinical outcomes and costs of a long term acute care hospital.

PubMed

Votto, John J; Scalise, Paul J; Barton, Randall W; Vogel, Cristine A

2011-01-01

Compare clinical outcomes and costs in a study group of long-term acute care hospital (LTCH) patients with a control group of LTCH-eligible patients in an acute care hospital. LTCHs were created to provide post-acute care services not available at other post-acute settings. This is based on the premise that these patients would otherwise have stayed at acute care hospitals as high-cost outliers. The LTCH hospital is intended to deliver care to patients more efficiently, however, there are little documented clinical and financial data regarding the comparative clinical outcomes and costs for patients. Retrospective medical and billing record review of patients from the following groups: (1) LTCH study comprising patients admitted directly from an acute care hospital to the study LTCH and discharged from the LTCH from September 2004 through August 2006; (2) a control group of LTCH-eligible, medically complex patients treated and discharged from an acute care hospital in FY 2002. The control group was selected from approximately 500 patients who had at least one of the ten most common principle diagnosis DRGs of the study LTCH with >30-day length of stay at the referring hospital and met NALTH admitting guidelines. Discharge disposition is an important outcome measure of the quality of care of medically complex patients. The in-hospital mortality rate trended lower and home discharge was 3 times higher for the LTCH study group than for the control group. As a possible result, SNF discharge of LTCH patients was approximately half that of the control group. Both mean patient cost per day and mean total cost per patient were significantly higher in the control group than in the LTCH study group. The patients in the LTCH study group had both better clinical outcomes and lower cost of care than the control group.

Safe patient handling perceptions and practices: a survey of acute care physical therapists.

PubMed

Olkowski, Brian F; Stolfi, Angela M

2014-05-01

Acute care physical therapists are at risk for developing work-related musculoskeletal disorders (WMSDs) due to manual patient handling. Safe patient handling (SPH) reduces WMSDs caused by manual handling. The purpose of this study was to describe the patient handling practices of acute care physical therapists and their perceptions regarding SPH. Additionally, this study determined whether an SPH program influences the patient handling practices and perceptions regarding SPH of acute care physical therapists. Subscribers to the electronic discussion board of American Physical Therapy Association's Acute Care Section were invited to complete a survey questionnaire. The majority of respondents used SPH equipment and practices (91.1%), were confident using SPH equipment and practices (93.8%), agreed that evidence supports the use of SPH equipment and practices (87.0%), and reported the use of SPH equipment and practices is feasible (92.2%). Respondents at a facility with an SPH program were more likely to use SPH equipment and practices, have received training in the use of SPH equipment and practices, agree that the use of SPH equipment and practices is feasible, and feel confident using SPH equipment and practices. The study might not reflect the perceptions and practices of the population of acute care physical therapists. Acute care physical therapists are trained to use SPH equipment and practices, use SPH equipment and practices, and have positive perceptions regarding SPH. Acute care physical therapists in a facility with an SPH program are more likely to use SPH equipment and practices, receive training in SPH equipment and practices, and have positive perceptions regarding SPH. Quasi-regulatory organizations should incorporate SPH programs into their evaluative standards.

Acute care nurses' perceptions of spirituality and spiritual care: an exploratory study in Singapore.

PubMed

Chew, Brendan Wk; Tiew, Lay Hwa; Creedy, Debra K

2016-09-01

To investigate acute care nurses' perceptions of spirituality and spiritual care and relationships with nurses' personal and professional characteristics. Spirituality and spiritual care are often neglected or absent in daily nursing practice. Nurses' perceptions of spirituality can be influenced by personal, professional and social factors and affect the provision of spiritual care. A cross-sectional, exploratory, nonexperimental design was used. All nursing staff (n = 1008) from a large acute care hospital in Singapore were invited to participate. Participants completed a demographic form and the Spiritual Care-Giving Scale. Completed surveys were received from 767 staff yielding a response rate of 76%. Descriptive statistics and General Linear Modelling were used to analyse data. Acute care nurses reported positive perceptions of spirituality and spiritual care. Religion, area of clinical practice and view of self as spiritual were associated with nurses' reported perspectives of spirituality and spiritual care. Nurses working in this acute care hospital in Singapore reported positive perceptions of spirituality and spiritual care. Respondents tended to equate religion with spirituality and were often unclear about what constituted spiritual care. They reported a sense of readiness to apply an interprofessional approach to spiritual care. However, positive perceptions of spirituality may not necessarily translate into practice. Spiritual care can improve health outcomes. Nurses' understanding of spirituality is essential for best practice. Interprofessional collaboration with clinicians, administrators, educators, chaplains, clergy and spiritual leaders can contribute to the development of practice guidelines and foster spiritual care by nurses. Further research is needed on the practical applications of spiritual care in nursing. © 2016 John Wiley & Sons Ltd.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

PubMed Central

Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer

2018-01-01

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization. PMID:29766123

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon.

PubMed

Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer; Mayberry, John

2018-01-01

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Pre-hospital policies for the care of patients with acute coronary syndromes in India: A policy document analysis.

PubMed

Patel, Amisha; Prabhakaran, Dorairaj; Berendsen, Mark; Mohanan, P P; Huffman, Mark D

2017-04-01

Ischemic heart disease is the leading cause of death in India. In high-income countries, pre-hospital systems of care have been developed to manage acute manifestations of ischemic heart disease, such as acute coronary syndrome (ACS). However, it is unknown whether guidelines, policies, regulations, or laws exist to guide pre-hospital ACS care in India. We undertook a nation-wide document analysis to address this gap in knowledge. From November 2014 to May 2016, we searched for publicly available emergency care guidelines and legislation addressing pre-hospital ACS care in all 29 Indian states and 7 Union Territories via Internet search and direct correspondence. We found two documents addressing pre-hospital ACS care. Though India has legislation mandating acute care for emergencies such as trauma, regulations or laws to guide pre-hospital ACS care are largely absent. Policy makers urgently need to develop comprehensive, multi-stakeholder policies for pre-hospital emergency cardiovascular care in India. Copyright © 2016. Published by Elsevier B.V.

Latent Growth Modeling of nursing care dependency of acute neurological inpatients.

PubMed

Piredda, M; Ghezzi, V; De Marinis, M G; Palese, A

2015-01-01

Longitudinal three-time point study, addressing how neurological adult patient care dependency varies from the admission time to the 3rd day of acute hospitalization. Nursing care dependency was measured with the Care Dependency Scale (CDS) and a Latent Growth Modeling approach was used to analyse the CDS trend in 124 neurosurgical and stroke inpatients. Care dependence followed a decreasing linear trend. Results can help nurse-managers planning an appropriate amount of nursing care for acute neurological patients during their initial stage of hospitalization. Further studies are needed aimed at investigating the determinants of nursing care dependence during the entire in-hospital stay.

A national survey of the primary and acute care pediatric nurse practitioner educational preparation.

PubMed

Hawkins-Walsh, Elizabeth; Berg, Mary; Docherty, Sharron; Lindeke, Linda; Gaylord, Nan; Osborn, Kristen

2011-01-01

The past decade has been marked by a gradual expansion of the traditional primary care role of the pediatric nurse practitioner (PNP) into practice arenas that call for more acute and critical care of children. The purpose of the study was to explore the educational programming needs of dual (combined) track PNP programs that prepare graduates to provide care to children and adolescents across the continuum of health and illness. A two-phase, exploratory, mixed method design was utilized. An electronic survey was completed by 65% of PNP program directors in the country. Semi-structured telephone interviews were conducted with hospital-based PNPs who were practicing in roles that met a range of health care needs across the primary and acute care continuum. Primary care and acute care programs have more common than unique elements, and the vast majority of clinical competencies are common to both types of program. Only three competencies appear to be unique to acute care programs. The Association of Faculties of Pediatric Nurse Practitioner Programs should utilize existing evidence and develop guidelines for dual PNP programs that focus on the provision of care to children across a wide continuum of health and illness. Copyright © 2011 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.

PAs and NPs in an emergency room-linked acute care clinic.

PubMed

Currey, C J

1984-12-01

The use of hospital emergency rooms for nonurgent care during evenings hours often strains medical resources and may affect the quality of emergency care. One facility's effective use of an after-hours acute care clinic staffed by PAs and NPs to divert nonurgent problems away from its emergency room is outlined. PAs and NPs work during peak demand hours (evenings and weekends) under the supervision of an emergency room physician, and receive supplementary support from other emergency room personnel. Incoming patients are referred to the emergency room or acute care clinic, depending on the nature of their problems. Acute care clinic patients are then treated by the PA or NP and either released or referred to an emergency room physician, if their conditions warrant additional treatment. As a result, use of the acute care clinic has greatly reduced the amount of non-urgent medical treatment in the emergency room and has provided other advantages to both patients and staff as well. These advantages and the encouraging statistics following six months of the clinic's operation are discussed.

Pediatric thermal injury: acute care and reconstruction update.

PubMed

Armour, Alexis D; Billmire, David A

2009-07-01

The acute and reconstructive care of each pediatric burn patient presents unique challenges to the plastic surgeon and the burn care team. : The purpose of this review article is to highlight the interdependence between the acute and reconstructive needs of pediatric burn patients as it pertains to each anatomical site. Relevant principles of acute pediatric burn care and burn reconstruction are outlined, based on the authors' experience and review of the literature. The need for late reconstruction in pediatric burn survivors is significantly influenced by the acute surgical and rehabilitative treatments. With their vulnerability to airway swelling, hypothermia, pulmonary edema, and ischemia-reperfusion injury, pediatric patients with large burns require precise, life-saving treatment in the acute phase. Decision-making in pediatric burn reconstruction must take into account the patient's future growth, maturity, and often lack of suitable donor sites. Appropriately selected reconstructive techniques are essential to optimize function, appearance, and quality of life in pediatric burn survivors.

Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol.

PubMed

Parsons Leigh, Jeanna; Niven, Daniel J; Boyd, Jamie M; Stelfox, Henry T

2017-01-19

Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process. The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be descriptive using a combination of qualitative and quantitative analyses. There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.

Acute Respiratory Failure in Renal Transplant Recipients: A Single Intensive Care Unit Experience.

PubMed

Ulas, Aydin; Kaplan, Serife; Zeyneloglu, Pinar; Torgay, Adnan; Pirat, Arash; Haberal, Mehmet

2015-11-01

Frequency of pulmonary complications after renal transplant has been reported to range from 3% to 17%. The objective of this study was to evaluate renal transplant recipients admitted to an intensive care unit to identify incidence and cause of acute respiratory failure in the postoperative period and compare clinical features and outcomes between those with and without acute respiratory failure. We retrospectively screened the data of 540 consecutive adult renal transplant recipients who received their grafts at a single transplant center and included those patients admitted to an intensive care unit during this period for this study. Acute respiratory failure was defined as severe dyspnea, respiratory distress, decreased oxygen saturation, hypoxemia or hypercapnia on room air, or requirement of noninvasive or invasive mechanical ventilation. Among the 540 adult renal transplant recipients, 55 (10.7%) were admitted to an intensive care unit, including 26 (47.3%) admitted for acute respiratory failure. Median time from transplant to intensive care unit admission was 10 months (range, 0-67 mo). The leading causes of acute respiratory failure were bacterial pneumonia (56%) and cardiogenic pulmonary edema (44%). Mean partial pressure of arterial oxygen to fractional inspired oxygen ratio was 174 ± 59, invasive mechanical ventilation was used in 13 patients (50%), and noninvasive mechanical ventilation was used in 8 patients (31%). The overall mortality was 16.4%. Acute respiratory failure was the reason for intensive care unit admission in almost half of our renal transplant recipients. Main causes of acute respiratory failure were bacterial pneumonia and cardiogenic pulmonary edema. Mortality of patients admitted for acute respiratory failure was similar to those without acute respiratory failure.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life.

PubMed

Dumont, Serge; Jacobs, Philip; Turcotte, Véronique; Turcotte, Stéphane; Johnston, Grace

2015-12-01

Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas. The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas. Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures. The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer. The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care. Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas. © The Author(s) 2015.

Urban–Rural Differences in Health-Care-Seeking Pattern of Residents of Abia State, Nigeria, and the Implication in the Control of NCDs

PubMed Central

Onyeonoro, Ugochukwu U.; Ogah, Okechukwu S.; Ukegbu, Andrew U.; Chukwuonye, Innocent I.; Madukwe, Okechukwu O.; Moses, Akhimiem O.

2016-01-01

BACKGROUND Understanding the differences in care-seeking pattern is key in designing interventions aimed at improving health-care service delivery, including prevention and control of noncommunicable diseases. The aim of this study was to identify the differences and determinants of care-seeking patterns of urban and rural residents in Abia State in southeast Nigeria. METHODS This was a cross-sectional, community-based, study involving 2999 respondents aged 18 years and above. Data were collected using the modified World Health Organization’s STEPS questionnaire, including data on care seeking following the onset of illness. Descriptive statistics and logistic regressions were used to analyze care-seeking behavior and to identify differences among those seeking care in urban and rural areas. RESULTS In both urban and rural areas, patent medicine vendors (73.0%) were the most common sources of primary care following the onset of illness, while only 20.0% of the participants used formal care. Significant predictors of difference in care-seeking practices between residents in urban and rural communities were educational status, income, occupation, and body mass index. CONCLUSIONS Efforts should be made to reduce barriers to formal health-care service utilization in the state by increasing health insurance coverage, strengthening the health-care system, and increasing the role of patent medicine vendors in the formal health-care delivery system. PMID:27721654

Studying Physician-Patient Communication in the Acute Care Setting: The Hospitalist Rapport Study

PubMed Central

Anderson, Wendy G.; Winters, Kathryn; Arnold, Robert M.; Puntillo, Kathleen A.; White, Douglas B.; Auerbach, Andrew D.

2010-01-01

Objective To assess the feasibility of studying physician-patient communication in the acute care setting. Methods We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked. Results Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: 1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities, and 2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges. Conclusion Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection. Practice Implications These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment. PMID:20444569

A patient-centered research agenda for the care of the acutely ill older patient.

PubMed

Wald, Heidi L; Leykum, Luci K; Mattison, Melissa L P; Vasilevskis, Eduard E; Meltzer, David O

2015-05-01

Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training. © 2015 Society of Hospital Medicine.

Modular acute system for general surgery: hand over the operation, not the patient.

PubMed

Poole, Garth H; Glyn, Tamara; Srinivasa, Sanket; Hill, Andrew G

2012-03-01

Various models have been proposed to effectively provide acute surgical care in Australasia. Recently, General Surgeons Australia (GSA) has published a 12-point plan with guiding principles on this matter. This study describes a model of providing acute general surgical care in a high-volume institution, evaluates clinical outcomes and critically appraises the system against the GSA 12-point plan. The acute care system is qualitatively described with quantitative measures of workload. The outcomes of acute laparoscopic cholecystectomy were used as a proxy of system performance. The system was critically appraised against the GSA 12-point plan. Teams are on call once per week with each surgeon on call once per fortnight. The three key elements of acute management - collecting patients, post-acute ward round and operating - are treated as modules. The patient remains under the care of the admitting consultant but is often operated on by another team. From June 2009 to 2010, there were 7429 acute general surgical admissions (mean: 20.4 patients per day) with 2999 acute operations (mean: 8.4 operations per day). The other activities of the department were not compromised. In that time, 388 acute laparoscopic cholecystectomies were performed with a conversion rate of 1.3% and no major bile duct injury. The system is compatible with the GSA 12-point plan. This study describes an efficient and safe system for providing acute general surgical care in a high-volume setting with satisfactory clinical outcomes. It is compatible with the GSA 12-point plan. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.

Acute Rubella Virus Infection among Women with Spontaneous Abortion in Mwanza City, Tanzania.

PubMed

Lulandala, Lukombodzo; Mirambo, Mariam M; Matovelo, Dismas; Gumodoka, Balthazar; Mshana, Stephen E

2017-03-01

Acute rubella virus infection in early pregnancy has been associated with poor pregnancy outcome ranging from spontaneous abortion, stillbirth and multiple birth defects known as Congenital Rubella Syndrome (CRS). Despite its importance the prevalence of acute rubella virus infections is not known among women with spontaneous abortion in most centres in developing countries. The present study was aimed to determine the seroprevalence of acute rubella infection among women with spontaneous abortion in Mwanza city. A total of 268 women with spontaneous abortion were enrolled from four different hospitals in Mwanza city between November 2015 and April 2016. Blood samples were collected; sera were extracted and stored at -80°C until processing. Acute rubella virus infection was diagnosed by the detection of rubella specific IgM antibodies using indirect Enzyme Linked Immunosorbent Assay (ELISA) as per manufacturer's instructions. Data were analysed by using STATA version 11. The mean age of enrolled women was 26.3±5.6 years. The prevalence of acute rubella virus infection was found to be 9/268 (3.7%, 95% CI: 1-5). Only women residing in urban areas (AOR: 5.65, 95% CI: 1.15-27.77, p=0.035) were found to predict acute rubella virus infection among cases with spontaneous abortion in Mwanza city. About four out of hundred women residing in urban areas with spontaneous abortion in Mwanza are acutely infected with rubella virus highlighting the potential of this virus in contributing to poor pregnancy outcome in this setting.

Hurricane Sandy - Public Health Situation Updates - PHE

Science.gov Websites

National Veterinary Response Team from HHS will provide primary and acute care for pets at a large pet Team from HHS anticipates providing primary and acute care for pets in the hard hit area New York City from HHS anticipates providing primary and acute care for pets in the hard hit area New York City known

Self-reported preparedness of New Zealand acute care providers to mass emergencies before the Canterbury Earthquakes: a national survey.

PubMed

Al-Shaqsi, Sultan; Gauld, Robin; McBride, David; Al-Kashmiri, Ammar; Al-Harthy, Abdullah

2015-02-01

Disasters occur more frequently. Acute care providers are the first to respond to mass emergencies from the healthcare sector. The preparedness of acute care providers in New Zealand to respond to mass emergencies has not been previously studied. To assess the self-reported training and experience of New Zealand acute care providers to respond to mass emergencies and the factors associated with strong preparedness. A cross-sectional national survey of 1500 acute care providers in New Zealand carried out between 2009 and 2010. The survey assessed experience, training and self-reported preparedness. It also determined the factors associated with strong perceived preparedness. The response rate to this survey was 60.7%. Nurses had a higher response rate than doctors or paramedics. Only 29.2% of acute care providers reported responding to a previous mass emergency event. There were 53.5% of acute care providers who reported having formal training in how to deal with mass emergencies, whereas 58.1% of participants reported that they were aware of their role during a healthcare mass emergency response. The factors associated with self-reported strong preparedness to deal with mass emergencies included: being a paramedic, previous training, participation in a drill, willingness to report to work during an infection or man-made emergency, ability to triage and general awareness of the role during a mass emergency. Almost half of New Zealand acute healthcare providers have no training in dealing with mass emergency events. Training and general awareness of the role during a mass emergency response were the main factors associated with strong self-reported preparedness of acute care providers. The apparent efficacy of training allied to lack of availability means that it should be a national priority. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Acute care hospitals' accountability to provincial funders.

PubMed

Kromm, Seija K; Ross Baker, G; Wodchis, Walter P; Deber, Raisa B

2014-09-01

Ontario's acute care hospitals are subject to a number of tools, including legislation and performance measurement for fiscal accountability and accountability for quality. Examination of accountability documents used in Ontario at the government, regional and acute care hospital levels reveals three trends: (a) the number of performance measures being used in the acute care hospital sector has increased significantly; (b) the focus of the health system has expanded from accountability for funding and service volumes to include accountability for quality and patient safety; and (c) the accountability requirements are misaligned at the different levels. These trends may affect the success of the accountability approach currently being used. Copyright © 2014 Longwoods Publishing.

Do acute-care surgeons follow best practices for breast abscess management? A single-institution analysis of 325 consecutive cases.

PubMed

Barron, Alison Unzeitig; Luk, Stephen; Phelan, Herb A; Williams, Brian H

2017-08-01

The breast surgery community has adopted needle aspiration as the standard of care for breast abscesses, which have a size less than 5 cm on ultrasound, no skin changes, and fewer than 5 days of symptoms. Our acute-care surgery (ACS) service manages all breast abscess consults at our urban safety-net hospital. We undertook this descriptive study to identify the rate of operative incisions and drainage performed by ACS surgeons which were not compatible with best practices for breast abscess management. We performed a retrospective review of the electronic health records of all patients on whom the ACS service was consulted for a breast abscess at our urban safety-net hospital between January 2010 and December 2014. We collected data on patient demographics, breast skin characteristics, length of symptoms, ultrasound results, and treatment modality. A total of 325 patients with breast abscesses were evaluated by ACS, of whom 21 met the breast community's indications for needle aspiration. Of the overall 325 subject sample, 281 (86.5%) underwent incision and drainage (I&D), and 44 (13.5%) underwent bedside needle aspiration. Of the 281 patients that underwent I&D, 269 (95.7%) met the breast surgery community's indications for I&D due to either skin changes (n = 90, 33.5%), abscess >5 cm on ultrasound (n = 88, 32.7%), or symptoms >5 days (n = 238, 88.5%). Of the 44 patients that underwent needle aspiration, only 9 (20.5%) met the current practice indications for aspiration. Of the 44 patients that underwent aspiration, 28 (63.6%) failed and went on to have an operation. The majority of these failed aspirations had symptoms >5 days (23 patients, 82.1%) or had skin changes at presentation (1 patient, 3.6%) or an abscess >5 cm on ultrasound (5 patients, 17.9%). As judged by best practices promulgated by the breast surgery community, ACS surgeons do not show excessive rates of operative I&D of breast abscess and in fact seem to overutilize needle aspiration. To our knowledge, this is the largest single institution series of the management of breast abscesses by ACS surgeons in the literature. Copyright © 2017 Elsevier Inc. All rights reserved.

Insular pathways to health care in the city: a multilevel analysis of access to hospital care in urban Kerala, India.

PubMed

Levesque, Jean-Frédéric; Haddad, Slim; Narayana, Delampady; Fournier, Pierre

2007-07-01

To identify individual and urban unit characteristics associated with access to inpatient care in public and private sectors in urban Kerala, and to discuss policy implications of inequalities in access. We analysed the NSSO survey (1995-1996) for urban Kerala with regard to source and trajectories of hospitalization. Multinomial multilevel regression models were built for 695 cases nested in 24 urban units. Private sector accounts for 62% of hospitalizations. Only 31% of hospitalizations are in free wards and 20% of public hospitalizations involve payment. Hospitalization pathways suggest a segmentation of public and private health markets. Members of poor and casual worker households have lower propensity of hospitalization in paying public wards or private hospitals. There were important variations between cities, with higher odds of private hospitalization in towns with fewer hospital beds overall and in districts with high private-public bed ratios. Cities from districts with better economic indicators and dominance of private services have higher proportion of private hospitalizations. The private sector is the predominant source of inpatient care in urban Kerala. The public sector has an important role in providing access to care for the poor. Investing in the quality of public services is essential to ensure equity in access.

Utility of CT classifications to predict unfavorable outcomes in children with acute pancreatitis.

PubMed

Izquierdo, Yojhan E; Fonseca, Eileen V; Moreno, Luz-Ángela; Montoya, Rubén D; Guerrero Lozano, Rafael

2018-02-21

Computed tomography (CT) is useful for the diagnosis of local complications in children with acute pancreatitis but its role as a prognostic tool remains controversial. To establish the correlation between the CT Severity Index and the Revised Atlanta Classification regarding unfavorable outcomes such as severe acute pancreatitis and need for Pediatric Special Care Unit attention in children with acute pancreatitis. We conducted a retrospective and concordance cohort study in which we obtained abdominal CT scans from 30 patients ages 0 to 18 years with acute pancreatitis. Two pediatric radiologists interpreted the results using the CT Severity Index and the Revised Atlanta Classification. The kappa coefficient was determined for each scale. The association among severe acute pancreatitis, need for admission to the Pediatric Special Care Unit and CT systems were established using chi-square or Mann-Whitney U tests. The best CT Severity Index value to predict the need for admission to the Pediatric Special Care Unit was estimated through a receiver operating characteristic (ROC) curve. Mean CT Severity Index was 5.1±2.8 (mean ± standard deviation on a scale of 0 to 10) for the severe acute pancreatitis group vs. 3.8±2.7 for the mild acute pancreatitis group (P=0.230). The CT Severity Index for the children who were not hospitalized at the Pediatric Special Care Unit was 2.2±2.2 vs. 5.6±2.4 for the group hospitalized at the Pediatric Special Care Unit (P=0.001). Only parenchymal necrosis >30% was associated with severe acute pancreatitis (P=0.021). A CT Severity Index ≥3 has a sensitivity of 89% and specificity of 72% to predict need for admission to the Pediatric Special Care Unit. None of the Revised Atlanta Classification categories was associated with severe acute pancreatitis or admission to the Pediatric Special Care Unit. A CT Severity Index ≥3 in children with acute pancreatitis who require CT assessment based on clinical criteria is associated with the need for admission to the Pediatric Special Care Unit. We found that pancreatic necrosis greater than 30% is the only tomographic parameter related to severe acute pancreatitis. New studies with a greater sample size are necessary to confirm this result.

Building on a national health information technology strategic plan for long-term and post-acute care: comments by the Long Term Post Acute Care Health Information Technology Collaborative.

PubMed

Alexander, Gregory L; Alwan, Majd; Batshon, Lynne; Bloom, Shawn M; Brennan, Richard D; Derr, John F; Dougherty, Michelle; Gruhn, Peter; Kirby, Annessa; Manard, Barbara; Raiford, Robin; Serio, Ingrid Johnson

2011-07-01

The LTPAC (Long Term Post Acute Care) Health Information Technology (HIT) Collaborative consists of an alliance of long-term services and post-acute care stakeholders. Members of the collaborative are actively promoting HIT innovations in long-term care settings because IT adoption for health care institutions in the United States has become a high priority. One method used to actively promote HIT is providing expert comments on important documents addressing HIT adoption. Recently, the Office of the National Coordinator for HIT released a draft of the Federal Health Information Technology Strategic Plan 2011-2015 for public comment. The following brief is intended to inform about recommendations and comments made by the Collaborative on the strategic plan. Copyright 2011, SLACK Incorporated.

Chronic oedema: a prevalent health care problem for UK health services.

PubMed

Moffatt, Christine J; Keeley, Vaughan; Franks, Peter J; Rich, Anna; Pinnington, Lorraine L

2017-10-01

Chronic oedema (CO) is a major clinical problem worldwide, which has many important secondary consequences for health, activity and participation. Effective treatment planning and organisation of services is dependent on an understanding of the condition and its epidemiology. This cross-sectional study was designed to estimate the point prevalence of CO within the health services of one UK urban population and to determine the proportions that have concurrent leg ulceration. Patients with CO in all anatomic sites were ascertained by health care professionals in one acute and one community hospital, all relevant outpatient and community nursing services, general practices and all nursing/residential homes in one urban catchment area (Derby City). The presence and distribution of oedema was confirmed through a brief clinical examination. A battery of demographic and clinical details was recorded for each case. Within the study population of Derby City residents, 971 patients were identified with CO [estimated crude prevalence 3·93 per 1000, 95% confidence interval (CI) 3·69-4·19]. The prevalence was the highest among those aged 85 or above (28·75 per 1000) and was higher among women (5·37 per 1000) than men (2·48 per 1000). The prevalence among hospital inpatients was 28·5%. Only five (3%) patients in the community population had oedema related to cancer or cancer treatment. Of the 304 patients identified with oedema from the Derby hospitals or community health services, 121 (40%) had a concurrent leg ulcer. Prevalence statistics and current demographic trends indicate that CO is a major and growing health care problem. © 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings

PubMed Central

Pian, Linping; Gillman, Lawrence M.; McBeth, Paul B.; Xiao, Zhengwen; Ball, Chad G.; Blaivas, Michael; Hamilton, Douglas R.; Kirkpatrick, Andrew W.

2013-01-01

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings. PMID:23431455

Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service.

PubMed

Salonga-Reyes, Armi; Scott, Ian A

2017-03-01

Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings. Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy. What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays. What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays. What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.

Functional survival after acute care for severe head injury at a designated trauma center in Hong Kong.

PubMed

Taw, Benedict B T; Lam, Alan C S; Ho, Faith L Y; Hung, K N; Lui, W M; Leung, Gilberto K K

2012-07-01

Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong. This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE). Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months. Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery. Copyright © 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.

Treatment-seeking behaviour, cost burdens and coping strategies among rural and urban households in Coastal Kenya: an equity analysis.

PubMed

Chuma, Jane; Gilson, Lucy; Molyneux, Catherine

2007-05-01

Ill-health can inflict costs on households directly through spending on treatment and indirectly through impacting on labour productivity. The financial burden can be high and, for poor households, contributes significantly to declining welfare. We investigated socio-economic inequities in self-reported illnesses, treatment-seeking behaviour, cost burdens and coping strategies in a rural and urban setting along the Kenyan coast. We conducted a survey of 294 rural and 576 urban households, 9 FGDs and 9 in-depth interviews in each setting. Key findings were significantly higher levels of reported chronic and acute conditions in the rural setting, differences in treatment-seeking patterns by socio-economic status (SES) and by setting, and regressive cost burdens in both areas. These data suggest the need for greater governmental and non-governmental efforts towards protecting the poor from catastrophic illness cost burdens. Promising health sector options are elimination of user fees, at least in targeted hardship areas, developing more flexible charging systems, and improving quality of care in all facilities. The data also strongly support the need for a multi-sectoral approach to protecting households. Potential interventions beyond the health sector include supporting the social networks that are key to household livelihood strategies and promoting micro-finance schemes that enable small amounts of credit to be accessed with minimal interest rates.

Prevalence of human parvovirus B19 in sickle cell disease and healthy controls.

PubMed

Teuscher, T; Baillod, B; Holzer, B R

1991-01-01

The serological HPV status of 35 patients with SCA (Hb SS), randomly chosen from a sickle cell clinic in rural south-west Togo and of 13 household members with normal haemoglobin type (Hb AA) was assessed. No difference in HPV-IgG seropositivity rate was found. In 30 urban hospital patients from Abidjan, Ivory Coast, who were in acute painful sickle cell crisis HPV-IgG seropositivity rate increased with age. In only one (HIV positive) patient HPV-IgM antibodies were detected. It is concluded that HPV-infection exists in West Africa (1) and that there is no evidence for increased seroprevalence in SCA (2). HPV does not seem to trigger acute painful crises in SCA (3). The age-specific HPV seropositivity increase in urban patients may be due to differing transmission rates in urban and rural areas.

Health and urban living.

PubMed

Dye, Christopher

2008-02-08

The majority of people now live in urban areas and will do so for the foreseeable future. As a force in the demographic and health transition, urbanization is associated with falling birth and death rates and with the shift in burden of illness from acute childhood infections to chronic, noncommunicable diseases of adults. Urban inhabitants enjoy better health on average than their rural counterparts, but the benefits are usually greater for the rich than for the poor, thus magnifying the differences between them. Subject to better evidence, I suggest that the main obstacles to improving urban health are not technical or even financial, but rather are related to governance and the organization of civil society.

Newborn Care Practices among Mother-Infant Dyads in Urban Uganda

PubMed Central

Kayom, Violet Okaba; Kakuru, Abel; Kiguli, Sarah

2015-01-01

Background. Most information on newborn care practices in Uganda is from rural communities which may not be generalized to urban settings. Methods. A community based cross-sectional descriptive study was conducted in the capital city of Uganda from February to May 2012. Quantitative and qualitative data on the newborn care practices of eligible mothers were collected. Results. Over 99% of the mothers attended antenatal care at least once and the majority delivered in a health facility. Over 50% of the mothers applied various substances to the cord of their babies to quicken the healing. Although most of the mothers did not bathe their babies within the first 24 hours of birth, the majority had no knowledge of skin to skin care as a thermoprotective method. The practice of bathing babies in herbal medicine was common (65%). Most of the mothers breastfed exclusively (93.2%) but only 60.7% initiated breastfeeding within the first hour of life, while a significant number (29%) used prelacteal feeds. Conclusion. The inadequate newborn care practices in this urban community point to the need to intensify the promotion of universal coverage of the newborn care practices irrespective of rural or urban communities and irrespective of health care seeking indicators. PMID:26713096

Effects of Teaching Health Care Workers on Diagnosis and Treatment of Pesticide Poisonings in Uganda

PubMed Central

Sibani, Claudia; Jessen, Kristian Kjaer; Tekin, Bircan; Nabankema, Victoria; Jørs, Erik

2017-01-01

Background: Acute pesticide poisoning in developing countries is a considerable problem, requiring diagnosis and treatment. This study describes how training of health care workers in Uganda affects their ability to diagnose and manage acute pesticide poisoning. Method: A postintervention cross-sectional study was conducted using a standardized questionnaire. A total of 326 health care workers in Uganda were interviewed on knowledge and handling of acute pesticide poisoning. Of those, 173 health care workers had received training, whereas 153 untrained health care workers from neighboring regions served as controls. Results: Trained health care workers scored higher on knowledge of pesticide toxicity and handling of acute pesticide poisoning. Stratification by sex, profession, experience, and health center level did not have any influence on the outcome. Conclusions: Training health care workers can improve their knowledge and treatment of pesticide poisonings. Knowledge of the subject is still insufficient among health care workers and further training is needed. PMID:28890656

Rural-Urban Differences in Preventable Hospitalizations among Community-Dwelling Veterans with Dementia

ERIC Educational Resources Information Center

Thorpe, Joshua M.; Van Houtven, Courtney H.; Sleath, Betsy L.; Thorpe, Carolyn T.

2010-01-01

Context: Alzheimer's patients living in rural communities may face significant barriers to effective outpatient medical care. Purpose: We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia. Methods: Medicare…

Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital.

PubMed

Lamas, Daniela J; Owens, Robert L; Nace, R Nicholas; Massaro, Anthony F; Pertsch, Nathan J; Gass, Jonathon; Bernacki, Rachelle E; Block, Susan D

2017-04-01

Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates. We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed. One long-term acute care hospital. Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates. Semi-structured conversation about quality of life, expectations, and planning for setbacks. A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year. Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.

End-of-Life Care in an Acute Care Hospital: Linking Policy and Practice

ERIC Educational Resources Information Center

Sorensen, Ros; Iedema, Rick

2011-01-01

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be…

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis.

PubMed

Callender, Thomas; Woodward, Mark; Roth, Gregory; Farzadfar, Farshad; Lemarie, Jean-Christophe; Gicquel, Stéphanie; Atherton, John; Rahimzadeh, Shadi; Ghaziani, Mehdi; Shaikh, Maaz; Bennett, Derrick; Patel, Anushka; Lam, Carolyn S P; Sliwa, Karen; Barretto, Antonio; Siswanto, Bambang Budi; Diaz, Alejandro; Herpin, Daniel; Krum, Henry; Eliasz, Thomas; Forbes, Anna; Kiszely, Alastair; Khosla, Rajit; Petrinic, Tatjana; Praveen, Devarsetty; Shrivastava, Roohi; Xin, Du; MacMahon, Stephen; McMurray, John; Rahimi, Kazem

2014-08-01

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs. Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified. The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

Heart Failure Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

PubMed Central

Callender, Thomas; Woodward, Mark; Roth, Gregory; Farzadfar, Farshad; Lemarie, Jean-Christophe; Gicquel, Stéphanie; Atherton, John; Rahimzadeh, Shadi; Ghaziani, Mehdi; Shaikh, Maaz; Bennett, Derrick; Patel, Anushka; Lam, Carolyn S. P.; Sliwa, Karen; Barretto, Antonio; Siswanto, Bambang Budi; Diaz, Alejandro; Herpin, Daniel; Krum, Henry; Eliasz, Thomas; Forbes, Anna; Kiszely, Alastair; Khosla, Rajit; Petrinic, Tatjana; Praveen, Devarsetty; Shrivastava, Roohi; Xin, Du; MacMahon, Stephen; McMurray, John; Rahimi, Kazem

2014-01-01

Background Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs. Methods and Findings Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%–64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%–41%) with beta-blockers, and 32% (95% CI: 25%–39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%–7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%–10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified. Conclusions The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary PMID:25117081

Advanced practice nursing role delineation in acute and critical care: application of the strong model of advanced practice.

PubMed

Mick, D J; Ackerman, M H

2000-01-01

This purpose of this study was to differentiate between the roles of clinical nurse specialists and acute care nurse practitioners. Hypothesized blending of the clinical nurse specialist and acute care nurse practitioner roles is thought to result in an acute care clinician who integrates the clinical skills of the nurse practitioner with the systems knowledge, educational commitment, and leadership ability of the clinical nurse specialist. Ideally, this role blending would facilitate excellence in both direct and indirect patient care. The Strong Model of Advanced Practice, which incorporates practice domains of direct comprehensive care, support of systems, education, research, and publication and professional leadership, was tested to search for practical evidence of role blending. This descriptive, exploratory, pilot study included subjects (N = 18) solicited from an academic medical center and from an Internet advanced practice listserv. Questionnaires included self-ranking of expertise in practice domains, as well as valuing of role-related tasks. Content validity was judged by an expert panel of advanced practice nurses. Analyses of descriptive statistics revealed that clinical nurse specialists, who had more experience both as registered nurses and in the advanced practice nurse role, self-ranked their expertise higher in all practice domains. Acute care nurse practitioners placed higher importance on tasks related to direct comprehensive care, including conducting histories and physicals, diagnosing, and performing diagnostic procedures, whereas clinical nurse specialists assigned greater importance to tasks related to education, research, and leadership. Levels of self-assessed clinical expertise as well as valuing of role-related tasks differed among this sample of clinical nurse specialists and acute care nurse practitioners. Groundwork has been laid for continuing exploration into differentiation in advanced practice nursing roles. As the clinical nurse specialist role changes and the acute care nurse practitioner role emerges, it is imperative that advanced practice nurses describe their contribution to health care. Associating advanced practice nursing activities with outcomes will help further characterize these 2 advanced practice roles.

Increasing expenditure on health care incurred by diabetic subjects in a developing country: a study from India.

PubMed

Ramachandran, Ambady; Ramachandran, Shobhana; Snehalatha, Chamukuttan; Augustine, Christina; Murugesan, Narayanasamy; Viswanathan, Vijay; Kapur, Anil; Williams, Rhys

2007-02-01

This study aimed to assess the direct cost incurred by diabetic subjects who were in different income groups in urban and rural India, as well as to examine the changing trends of costs in the urban setting from 1998 to 2005. A total of 556 diabetic subjects from various urban and rural regions of seven Indian states were enrolled. A brief uniform coded questionnaire (24 items) on direct cost was used. Annual family income was higher in urban subjects (rupees [Rs] 100,000 or $2,273) than in the rural subjects (Rs 36,000 or $818) (P < 0.001). Total median expenditure on health care was Rs 10,000 ($227) in urban and Rs 6,260 ($142) in rural (P < 0.001) subjects. Treatment costs increased with duration of diabetes, presence of complications, hospitalization, surgery, insulin therapy, and urban setting. Lower-income groups spent a higher proportion of their income on diabetes care (urban poor 34% and rural poor 27%). After accounting for inflation, a secular increase of 113% was observed in the total expenses between 1998 and 2005 in the urban population. The highest increase in percentage of household income devoted to diabetes care was in the lowest economic group (34% of income in 1998 vs. 24.5% in 2005) (P < 0.01). There was a significant improvement in urban subjects in medical reimbursement from 2% (1998) to 21.3% (2005). Urban and rural diabetic subjects spend a large percentage of income on diabetes management. The economic burden on urban families in developing countries is rising, and the total direct cost has doubled from 1998 to 2005.

Improving performance management for delivering appropriate care for patients no longer needing acute hospital care.

PubMed

Penney, Christine; Henry, Effie

2008-01-01

The public, providers and policy-makers are interested in a service continuum where care is provided in the appropriate place. Alternate level of care is used to define patients who no longer need acute care but remain in an acute care bed. Our aims were to determine how subacute care and convalescent care should be defined in British Columbia (BC); how these care levels should be aligned with existing legislation to provide more consistent service standards to patients and what reporting requirements were needed for system planning and performance management. A literature review was conducted to understand the international trends in performance management, care delivery models and change management. A Canada-wide survey was carried out to determine the directions of other provinces on the defined issues and a BC survey provided a current state analysis of programming within the five regional health authorities (HAs). A provincial policy framework for subacute and convalescent care has been developed to begin to address the concerns raised and provide a base for performance measurement. The policy has been approved and disseminated to BC HAs for implementation. An implementation plan has been developed and implementation activities have been integrated into the work of existing provincial committees. Evaluation will occur through performance measurement. The benefits anticipated include: clear policy guidance for programme development; improved comparability of performance information for system monitoring, planning and integrity of the national acute care Discharge Abstracting Database; improved efficiency in acute care bed use; and improved equity of access, insurability and quality for patients requiring subacute and convalescent care. While a national reporting system exists for acute care in Canada, this project raises questions about the implications for this system, given the shifting definition of acute care as other care levels emerge. Questions are also raised by the finding in Australia that the current case-mix system is inadequate to describe these patients. Further, given the inadequacy of our understanding of health system capacity and output, consideration of a more comprehensive national reporting system along the care continuum may be warranted. This project is an example of effective collaboration between the provincial government, a national organization and HAs, and suggests that provincial governments can participate in a meaningful way to accomplish research-informed health services policy.

Informal Consultations Provided to General Internists by the Gastroenterology Department of an HMO

PubMed Central

Pearson, Steven D; Moreno, Ricardo; Trnka, Yvona

1998-01-01

OBJECTIVE To study the process, outcomes, and time spent on informal consultations provided by gastroenterologists to the primary care general internists of an HMO. DESIGN Observational study. SETTING A large, urban staff-model HMO. PATIENTS/PARTICIPANTS Seven gastroenterologists constituting the total workforce of the gastroenterology department of the HMO. MEASUREMENTS AND MAIN RESULTS Data on 91 informal consultations were obtained, of which 55 (60%) involved the acute management of a patient with new symptoms or test results, and 36 (40%) were for questions related to nonacute diagnostic test selection or medical therapy. Questions regarding patients previously unknown to the gastroenterology department accounted for 74 (81%) of the consultations. Formal referral was recommended in only 16 (22%) of these cases. As judged by the time data gathered on the 91 consultations, the gastroenterologists spent approximately 7.2 hours per week to provide informal consultation for the entire HMO. CONCLUSIONS Gastroenterologists spend a significant amount of time providing informal consultation to their general internist colleagues in this HMO. The role informal consultation plays in the workload of physicians and in the clinical care of populations is an important question for health care system design, policy, and research. PMID:9686708

Rural-Urban Differences in the Long-Term Care of the Disabled Elderly in China

PubMed Central

Li, Mei; Zhang, Yang; Zhang, Zhenyu; Zhang, Ying; Zhou, Litao; Chen, Kun

2013-01-01

Background In China, the rapid rate of population aging and changes in the prevalence of disability among elderly people could have significant effects on the demand for long-term care. This study aims to describe the urban-rural differences in use and cost of long-term care of the disabled elderly and to explore potential influencing factors. Methods This study uses data from a cross-sectional survey and a qualitative investigation conducted in Zhejiang province in 2012. The participants were 826 individuals over 60 years of age, who had been bedridden or suffered from dementia for more than 6 months. A generalized linear model and two-part regression model were applied to estimate costs, with adjustment of covariates. Results Pensions provide the main source of income for urban elderly, while the principal income source for rural elderly is their family. Urban residents spend more on all services than do rural residents. Those who are married spend less on daily supplies and formal care than the unmarried do. Age, incapacitation time, comorbidity number, level of income, and bedridden status influence spending on medical care (β=-0.0316, -0.0206, 0.1882, 0.3444, and -0.4281, respectively), but the cost does not increase as the elderly grow older. Urban residents, the married, and those with a higher income level tend to spend more on medical equipment. Urban residence and living status are the two significant factors that affect spending on personal hygiene products. Conclusions The use of long-term care services varies by living area. Long-term care of the disabled elderly imposes a substantial burden on families. Our study revealed that informal care involves huge opportunity costs to the caregivers. Chinese policy makers need to promote community care and long-term care insurance to relieve the burden of families of disabled elderly, and particular attention should be given to the rural elderly. PMID:24224025

Rural-urban differences in the long-term care of the disabled elderly in China.

PubMed

Li, Mei; Zhang, Yang; Zhang, Zhenyu; Zhang, Ying; Zhou, Litao; Chen, Kun

2013-01-01

In China, the rapid rate of population aging and changes in the prevalence of disability among elderly people could have significant effects on the demand for long-term care. This study aims to describe the urban-rural differences in use and cost of long-term care of the disabled elderly and to explore potential influencing factors. This study uses data from a cross-sectional survey and a qualitative investigation conducted in Zhejiang province in 2012. The participants were 826 individuals over 60 years of age, who had been bedridden or suffered from dementia for more than 6 months. A generalized linear model and two-part regression model were applied to estimate costs, with adjustment of covariates. Pensions provide the main source of income for urban elderly, while the principal income source for rural elderly is their family. Urban residents spend more on all services than do rural residents. Those who are married spend less on daily supplies and formal care than the unmarried do. Age, incapacitation time, comorbidity number, level of income, and bedridden status influence spending on medical care (β=-0.0316, -0.0206, 0.1882, 0.3444, and -0.4281, respectively), but the cost does not increase as the elderly grow older. Urban residents, the married, and those with a higher income level tend to spend more on medical equipment. Urban residence and living status are the two significant factors that affect spending on personal hygiene products. The use of long-term care services varies by living area. Long-term care of the disabled elderly imposes a substantial burden on families. Our study revealed that informal care involves huge opportunity costs to the caregivers. Chinese policy makers need to promote community care and long-term care insurance to relieve the burden of families of disabled elderly, and particular attention should be given to the rural elderly.

Implementation of the integrated palliative care outcome scale in acute care settings - a feasibility study.

PubMed

Lind, Susanne; Sandberg, J; Brytting, T; Fürst, C J; Wallin, L

2018-01-21

Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings. A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals. Result Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers' involvement in the implementation differed between the units. Significance of the results The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.

Functional independence of residents in urban and rural long-term care facilities in Taiwan.

PubMed

Lin, Kwan-Hwa; Wu, Shiao-Chi; Hsiung, Chia-Ling; Hu, Ming-Hsia; Hsieh, Ching-Lin; Lin, Jau-Hong; Kuo, Mei-Ying

2004-02-04

To compare the score of functional independence measure (FIM) between urban and rural residents living in long-term care facilities (LTCF) in Taiwan. A total of 437 subjects in 112 licensed LTCF in Taiwan were randomly selected by stratification strategy. Physical therapists interviewed the subjects in nursing homes (NH) and intermediate care facilities (ICF) to obtain the basic data, and the FIM score. (1) There was no significant difference in basic demographic data between urban and rural LTC subjects. (2) Most of the subjects in urban and rural LTCF were males, less than 80 years old, single/widowed, having multiple diseases, using more than one assistive devices, and having social welfare financial support. (3) Motor abilities (eating, grooming, and transfer) and cognition (comprehension, social interaction and problem solving) in rural LTCF subjects were significantly (p < 0.05) higher than those in urban areas as revealed by the FIM assessment. (4) The median of FIM total score of rural LTCF subjects was 90.5, which was significantly (p < 0.05) higher than that of urban LTCF subjects (median = 76). Some of the functional performance of subjects in rural long-term care institutions is better than those in urban areas. Our results may provide guidelines for the manpower and equipment supply estimation.

Building Care Bridges between Acute and Long-Term Care with Nursing Diagnosis.

ERIC Educational Resources Information Center

Taylor, Carol A.

The increasing age of the American population and the current emphasis on cost containment in health care make the 1980s an ideal time for building bridges to span the health care needs of elderly persons in acute care and long-term care. While hospitals often discharge patients to nursing homes as an intermediate step between hospitalization and…

Representing and Retrieving Patients' Falls Risk Factors and Risk for Falls among Adults in Acute Care through the Electronic Health Record

ERIC Educational Resources Information Center

Pfaff, Jann

2013-01-01

Defining fall risk factors and predicting fall risk status among patients in acute care has been a topic of research for decades. With increasing pressure on hospitals to provide quality care and prevent hospital-acquired conditions, the search for effective fall prevention interventions continues. Hundreds of risk factors for falls in acute care…

Urban-rural disparity and determinants of delivery care utilization in Oromia region, Ethiopia: Community-based cross-sectional study.

PubMed

Kenea, Dinke; Jisha, Hunduma

2017-02-01

Low delivery care utilization continues to be a public health problem that significantly contributes to maternal morbidity and mortality, especially in developing countries like Ethiopia. The aim of the study is to determine the extent of urban-rural disparity of delivery care utilization and its determinants. A community-based cross-sectional quantitative study supplemented with qualitative data was conducted from February 15 to March 10, 2014. Data were collected from eligible woman using interviewer-guided semistructured questionnaires and focus group discussions. Logistic regression analysis with 95% confidence interval and p-value less than 5% was used to identify potential determinant variables. From 567 women, institutional delivery care was attended by 45.9% (260) respondents of whom 69.3% were urban and 21.3% were rural. Mass media and antenatal care attendance were the major determinants in urban respondents, whereas children ever born, partners' occupation, women's autonomy, and pregnancy-related health problems were statistically significant associations in rural women. The need for maternal health care is not met to the required level. There is a significant disparity in delivery care attendance among urban and rural women of the study area. Women's empowerment and awareness creation should be extensively worked on through mass media and posters or health information. © 2017 John Wiley & Sons Australia, Ltd.

Patient satisfaction with triage nursing care in Hong Kong.

PubMed

Chan, Jaime Nga Han; Chau, Janita

2005-06-01

This paper reports a study to examine the relationship between patient satisfaction and triage nursing care in order to assist nurses in defining more clearly their roles, and ultimately to improve the quality of care delivered to emergency patients. Patient satisfaction is considered an important indicator of quality care from the perspective of the consumer and has been widely studied in many settings. However, few studies have examined patient satisfaction with emergency nursing services in the particular area of triage. A descriptive, correlational study was conducted in 2001 in one urban acute hospital in Hong Kong using Consumer Emergency Care Satisfaction Scale (CECSS), and patient and nurse demographic data were also collected. Following a power calculation, systematic sampling was carried out, and the final sample consisted of 56 urgent, semi-urgent and non-urgent patients triaged. The response rate was 61%. The majority of the participants were satisfied with their triage nursing care and teaching. However, difficulties were encountered during the data collection process, resulting in a relatively low response rate. Correlational analyses revealed that patient satisfaction with triage nursing care was statistically significantly correlated with age and the type of nursing intervention received. Older people were more satisfied with the teaching offered by triage nurses and patients who had received specific nursing interventions gave more positive ratings on the teaching subscale of the CECSS. There were no statistically significant relationships between patient satisfaction with triage nursing care and nurse characteristics, including gender, work experiences and educational level. Patients were generally satisfied with the care provided by the triage nurses. Measuring patient satisfaction with triage nursing care remains a major challenge for health care providers in emergency care settings.

Committee opinion no. 515: Health care for urban American Indian and Alaska Native women.

PubMed

2012-01-01

Sixty percent of American Indian and Alaska Native women live in metropolitan areas. Most are not eligible for health care provided by the federal Indian Health Service (IHS). The IHS partly funds 34 Urban Indian Health Organizations, which vary in size and services. Some are small informational and referral sites that are limited even in the scope of outpatient services provided. Compared with other urban populations, urban American Indian and Alaska Native women have higher rates of teenaged pregnancy, late or no prenatal care, and alcohol and tobacco use in pregnancy. Their infants have higher rates of preterm birth, mortality, and sudden infant death syndrome than infants in the general population. Barriers to care experienced by American Indian and Alaska Native women should be addressed. The American College of Obstetricians and Gynecologists encourages Fellows to be aware of the risk profile of their urban American Indian and Alaska Native patients and understand that they often are not eligible for IHS coverage and may need assistance in gaining access to other forms of coverage. The American College of Obstetricians and Gynecologists also recommends that Fellows encourage their federal legislators to support adequate funding for the Indian Health Care Improvement Act, permanently authorized as part of the Patient Protection and Affordable Care Act.

Social, economic and environmental risk factors for acute lower respiratory infections among children under five years of age in Rwanda.

PubMed

Harerimana, Jean-Modeste; Nyirazinyoye, Leatitia; Thomson, Dana R; Ntaganira, Joseph

2016-01-01

In low and middle-income countries, acute lower respiratory illness is responsible for roughly 1 in every 5 child deaths. Rwanda has made major health system improvements including its community health worker systems, and it is one of the few countries in Africa to meet the 2015 Millennium Development Goals, although prevalence of acute lower respiratory infections (4 %) is similar to other countries in sub-Saharan Africa. This study aims to assess social, economic, and environmental factors associated with acute lower respiratory infections among children under five to inform potential further improvements in the health system. This is a cross-sectional study using data collected from women interviewed in the 2010 DHS about 8,484 surviving children under five. Based on a literature review, we defined 19 health, social, economic, and environmental potential risk factors, tested bivariate associations with acute lower respiratory infections, and advanced variables significant at the 0.1 confidence level to logistic regression modelling. We used manual backward stepwise regression to arrive at a final model. All analyses were performed in Stata v13 and adjusted for complex sample design. The following factors were independently associated with acute lower respiratory infections: child's age, anemia level, and receipt of Vitamin A; household toilet type and residence, and season of interview. In multivariate regression, being in the bottom ten percent of households (OR: 1.27, 95 % CI: 0.85-1.87) or being interviewed during the rainy season (OR: 1.61, 95 % CI: 1.24-2.09) was positively associated with acute lower respiratory infections, while urban residence (OR: 0.58, 95 % CI: 0.38-0.88) and being age 24-59 months versus 0-11 months (OR: 0.53, 95 % CI: 0.40-0.69) was negatively associated with acute lower respiratory infections. Potential areas for intervention including community campaigns about acute lower respiratory infections symptoms and treatment, and continued poverty reduction through rural electrification and modern stove distribution which may reduce use of dirty cooking fuel, improve living conditions, and reduce barriers to health care.

Pitfalls of implementing acute care surgery.

PubMed

Kaplan, Lewis J; Frankel, Heidi; Davis, Kimberly A; Barie, Philip S

2007-05-01

Incorporating emergency general surgery into the current practice of the trauma and critical care surgeon carries sweeping implications for future practice and training. Herein, we examine the known benefits of the practice of emergency general surgery, contrast it with the emerging paradigm of acute care surgery, and examine pitfalls already encountered in integration of emergency general surgery into a traditional trauma/critical care surgery service. A MEDLINE literature search was supplemented with local experience and national presentations at major meetings to provide data for this review. Considerations including faculty complement, service structure, resident staffing, physician extenders, the decreased role of community hospitals in providing trauma and emergency general surgery care, and the effects on an elective operative schedule are inadequately explored at present. There are no firm recommendations as to how to incorporate emergency general surgery into a trauma/critical care practice that will satisfy both academic and community practice paradigms. The near future seems likely to embrace the expanded training and clinical care program termed acute care surgery. A host of essential elements have yet to be examined to undertake a critical analysis of the applicability, advisability, and appropriate structure of both emergency general surgery and acute care surgery in the United States. Proceeding along this pathway may be fraught with training, education, and implementation pitfalls that are ideally addressed before deploying acute care surgery as a national standard.

Air Land Sea Bulletin. Issue No. 2011-2, May 2011

DTIC Science & Technology

2011-05-01

no surprise that all of the world-changing events happening in the past few months have occurred in urban areas. In fact, experts project that in...or two categories, only the urban setting was deemed the most difficult in all of them.4 Figure 2 provides a comparison of the environments. Now...ALSB 2011-2 12 factor in all future military opera- tions. The closeness of structures in the urban setting requires CD to be more acutely

Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England

PubMed Central

Morris, Stephen; Hoffman, Alex; Hunter, Rachael M.; Boaden, Ruth; McKevitt, Christopher; Perry, Catherine; Pursani, Nanik; Rudd, Anthony G.; Turner, Simon J.; Tyrrell, Pippa J.; Wolfe, Charles D.A.; Fulop, Naomi J.

2015-01-01

Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models. PMID:26130092

Prehospital delay and independent/interdependent construal of self among Japanese patients with acute myocardial infarction.

PubMed

Fukuoka, Yoshimi; Dracup, Kathleen; Rankin, Sally H; Froelicher, Erika Sivarajan; Kobayashi, Fumio; Hirayama, Haro; Ohno, Miyoshi; Matsumoto, David

2005-05-01

Reducing the time from symptom onset to reperfusion therapy is an important approach to minimizing myocardial damage and to preventing death from acute myocardial infarction (AMI). Previous studies suggest that certain ethnic or national groups, such as the Japanese, are more likely to delay in accessing care than other groups. The aims of this paper were the following; (1) to examine whether culture (defined as independent and interdependent construal of self) is associated with delay in accessing medical care in Japanese patients experiencing symptoms of AMI; (2) to determine if the relationship between independent and interdependent construal of self and prehospital delay time is mediated by cognitive responses and/or emotional responses; and (3) to determine if independent and interdependent construal of self independently predicts choice of treatment site (clinic vs. hospital). A cross-sectional study was conducted at hospitals in urban areas in Japan. One hundred and forty-five consecutive patients who were admitted with AMI within 72 h of the onset of symptoms were interviewed using the modified response to symptoms questionnaire and the independent and interdependent construal of self scale. The interdependent construal of self scores were significantly associated with prehospital delay time, controlling for demographics, medical history, and symptoms (p<.001). However, the relationship between independent and interdependent self and prehospital delay times was not mediated by cognitive or emotional responses. In multiple logistic regression analysis, patients with high independent construal of self were more likely to seek care at a hospital rather than a clinic compared to those with lower independent construal of self. In conclusion, cultural variation within this Japanese group was observed and was associated with prehospital delay time.

[A Delphi Method Survey of the Core Competences of Post-Acute-Care Nurses in Caring for Acute Stroke Patients].

PubMed

Chi, Shu-Ching; Yeh, Lily; Lu, Meei-Shiow; Lin, Pei-Yu

2015-12-01

Post-acute care (PAC) service is becoming increasingly important in Taiwan as a core focus of government policies that are designed to ensure continuity of care. In order to improve PAC nursing education and quality of care, the present study applies a modified Delphi method to identify the core competences of nurses who provide PAC services to acute stroke patients. We surveyed 18 experts in post-acute care and long-term care anonymously using a 29-question questionnaire in order to identify the essential professional skills that are required to perform PAC effectively. The results of this survey indicate that the core competences of PAC may be divided into two categories: Case Management and Care Management. Case Management includes Direct Care, Communication, Health Care Education, Nursing Consulting, and Family Assessment & Health Care. Care Management includes Interdisciplinary Teamwork, Patient Care Management, and Resource Integration. The importance and practicality of each item was evaluated using a 7-point Likert scale. The experts required 2 rounds to reach a consensus about the importance and 3 rounds to determine the practicality of PAC core competences. This process highlighted the differing points of view that are held by professionals in the realms of nursing, medicine, and national health policy. The PAC in-job training program in its current form inadequately cul-tivates core competence in Care Management. The results of the present study may be used to inform the development of PAC nurse orientation training programs and continuing education courses.

Delivering quality care: what can emergency gynaecology learn from acute obstetrics?

PubMed

Bika, O H; Edozien, L C

2014-08-01

Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.

Do the Preferences of Healthcare Provider Selection Vary among Rural and Urban Patients with Different Income and Cause Different Outcome?

PubMed

Yu, Tsung-Hsien; Chung, Kuo-Piao; Wei, Chung-Jen; Chien, Kuo-Liong; Hou, Yu-Chang

2016-01-01

Equal access to healthcare facilities and high-level quality of care are important strategies to eliminate the disparity in outcome of care. However, the existing literature regarding how urban or rural dwelling patients with different income level select healthcare providers is insufficient. The purposes of this study were to examine whether differences of healthcare provider selection exist among urban and rural coronary artery bypass surgery (CABG) patients with different income level. If so, we further investigated the associated impact on mortality. A retrospective, multilevel study design was conducted using claims data from 2007-2011 Taiwan's Universal Health Insurance Scheme. Healthcare providers' performance and patients' travelling distance to hospitals were used to define the patterns of healthcare provider selection. Baron and Kenny's procedures for mediation effect were conducted. There were 10,108 CABG surgeries included in this study. The results showed that urban dwelling and higher income patients were prone to receive care from better-performance providers. The travelling distances of urban dwelling patients was 15 KM shorter, especially when they received better-performance provider's care. The results also showed that the difference of healthcare provider selection and mortality rate existed between rural and urban dwelling patients with different income levels. After the procedure of mediation effect testing, the results showed that the healthcare provider selection partially mediated the relationships between patients' residential areas with different income levels and 30-day mortality. Preferences of healthcare provider selection vary among rural and urban patients with different income, and such differences partially mediated the outcome of care. Health authorities should pay attention to this issue, and propose appropriate solutions to eliminate the disparity in outcome of CABG care.

A Systematic Review of the Time Series Studies Addressing the Endemic Risk of Acute Gastroenteritis According to Drinking Water Operation Conditions in Urban Areas of Developed Countries

PubMed Central

Beaudeau, Pascal

2018-01-01

Time series studies (TSS) can be viewed as an inexpensive way to tackle the non-epidemic health risk from fecal pathogens in tap water in urban areas. Following the PRISMA recommendations, I reviewed TSS addressing the endemic risk of acute gastroenteritis risk according to drinking water operation conditions in urban areas of developed countries. Eighteen studies were included, covering 17 urban sites (seven in North-America and 10 in Europe) with study populations ranging from 50,000 to 9 million people. Most studies used general practitioner consultations or visits to hospitals for acute gastroenteritis (AGE) as health outcomes. In 11 of the 17 sites, a significant and plausible association was found between turbidity (or particle count) in finished water and the AGE indicator. When provided and significant, the interquartile excess of relative risk estimates ranged from 3–13%. When examined, water temperature, river flow, and produced flow were strongly associated with the AGE indicator. The potential of TSS for the study of the health risk from fecal pathogens in tap water is limited by the lack of specificity of turbidity and its site-sensitive value as an exposure proxy. Nevertheless, at the DWS level, TSS could help water operators to identify operational conditions most at risk, almost if considering other water operation indicators, in addition to turbidity, as possible relevant proxies for exposure. PMID:29701701

Out-of-hospital opioid therapy of palliative care patients with "acute dyspnoea": a retrospective multicenter investigation.

PubMed

Wiese, Christoph H R; Barrels, Utz E; Graf, Bernhard M; Hanekop, Gerd G

2009-01-01

Prehospital emergency physicians (EP) are often confronted with the acute care of palliative care patients. Dyspnoea is a frequent acute symptom and its causes often differ from the generally known emergency medical causes. Till now, there have been no relevant concepts for emergency care of palliative care patients for their specific symptoms. Over a 24-month period, the authors retrospectively investigated all out-of-hospital emergency medical services for palliative care patients with acute dyspnoea at four emergency physician support points. The evaluation of these services was followed retrospectively on the basis of the therapy carried out by the EP (Group 1: therapy with morphine and oxygen; Group 2: therapy with morphine, bronchodilator effective drugs and oxygen; Group 3: therapy with bronchodilator effective drugs and oxygen; Group 4: therapy with oxygen; Group 5: no medical treatment). Moreover, EPs were interviewed about their actions and their uncertainties in the treatment of palliative care patients. The diagnosis of acute dyspnoea in palliative care patients occurred 121 times (116 patients were integrated in the present investigation) within the defined period. In total, 116 patients were included (Group 1: 21, Group 2: 29, Group 3: 31, Group 4: 28, and Group 5: 7). Dyspnoea was satisfactorily treated in 41 percent of the patients (Group 1: 67 percent, Group 2: 52 percent, Group 3: 22 percent, Group 4: 18 percent, and Group 5: 71 percent). Most EPs (70 percent) revealed uncertainties in emergency medical therapy for patients at the end of life. The current investigation showed a significant relief of acute dyspnoea when using opioids, in contrast with the established out-of-hospital emergency medical therapy for acute dyspnoea. Therefore, opioids should be recommended for emergency medical therapy of dyspnoea in palliative care patients. Clinical studies that recommend the use of effective opioids for the treatment of dyspnoea in palliative care patients are supported by the current retrospective study. Most EPs felt uncertain in the treatment of palliative care patients. Therefore, advanced training in palliative care medicine and end-of-life care should be integrated into emergency medical training.

Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

PubMed Central

Baillie, Lesley; Gallini, Andrew; Corser, Rachael; Elworthy, Gina; Scotcher, Ann; Barrand, Annabelle

2014-01-01

Introduction Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare services. Theory and methods The research design was a multimethod, qualitative case study of one healthcare system in England; four acute hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n = 17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework approach. Findings Three themes are presented: Care transitions within a vertically integrated healthcare system, Interprofessional communication and relationships; Patient and family involvement in care transitions. Discussion and conclusions A vertically integrated healthcare system supported care transitions from acute hospital wards through removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other's roles and build relationships and trust. PMID:24868193

Oral health care utilization by US rural residents, National Health Interview Survey 1999.

PubMed

Vargas, Clemencia M; Dye, Bruce A; Hayes, Kathy

2003-01-01

To compare the dental care utilization practices of rural and urban residents in the United States. Data on dental care utilization from the 1999 National Health Interview Survey for persons 2 years of age and older (n=42, 139) were analyzed by rural/urban status. Percentages and 95 percent confidence intervals were calculated to produce national estimates for having had a visit in the past year, the number of visits, reasons given for last dental visit and for not visiting a dentist, unmet dental needs, and private dental insurance. Rural residents were more likely to report that their last dental visit was because something was "bothering or hurting" (23.3% vs 17.6%) and that they had unmet dental needs (10.1% vs 7.5%). Urban residents were more likely to report having a dental visit in the past year (57.7% vs 66.5%) and having private dental insurance (32.7% vs 37.2%), compared to rural residents. There were no significant differences in most reasons given for not visiting the dentist between rural and urban respondents. Dental care utilization characteristics differ between rural and urban residents in the United States, with rural residents tending to underutilize dental care.

What is the Best Strategy to Minimize After-Care Costs for Total Joint Arthroplasty in a Bundled Payment Environment?

PubMed

Slover, James D; Mullaly, Kathleen A; Payne, Ashley; Iorio, Richard; Bosco, Joseph

2016-12-01

The post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies. We used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility. The results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. The data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy. Copyright © 2016 Elsevier Inc. All rights reserved.

Examining Factors That Impact Inpatient Management of Diabetes and the Role of Insulin Pen Devices.

PubMed

Smallwood, Chelsea; Lamarche, Danièle; Chevrier, Annie

2017-02-01

Insulin administration in the acute care setting is an integral component of inpatient diabetes management. Although some institutions have moved to insulin pen devices, many acute care settings continue to employ the vial and syringe method of insulin administration. The aim of this study was to evaluate the impact of insulin pen implementation in the acute care setting on patients, healthcare workers and health resource utilization. A review of published literature, including guidelines, was conducted to identify how insulin pen devices in the acute care setting may impact inpatient diabetes management. Previously published studies have revealed that insulin pen devices have the potential to improve inpatient management through better glycemic control, increased adherence and improved self-management education. Furthermore, insulin pen devices may result in cost savings and improved safety for healthcare workers. There are benefits to the use of insulin pen devices in acute care and, as such, their implementation should be considered. Copyright © 2016 Becton Dickinson Canada Inc. Published by Elsevier Inc. All rights reserved.

Decision-making in nursing practice: An integrative literature review.

PubMed

Nibbelink, Christine W; Brewer, Barbara B

2018-03-01

To identify and summarise factors and processes related to registered nurses' patient care decision-making in medical-surgical environments. A secondary goal of this literature review was to determine whether medical-surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making. PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy. Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research. Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses' decision-making for enhanced patient outcomes. © 2017 John Wiley & Sons Ltd.

Readmission Patterns Over 90-Day Episodes of Care Among Medicare Fee-for-Service Beneficiaries Discharged to Post-acute Care.

PubMed

Middleton, Addie; Kuo, Yong-Fang; Graham, James E; Karmarkar, Amol; Lin, Yu-Li; Goodwin, James S; Haas, Allen; Ottenbacher, Kenneth J

2018-04-21

Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. Retrospective cohort study. Acute care hospitals. Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. 90-day unplanned readmissions. The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Assessing Needs for Gerontological Education in Urban and Rural Areas of Ohio

ERIC Educational Resources Information Center

Van Dussen, Daniel J.; Leson, Suzanne M.; Emerick, Eric S.; Voytek, Joseph A.; Ewen, Heidi H.

2016-01-01

Purpose of the Study: This project surveyed health care professionals from both urban and rural care settings in Ohio and examined differences in professionals' needs and interests in continuing gerontological education. Design and Methods: The survey data were analyzed for 766 health care professionals descriptively, using cross-tabulations and…

Proceedings of the Conference on Industry and Day Care (Urban Research Corporation, Chicago, 1970).

ERIC Educational Resources Information Center

Urban Research Corp., Chicago, IL.

This booklet of conference proceedings reflects the efforts of the Urban Research Corporation to continue conversation between industry and day care specialists. A group of 175 industry representatives, early childhood specialists, community agency representatives, and day care operators and franchisers convened to discuss their mutual concerns.…

Influence of inpatient service specialty on care processes and outcomes for patients with non ST-segment elevation acute coronary syndromes.

PubMed

Roe, Matthew T; Chen, Anita Y; Mehta, Rajendra H; Li, Yun; Brindis, Ralph G; Smith, Sidney C; Rumsfeld, John S; Gibler, W Brian; Ohman, E Magnus; Peterson, Eric D

2007-09-04

Since the broad dissemination of practice guidelines, the association of specialty care with the treatment of patients with acute coronary syndromes has not been studied. We evaluated 55 994 patients with non-ST-segment elevation acute coronary syndromes (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative from January 2001 through September 2003 at 301 tertiary US hospitals with full revascularization capabilities. We compared baseline characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service (cardiology versus noncardiology). A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (

Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients.

PubMed

Ekerstad, Niklas; Karlson, Björn W; Andersson, David; Husberg, Magnus; Carlsson, Per; Heintz, Emelie; Alwin, Jenny

2018-05-18

The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective. Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups. Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit. A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female. The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up. We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285). The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Hospital-based, acute care after ambulatory surgery center discharge.

PubMed

Fox, Justin P; Vashi, Anita A; Ross, Joseph S; Gross, Cary P

2014-05-01

As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers. Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix. We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1-1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6-32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th-75th percentile = 1.0-2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0-39.0]). Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality. Published by Mosby, Inc.

The perspective of allied health staff on the role of nurses in sub-acute care.

PubMed

Digby, Robin; Bolster, Danielle; Perta, Andrew; Bucknall, Tracey K

2018-06-12

To explore allied health staff perceptions on the role of nurses in sub-acute care wards. A consequence of earlier discharge from acute hospitals is higher acuity of patients in sub-acute care. The impact on nurses' roles and required skill mix remains unknown. Similarly, nurses' integration into the rehabilitation team is ambiguous. Descriptive qualitative inquiry. Semi-structured interviews conducted with 14 allied health staff from one sub-acute care facility in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Analysis using the framework approach. Three main themes were evident: 1) The changing context of care: patient acuity, rapid patient discharge and out-dated buildings influenced care, 2) Generalist as opposed to specialist rehabilitation nurses: a divide between traditional nursing roles of clinical and personal care and a specialist rehabilitation role, and 3) Interdisciplinary relations and communication demonstrated lack of respect for nurses and integrating holistic care into everyday routines. Allied health staff had limited understanding of nurses' role in sub-acute care, and expectations varied. Power relationships appeared to hamper teamwork. Failure to include nurses in team discussions and decision-making could hinder patient outcomes. Progressing patients to levels of independence involves both integrating rehabilitation into activities of daily living with nurses and therapy-based sessions. Promotion of the incorporation of nursing input into patient rehabilitation is needed with both nurses and allied health staff. Lack of understanding of the nurses' role contributes to lack of respect for the nursing contribution to rehabilitation. Nurses have a key role in rehabilitation sometimes impeded by poor teamwork with allied health staff. Processes in sub-acute care wards need examination to facilitate more effective team practices inclusive of nurses. Progressing patients' independence in rehabilitation units involves activities of daily living with nurses as much as therapy-based sessions. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Geospatial relationships of air pollution and acute asthma events across the Detroit-Windsor international border: study design and preliminary results.

PubMed

Lemke, Lawrence D; Lamerato, Lois E; Xu, Xiaohong; Booza, Jason C; Reiners, John J; Raymond Iii, Delbert M; Villeneuve, Paul J; Lavigne, Eric; Larkin, Dana; Krouse, Helene J

2014-07-01

The Geospatial Determinants of Health Outcomes Consortium (GeoDHOC) study investigated ambient air quality across the international border between Detroit, Michigan, USA and Windsor, Ontario, Canada and its association with acute asthma events in 5- to 89-year-old residents of these cities. NO2, SO2, and volatile organic compounds (VOCs) were measured at 100 sites, and particulate matter (PM) and polycyclic aromatic hydrocarbons (PAHs) at 50 sites during two 2-week sampling periods in 2008 and 2009. Acute asthma event rates across neighborhoods in each city were calculated using emergency room visits and hospitalizations and standardized to the overall age and gender distribution of the population in the two cities combined. Results demonstrate that intra-urban air quality variations are related to adverse respiratory events in both cities. Annual 2008 asthma rates exhibited statistically significant positive correlations with total VOCs and total benzene, toluene, ethylbenzene and xylene (BTEX) at 5-digit zip code scale spatial resolution in Detroit. In Windsor, NO2, VOCs, and PM10 concentrations correlated positively with 2008 asthma rates at a similar 3-digit postal forward sortation area scale. The study is limited by its coarse temporal resolution (comparing relatively short term air quality measurements to annual asthma health data) and interpretation of findings is complicated by contrasts in population demographics and health-care delivery systems in Detroit and Windsor.

Urbanisation and child health in resource poor settings with special reference to under-five mortality in Africa.

PubMed

Garenne, Michel

2010-06-01

The health of children improved dramatically worldwide during the 20th century, although with major contrasts between developed and developing countries, and urban and rural areas. The quantitative evidence on urban child health from a broad historical and comparative perspective is briefly reviewed here. Before the sanitary revolution, urban mortality tended to be higher than rural mortality. However, after World War I, improvements in water, sanitation, hygiene, nutrition and child care resulted in lower urban child mortality in Europe. Despite a similar mortality decline, urban mortality in developing countries since World War II has been generally lower than rural mortality, probably because of better medical care, higher socio-economic status and better nutrition in urban areas. However, higher urban mortality has recently been seen in the slums of large cities in developing countries as a result of extreme poverty, family disintegration, lack of hygiene, sanitation and medical care, low nutritional status, emerging diseases (HIV/AIDS and tuberculosis) and other health hazards (environmental hazards, accidents, violence). These emerging threats need to be addressed by appropriate policies and programmes.

Implementing a resident acute care surgery service: Improving resident education and patient care.

PubMed

Kantor, Olga; Schneider, Andrew B; Rojnica, Marko; Benjamin, Andrew J; Schindler, Nancy; Posner, Mitchell C; Matthews, Jeffrey B; Roggin, Kevin K

2017-03-01

To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n = 10) and postimplementation (n = 5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12 months of the service (June 2014 to June 2015). During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4-44) for preresident acute care surgery residents to 30.8 ± 8.8 (range 27-36) for postresident acute care surgery residents (P < .01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P < .01 on a 6-point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P < .01) on service evaluations of resident acute care surgery (n = 27) in comparison with other general operative services (n = 127). In addition, creation of a 1-team consult service resulted in a more streamlined consult process with average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5-90 minutes). The implementation of a resident acute care surgery service has increased resident autonomy, teaching assistant cases, and satisfaction with operative case variety, as well as the efficiency of operative consultation at our institution. Copyright © 2016 Elsevier Inc. All rights reserved.

Examining the Effect of Household Wealth and Migration Status on Safe Delivery Care in Urban India, 1992–2006

PubMed Central

Singh, Prashant Kumar; Rai, Rajesh Kumar; Singh, Lucky

2012-01-01

Background Although the urban health issue has been of long-standing interest to public health researchers, majority of the studies have looked upon the urban poor and migrants as distinct subgroups. Another concern is, whether being poor and at the same time migrant leads to a double disadvantage in the utilization of maternal health services? This study aims to examine the trends and factors that affect safe delivery care utilization among the migrants and the poor in urban India. Methodology/Principal Findings Using data from the National Family Health Survey, 1992–93 and 2005–06, this study grouped the household wealth and migration status into four distinct categories poor-migrant, poor-non migrant, non poor-migrant, non poor-non migrant. Both chi-square test and binary logistic regression were performed to examine the influence of household wealth and migration status on safe delivery care utilization among women who had experienced a birth in the four years preceding the survey. Results suggest a decline in safe delivery care among poor-migrant women during 1992–2006. The present study identifies two distinct groups in terms of safe delivery care utilization in urban India – one for poor-migrant and one for non poor-non migrants. While poor-migrant women were most vulnerable, non poor-non migrant women were the highest users of safe delivery care. Conclusion This study reiterates the inequality that underlies the utilization of maternal healthcare services not only by the urban poor but also by poor-migrant women, who deserve special attention. The ongoing programmatic efforts under the National Urban Health Mission should start focusing on the poorest of the poor groups such as poor-migrant women. Importantly, there should be continuous evaluation to examine the progress among target groups within urban areas. PMID:22970324

Spatial Accessibility to Health Care Services: Identifying under-Serviced Neighbourhoods in Canadian Urban Areas.

PubMed

Shah, Tayyab Ikram; Bell, Scott; Wilson, Kathi

2016-01-01

Urban environments can influence many aspects of health and well-being and access to health care is one of them. Access to primary health care (PHC) in urban settings is a pressing research and policy issue in Canada. Most research on access to healthcare is focused on national and provincial levels in Canada; there is a need to advance current understanding to local scales such as neighbourhoods. This study examines spatial accessibility to family physicians using the Three-Step Floating Catchment Area (3SFCA) method to identify neighbourhoods with poor geographical access to PHC services and their spatial patterning across 14 Canadian urban settings. An index of spatial access to PHC services, representing an accessibility score (physicians-per-1000 population), was calculated for neighborhoods using a 3km road network distance. Information about primary health care providers (this definition does not include mobile services such as health buses or nurse practitioners or less distributed services such as emergency rooms) used in this research was gathered from publicly available and routinely updated sources (i.e. provincial colleges of physicians and surgeons). An integrated geocoding approach was used to establish PHC locations. The results found that the three methods, Simple Ratio, Neighbourhood Simple Ratio, and 3SFCA that produce City level access scores are positively correlated with each other. Comparative analyses were performed both within and across urban settings to examine disparities in distributions of PHC services. It is found that neighbourhoods with poor accessibility scores in the main urban settings across Canada have further disadvantages in relation to population high health care needs. The results of this study show substantial variations in geographical accessibility to PHC services both within and among urban areas. This research enhances our understanding of spatial accessibility to health care services at the neighbourhood level. In particular, the results show that the low access neighbourhoods tend to be clustered in the neighbourhoods at the urban periphery and immediately surrounding the downtown area.

What is left unsaid: an interpretive description of the information needs of parents of children with asthma.

PubMed

Archibald, Mandy M; Caine, Vera; Ali, Samina; Hartling, Lisa; Scott, Shannon D

2015-02-01

Parents of children with asthma provide the vast majority of day-to-day asthma care. Understanding their information needs is an essential step to provide meaningful and effective family-centered asthma education. To gain insight into the information needs and information deficits of parents of children with asthma, we conducted an interpretive descriptive study to capture the perspectives of 21 parents from diverse backgrounds whose 23 children with asthma had a range of illness trajectories and management scenarios. Parents were purposively sampled from two asthma clinics and one pediatric emergency department in a large urban center in North America. Semi-structured interviews were conducted in 2011-2012. In data analysis, parents' self-identified information needs were distinguished from analysts' interpretations of information deficits. Participants' knowledge did not always reflect time since diagnosis, and information needs and deficits persisted for years. Parents often reported receiving little or no little or no education about asthma and its management. An asthma management information hierarchy was identified, starting with the most foundational, recognizing severity; followed by acute management; prevention versus crisis orientation; and knowing "about" asthma. In the absence of adequate and accurate education, parents' beliefs about the nature of asthma as an acute rather than chronic condition shaped their asthma management decisions and information-seeking behaviors. Information deficits were affected by interactions with health care providers. These parents' pervasive unmet information needs and deficits highlight the need for comprehensive, problem-oriented asthma education. © 2015 Wiley Periodicals, Inc.

Finding consensus on frailty assessment in acute care through Delphi method

PubMed Central

2016-01-01

Objective We seek to address gaps in knowledge and agreement around optimal frailty assessment in the acute medical care setting. Frailty is a common term describing older persons who are at increased risk of developing multimorbidity, disability, institutionalisation and death. Consensus has not been reached on the practical implementation of this concept to assess clinically and manage older persons in the acute care setting. Design Modified Delphi, via electronic questionnaire. Questions included ranking items that best recognise frailty, optimal timing, location and contextual elements of a successful tool. Intraclass correlation coefficients for overall levels of agreement, with consensus and stability tested by 2-way ANOVA with absolute agreement and Fisher's exact test. Participants A panel of national experts (academics, front-line clinicians and specialist charities) were invited to electronic correspondence. Results Variables reflecting accumulated deficit and high resource usage were perceived by participants as the most useful indicators of frailty in the acute care setting. The Acute Medical Unit and Care of the older Persons Ward were perceived as optimum settings for frailty assessment. ‘Clinically meaningful and relevant’, ‘simple (easy to use)’ and ‘accessible by multidisciplinary team’ were perceived as characteristics of a successful frailty assessment tool in the acute care setting. No agreement was reached on optimal timing, number of variables and organisational structures. Conclusions This study is a first step in developing consensus for a clinically relevant frailty assessment model for the acute care setting, providing content validation and illuminating contextual requirements. Testing on clinical data sets is a research priority. PMID:27742633

Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects.

PubMed

Roth, David L; Sheehan, Orla C; Huang, Jin; Rhodes, James D; Judd, Suzanne E; Kilgore, Meredith; Kissela, Brett; Bettger, Janet Prvu; Haley, William E

2016-10-01

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

Risk factors for discharge to an acute care hospital from inpatient rehabilitation among stroke patients.

PubMed

Roberts, Pamela S; DiVita, Margaret A; Riggs, Richard V; Niewczyk, Paulette; Bergquist, Brittany; Granger, Carl V

2014-01-01

To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke. Retrospective cohort study. Academic medical center. A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings. Logistic regression analysis. Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit. No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance. Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting. Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Stakeholder benefit from depression disease management: differences by rurality?

PubMed

Xu, Stanley; Rost, Kathryn; Dong, Fran; Dickinson, L Miriam

2011-01-01

Despite increasing consensus about the value of depression disease management programs, the field has not identified which stakeholders should absorb the relatively small additional costs associated with these programs. This paper investigates whether two proposed stakeholders (health plans and employer purchasers) economically benefit from depression care management (reduced outpatient utilization and work costs, respectively) in two delivery systems (rural and urban). This study examined the main and differential effects of depression care management on outpatient utilization and work costs over 24 months in a preplanned secondary analysis of 479 depressed patients from rural and urban primary care practices in a randomized controlled trial. Over 24 months, the intervention did not significantly reduce outpatient utilization costs in the entire cohort (-$191, 95% confidence interval (CI)=-$2,083 to $1,647), but it did decrease work costs (-$1,970, 95% CI=-$3,934 to -$92). While not statistically significant, rural-urban differences in work costs were in the same direction, while rural-urban differences in utilization costs differed in direction. These findings provide preliminary evidence that employers who elect to cover depression care management costs should receive comparable economic benefits in the rural and urban employees they insure. Given the limited sample size, further research may be needed to determine whether health plans who elect to cover depression care management costs will receive comparable economic benefits in the rural and urban enrollees they insure.

[Management of chemical burns and inhalation poisonings in acute medical care procedures of the State Fire Service].

PubMed

Chomoncik, Mariusz; Nitecki, Jacek; Ogonowska, Dorota; Cisoń-Apanasewicz, Urszula; Potok, Halina

2013-01-01

Emergency Medical Services (EMS) were founded by the government to perform tasks aimed at providing people with help in life-threatening conditions. The system comprises two constituent parts. The first one is public administrative bodies which are to organise, plan, coordinate and supervise the completion of the tasks. The other constituent is EMS units which keep people, resources and units in readiness. Supportive services, which include: the State Fire Service (SFS) and the National Firefighting and Rescue System (NFRS), are of great importance for EMS because they are eligible for providing acute medical care (professional first aid). Acute medical care covers actions performed by rescue workers to help people in life-threatening conditions. Rescue workers provide acute medical care in situations when EMS are not present on the spot and the injured party can be accessed only with the use of professional equipment by trained workers of NFRS. Whenever necessary, workers of supportive services can assist paramedics' actions. Cooperation of all units of EMS and NFRS is very important for rescue operations in the integrated rescue system. Time is a key aspect in delivering first aid to a person in life-threatening conditions. Fast and efficient first aid given by the accident's witness, as well as acute medical care performed by a rescue worker can prevent death and minimise negative effects of an injury or intoxication. It is essential that people delivering first aid and acute medical care should act according to acknowledged and standardised procedures because only in this way can the process of decision making be sped up and consequently, the number of possible complications following accidents decreased. The present paper presents an analysis of legal regulations concerning the management of chemical burn and inhalant intoxication in acute medical care procedures of the State Fire Service. It was observed that the procedures for rescue workers entitled to provide acute medical care should be correlated with the procedures for emergency medical teams.

The Influence of Health Policy and Market Factors on the Hospital Safety Net

PubMed Central

Bazzoli, Gloria J; Lindrooth, Richard C; Kang, R ay; Hasnain-Wynia, R omana

2006-01-01

Objective To examine how the financial pressures resulting from the Balanced Budget Act (BBA) of 1997 interacted with private sector pressures to affect indigent care provision. Data Sources/Study Setting American Hospital Association Annual Survey, Area Resource File, InterStudy Health Maintenance Organization files, Current Population Survey, and Bureau of Primary Health Care data. Study Design We distinguished core and voluntary safety net hospitals in our analysis. Core safety net hospitals provide a large share of uncompensated care in their markets and have large indigent care patient mix. Voluntary safety net hospitals provide substantial indigent care but less so than core hospitals. We examined the effect of financial pressure in the initial year of the 1997 BBA on uncompensated care for three hospital groups. Data for 1996–2000 were analyzed using approaches that control for hospital and market heterogeneity. Data Collection/Extraction Methods All urban U.S. general acute care hospitals with complete data for at least 2 years between 1996 and 2000, which totaled 1,693 institutions. Principal Findings Core safety net hospitals reduced their uncompensated care in response to Medicaid financial pressure. Voluntary safety net hospitals also responded in this way but only when faced with the combined forces of Medicaid and private sector payment pressures. Nonsafety net hospitals did not exhibit similar responses. Conclusions Our results are consistent with theories of hospital behavior when institutions face reductions in payment. They raise concern given continuing state budget crises plus the focus of recent federal deficit reduction legislation intended to cut Medicaid expenditures. PMID:16899001

Mortality and nursing home placement of dementia patients in rural and urban areas: a cohort study from the Swedish Dementia Registry.

PubMed

Roheger, Mandy; Zupanic, Eva; Kåreholt, Ingemar; Religa, Dorota; Kalbe, Elke; Eriksdotter, Maria; Garcia-Ptacek, Sara

2018-04-14

Life in rural and urban areas differs in regard to social support and health care. Our aim was to examine the association between nursing home placement and survival of patients with dementia living in urban vs. rural areas. We performed a longitudinal cohort study of patients with dementia at time of diagnosis (n = 58 154) and at first follow-up (n = 21 522) including patients registered from 2007 through 2014 in the Swedish Dementia Registry (SveDem). Descriptive statistics are shown. Odds ratios with 95% CI are presented for nursing home placement and hazard ratios for survival analysis. In age- and sex-adjusted analyses, patients living in urban areas were more likely to be in nursing homes at the time of dementia diagnosis than patients in rural areas (1.49, 95% CI: 1.29-1.73). However, there were no differences in rural vs urban areas in either survival after dementia diagnosis (urban: 0.99, 0.95-1.04, intermediate: 1.00, 0.96-1.04), or nursing home placement at first follow-up (urban: 1.00, 0.88-1.13; intermediate: 0.95, 0.85-1.06). Persons with dementia living in rural areas are less likely to live in a nursing home than their urban counterparts at the time of dementia diagnosis, but these differences disappear by the time of first follow-up. Differences in access to nursing homes between urban and rural settings could explain these findings. Results should be considered in the future healthcare decisions to ensure equality of health care across rural and urban areas. © 2018 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.

Lymphatic filariasis patient identification in a large urban area of Tanzania: An application of a community-led mHealth system.

PubMed

Mwingira, Upendo; Chikawe, Maria; Mandara, Wilfred Lazarus; Mableson, Hayley E; Uisso, Cecilia; Mremi, Irene; Malishee, Alpha; Malecela, Mwele; Mackenzie, Charles D; Kelly-Hope, Louise A; Stanton, Michelle C

2017-07-01

Lymphatic filariasis (LF) is best known for the disabling and disfiguring clinical conditions that infected patients can develop; providing care for these individuals is a major goal of the Global Programme to Eliminate LF. Methods of locating these patients, knowing their true number and thus providing care for them, remains a challenge for national medical systems, particularly when the endemic zone is a large urban area. A health community-led door-to-door survey approach using the SMS reporting tool MeasureSMS-Morbidity was used to rapidly collate and monitor data on LF patients in real-time (location, sex, age, clinical condition) in Dar es Salaam, Tanzania. Each stage of the phased study carried out in the three urban districts of city consisted of a training period, a patient identification and reporting period, and a data verification period, with refinements to the system being made after each phase. A total of 6889 patients were reported (133.6 per 100,000 population), of which 4169 were reported to have hydrocoele (80.9 per 100,000), 2251 lymphoedema-elephantiasis (LE) (43.7 per 100,000) and 469 with both conditions (9.1 per 100,000). Kinondoni had the highest number of reported patients in absolute terms (2846, 138.9 per 100,000), followed by Temeke (2550, 157.3 per 100,000) and Ilala (1493, 100.5 per 100,000). The number of hydrocoele patients was almost twice that of LE in all three districts. Severe LE patients accounted for approximately a quarter (26.9%) of those reported, with the number of acute attacks increasing with reported LE severity (1.34 in mild cases, 1.78 in moderate cases, 2.52 in severe). Verification checks supported these findings. This system of identifying, recording and mapping patients affected by LF greatly assists in planning, locating and prioritising, as well as initiating, appropriate morbidity management and disability prevention (MMDP) activities. The approach is a feasible framework that could be used in other large urban environments in the LF endemic areas.

A comparison of the workload of rural and urban primary care physicians in Germany: analysis of a questionnaire survey

PubMed Central

2011-01-01

Background Many western countries are facing an existing or imminent shortage of primary care physicians especially in rural areas. In Germany, working in rural areas is often thought to be associated with more working hours, a higher number of patients and a lower income than working in urban areas. These perceptions might be key reasons for the shortage. The aim of this analysis was to explore if working time, number of treated patients per week or proportion of privately insured patients vary between rural and urban areas in Germany using two different definitions of rurality within a sample of primary care physicians including general practitioners, general internists and paediatricians. Methods This is a secondary analysis of pre-collected data raised by a questionnaire that was sent to a representative random sample of 1500 primary care physicians chosen by data of the National Association of Statutory Health Insurance Physicians from all federal states in Germany. We employed two different methods of defining rurality; firstly, level of rurality as rated by physicians themselves (urban area, small town, rural area); secondly, rurality defined according to the Organisation for Economic Co-operation and Development. Results This analysis was based upon questionnaire data from 715 physicians. Primary care physicians in single-handed practices in rural areas worked on average four hours more per week than their urban counterparts (p < 0.05). Physicians' gender, the number of patients treated per week and the type of practice (single/group handed) were significantly related to the number of working hours. Neither the proportion of privately insured patients nor the number of patients seen per week differed significantly between rural and urban areas when applying the self-rated classification of rurality. Conclusion Overall this analysis identified few differences between urban and rural primary care physician working conditions. To counter future misdistribution of primary care, students should receive practical experience in rural areas to get more practical knowledge on working conditions. PMID:21988900

Learning from death: a hospital mortality reduction programme.

PubMed

Wright, John; Dugdale, Bob; Hammond, Ian; Jarman, Brian; Neary, Maria; Newton, Duncan; Patterson, Chris; Russon, Lynne; Stanley, Philip; Stephens, Rose; Warren, Erica

2006-06-01

There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care. A large acute hospital in an urban district in the North of England. Before and after evaluation of a hospital mortality reduction programme. Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control. Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002-2005. Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality.

Death Associated with Inadequate Reassessment of Venous Thromboembolism Prophylaxis at and after Hospital Discharge.

PubMed

2015-01-01

Venous thromboembolism (VTE) prophylaxis, also known as thromboprophylaxis, reduces the risk of deep vein thrombosis, pulmonary embolism, and associated complications, including death, in high-risk patients. VTE prophylaxis is recommended for acutely ill, hospitalized medical patients at risk of thrombosis. Anticoagulants, the pharmacologic agents of choice to prevent VTE, are considered high-alert medications. By definition, therefore, anticoagulants bear a hightened risk of causing significant patient harm when they are used in error. As part of ongoing collaboration with a provincial death investigation service, ISMP Canada received a report of a fatal incident that involved continuation of VTE prophylaxis with enoxaparin for a patient discharge to a long-term care (LTC) facility from an acute care setting. The findings and recommendations from this case are charged to highlight the need to build routine reassessment of VTE prophylaxis into the process for discharging patients from the acute care setting and upon transfer to another facility or to primary care. The incident described in this bulletin highlights the importance of continually reassessing the need for VTE prophylaxis, especially at transitions of care, such as discharge from an acute care setting. Evidence and guidelines confirm the benefits of VTE prophylaxis in certain patients during a hospital stay for an acute illness, but the balance of benefits and risks may become unfavourable once the patient is discharged. Clear documentation from the acute care facility can assist the receiving facility and health-care providers, as well as family caregivers, when determining whether thromboprophylaxis is still warranted. Until clear guidance to continue thromboprophylaxis after acute care is available, health-care organizations and practitioners across the spectrum of care are urged to share and consider the strategies presented in this bulletin to ensure the safe use of VTE prophylaxis and improved communication among health-care providers. ISMP Canada will be integrating the learning from this case in an update of the Hospital-Self-Assessment for Anticoagulant Safety. This assessment is available on a complimentary basis to all facilities across Canada after sign up at HTTPS://mssa.ismp-canada.org/hsasas/.

Rural access to clinical pharmacy services.

PubMed

Patterson, Brandon J; Kaboli, Peter J; Tubbs, Traviss; Alexander, Bruce; Lund, Brian C

2014-01-01

To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe the use of clinical telepharmacy within the Veterans Health Administration (VHA) health care system. Using 2011 national VHA data, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with random effects logistic regression. Individual service types (e.g., anticoagulation clinics) and delivery modes (e.g., telehealth) were also examined. Of 3,040,635 patients, 711,348 (23.4%) received CPS. Service use varied by patient residence (urban: 24.9%; rural: 19.7%) and principal site of primary care (medical center: 25.9%; urban clinic: 22.5%; rural clinic: 17.6%). However, in adjusted analyses, urban-rural differences were explained primarily by primary care site and less so by patient residence. Similar findings were observed for individual CPS types. Telehealth encounters were common, accounting for nearly one-half of patients receiving CPS. Video telehealth was infrequent (<0.2%), but more common among patients of rural clinics than those receiving CPS at medical centers (odds ratio [OR] = 9.7; 95% CI 9.0-10.5). We identified a potential disparity between rural and urban patients' access to CPS, which was largely explained by greater reliance on community clinics for primary care than on medical centers. Future research is needed to determine if this disparity will be alleviated by emerging organizational changes, including expanding telehealth capacity and integrating pharmacists into primary care teams, and whether lessons learned at VHA translate to other settings.

Acute Rubella Virus Infection among Women with Spontaneous Abortion in Mwanza City, Tanzania

PubMed Central

Lulandala, Lukombodzo; Matovelo, Dismas; Gumodoka, Balthazar; Mshana, Stephen E

2017-01-01

Introduction Acute rubella virus infection in early pregnancy has been associated with poor pregnancy outcome ranging from spontaneous abortion, stillbirth and multiple birth defects known as Congenital Rubella Syndrome (CRS). Despite its importance the prevalence of acute rubella virus infections is not known among women with spontaneous abortion in most centres in developing countries. Aim The present study was aimed to determine the seroprevalence of acute rubella infection among women with spontaneous abortion in Mwanza city. Materials and Methods A total of 268 women with spontaneous abortion were enrolled from four different hospitals in Mwanza city between November 2015 and April 2016. Blood samples were collected; sera were extracted and stored at -80°C until processing. Acute rubella virus infection was diagnosed by the detection of rubella specific IgM antibodies using indirect Enzyme Linked Immunosorbent Assay (ELISA) as per manufacturer’s instructions. Data were analysed by using STATA version 11. Results The mean age of enrolled women was 26.3±5.6 years. The prevalence of acute rubella virus infection was found to be 9/268 (3.7%, 95% CI: 1-5). Only women residing in urban areas (AOR: 5.65, 95% CI: 1.15-27.77, p=0.035) were found to predict acute rubella virus infection among cases with spontaneous abortion in Mwanza city. Conclusion About four out of hundred women residing in urban areas with spontaneous abortion in Mwanza are acutely infected with rubella virus highlighting the potential of this virus in contributing to poor pregnancy outcome in this setting. PMID:28511456

[The experience of organization of medical care of patients with acute coronary syndrome in multi-type hospital].

PubMed

Zagidullin, B I; Khairullin, I I; Stanichenko, N S; Zagidullin, I M; Zagidullin, N Sh

2016-01-01

In Naberezhnye Chelny, a number of structural and technological reformations of service of emergency medical care was implemented in 2009-2012. The reformation manifested in organization of unified emergency center of medical care of patients with acute coronary syndrome; joining up of cardiological departments of two hospitals; organization of X-ray surgical department; enhancement of logistics of admission department and interaction with emergency medical care; optimization of mode of medical care rendering at pre-hospital and hospital stages. The implemented reforms permitted increasing accessibility and timeliness of reperfusion therapy under acute coronary syndrome; to implement transcutaneous coronary interventions into practice and increase their number annually; to decrease “door-balloon” index up to 30-40%. As a result, lethality of acute myocardium infarction decreased from 12 to 3 to 5.8% in 2010-2014.

Impact of a person-centred dementia care training programme on hospital staff attitudes, role efficacy and perceptions of caring for people with dementia: A repeated measures study.

PubMed

Surr, C A; Smith, S J; Crossland, J; Robins, J

2016-01-01

People with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care. This study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia. A repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4-6 weeks post-baseline), and following Intermediate level training (T3: 3-4 months post-baseline). One NHS Trust in the North of England, UK. 40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses. All participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (0.5 day) and Intermediate (3 days), delivered over a 3-4 months period. Staff demographics and previous exposure to dementia training were collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES). The training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADQ between baseline and after completion of Foundation level training, but not for either of the other measures. Training acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy. Copyright © 2015 Elsevier Ltd. All rights reserved.

CTE's Role in Urban Education

ERIC Educational Resources Information Center

Hyslop, Alisha; Imperatore, Catherine

2013-01-01

Education in the United States is facing a crisis of completion and performance, both at the secondary and postsecondary levels, with high dropout rates and a significant number of students ill-prepared for further education and careers. These problems are even more acute in America's urban schools. Today's CTE is on the cutting edge of…

Acute prurigo simplex in humans caused by pigeon lice.

PubMed

Stolf, Hamilton Ometto; Reis, Rejane d'Ávila; Espósito, Ana Cláudia Cavalcante; Haddad Júnior, Vidal

2018-03-01

Pigeon lice are insects that feed on feathers of these birds; their life cycle includes egg, nymph and adult and they may cause dermatoses in humans. Four persons of the same family, living in an urban area, presented with widespread intensely pruritic erythematous papules. A great number of lice were seen in their house, which moved from a nest of pigeons located on the condenser of the air-conditioning to the dormitory of one of the patients. Even in urban environments, dermatitis caused by parasites of birds is a possibility in cases of acute prurigo simplex. Pigeon lice are possible etiological agents of this kind of skin eruption, although they are often neglected, even by dermatologists.

Acute prurigo simplex in humans caused by pigeon lice*

PubMed Central

Stolf, Hamilton Ometto; Reis, Rejane d'Ávila; Espósito, Ana Cláudia Cavalcante; Haddad Júnior, Vidal

2018-01-01

Pigeon lice are insects that feed on feathers of these birds; their life cycle includes egg, nymph and adult and they may cause dermatoses in humans. Four persons of the same family, living in an urban area, presented with widespread intensely pruritic erythematous papules. A great number of lice were seen in their house, which moved from a nest of pigeons located on the condenser of the air-conditioning to the dormitory of one of the patients. Even in urban environments, dermatitis caused by parasites of birds is a possibility in cases of acute prurigo simplex. Pigeon lice are possible etiological agents of this kind of skin eruption, although they are often neglected, even by dermatologists. PMID:29723376

Healthcare Disparities in Critical Illness

PubMed Central

Soto, Graciela J.; Martin, Greg S.; Gong, Michelle Ng

2013-01-01

Objective To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. Data Sources MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. Study Selection Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. Data Extraction Study findings are presented according to their association with the incidence, clinical presentation, management, and outcomes in acute critical illness. Data Synthesis This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data is organized along the course of acute critical illness. Conclusions The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research. PMID:24121467

Healthcare disparities in critical illness.

PubMed

Soto, Graciela J; Martin, Greg S; Gong, Michelle Ng

2013-12-01

To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness. This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness. The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Depression screening: utility of the patient health questionnaire in patients with acute coronary syndrome.

PubMed

McGuire, Anthony W; Eastwood, Jo-Ann; Macabasco-O'Connell, Aurelia; Hays, Ron D; Doering, Lynn V

2013-01-01

Depression screening in cardiac patients has been recommended by the American Heart Association, but the best approach remains unclear. To evaluate nurse-administered versions of the Patient Health Questionnaire for depression screening in patients hospitalized for acute coronary syndrome. Staff nurses in an urban cardiac care unit administered versions 2, 9, and 10 of the questionnaire to 100 patients with acute coronary syndrome. The Depression Interview and Structured Hamilton was administered by advanced practice nurses blinded to the results of the Patient Health Questionnaire. With the results of the Depression Interview and Structured Hamilton as a criterion, receiver operating characteristic analyses were done for each version of the Patient Health Questionnaire. The Delong method was used for pairwise comparisons. Cutoff scores balancing false-negatives and false-positives were determined by using the Youden Index. Each version of the questionnaire had excellent area-under- the-curve statistics: 91.2%, 92.6%, and 93.4% for versions 2, 9, and 10, respectively. Differences among the 3 versions were not significant. Each version yielded higher symptom scores in depressed patients than in nondepressed patients: version 2 scores, 3.4 vs 0.6, P = .001; version 9 scores, 13 vs 3.4, P < .001; and version 10 scores, 14.5 vs 3.6, P < .001. For depression screening in hospitalized patients with acute coronary syndrome, the Patient Health Questionnaire 2 is as accurate as longer versions when administered by nurses. Further study is needed to determine if screening with this tool changes clinical decision making or improves outcomes in these patients.

The impact of managed care and current governmental policies on an urban academic health care center.

PubMed

Rodriguez, J L; Peterson, D J; Muehlstedt, S G; Zera, R T; West, M A; Bubrick, M P

2001-10-01

Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.

Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination.

PubMed

Snyder, Claire F; Frick, Kevin D; Herbert, Robert J; Blackford, Amanda L; Neville, Bridget A; Lemke, Klaus W; Carducci, Michael A; Wolff, Antonio C; Earle, Craig C

2015-12-01

The purpose of this study is to investigate provider specialty, care coordination, and cancer survivors' comorbid condition care. This retrospective cross-sectional Surveillance, Epidemiology, and End Results (SEER)-Medicare study included cancer survivors diagnosed in 2004, 2-3 years post-cancer diagnosis, in fee-for-service Medicare. We examined (1) provider specialties (primary care providers (PCPs), oncology specialists, other specialists) visited post-hospitalization, (2) role of provider specialties in chronic and acute condition management, and (3) an ambulatory care coordination measure. Outcome measures covered (1) visits post-hospitalization for nine conditions, (2) chronic disease management (lipid profile, diabetic eye exam, diabetic monitoring), and (3) acute condition management (electrocardiogram (EKG) for congestive heart failure (CHF), imaging for CHF, EKG for transient ischemic attack, cholecystectomy, hip fracture repair). Among 8661 cancer survivors, patients were more likely to visit PCPs than oncologists or other specialists following hospitalizations for 8/9 conditions. Patients visiting a PCP (vs. not) were more likely to receive recommended care for 3/3 chronic and 1/5 acute condition indicators. Patients visiting a nother specialist (vs. not) were more likely to receive recommended care for 3/3 chronic and 2/5 acute condition indicators. Patients visiting an oncology specialist (vs. not) were more likely to receive recommended care on 2/3 chronic indicators and less likely to receive recommended care on 1/5 acute indicators. Patients at greatest risk for poor coordination were more likely to receive appropriate care on 4/6 indicators. PCPs are central to cancer survivors' non-cancer comorbid condition care quality. Implications for Cancer Survivors PCP involvement in cancer survivors' care should be promoted.

Indicators of Home Care Use in Urban and Rural Settings

ERIC Educational Resources Information Center

Mitchell, Lori A.; Strain, Laurel A.; Blandford, Audrey A.

2007-01-01

This study employs a longitudinal design to examine rural-urban differences in home care service use over time, drawing on data from the Manitoba Study of Health and Aging (MSHA). Characteristics of community-dwelling, cognitively intact adults aged 65 years or older not receiving home care services in the province of Manitoba (n = 855) were…

Performing well in financial management and quality of care: evidence from hospital process measures for treatment of cardiovascular disease.

PubMed

Dong, Gang Nathan

2015-02-01

Fiscal constraints faced by U.S. hospitals as a result of the recent economic downturn are leading to business practices that reduce costs and improve financial and operational efficiency in hospitals. There naturally arises the question of how this finance-driven management culture could affect the quality of care. This paper attempts to determine whether the process measures of treatment quality are correlated with hospital financial performance. Panel study of hospital care quality and financial condition between 2005 and 2010 for cardiovascular disease treatment at acute care hospitals in the United States. Process measures for condition-specific treatment of heart attack and heart failure and hospital-level financial condition ratios were collected from the CMS databases of Hospital Compare and Cost Reports. There is a statistically significant relationship between hospital financial performance and quality of care. Hospital profitability, financial leverage, asset liquidity, operating efficiency, and costs appear to be important factors of health care quality. In general, public hospitals provide lower quality care than their nonprofit counterparts, and urban hospitals report better quality score than those located in rural areas. Specifically, the first-difference regression results indicate that the quality of treatment for cardiovascular patients rises in the year following an increase in hospital profitability, financial leverage, and labor costs. The results suggest that, when a hospital made more profit, had the capacity to finance investment using debt, paid higher wages presumably to attract more skilled nurses, its quality of care would generally improve. While the pursuit of profit induces hospitals to enhance both quantity and quality of services they offer, the lack of financial strength may result in a lower standard of health care services, implying the importance of monitoring the quality of care among those hospitals with poor financial health.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

PubMed

Ng'anjo Phiri, Selia; Fylkesnes, Knut; Moland, Karen Marie; Byskov, Jens; Kiserud, Torvid

2016-01-01

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care.

PubMed

Paul, Christine L; Ryan, Annika; Rose, Shiho; Attia, John R; Kerr, Erin; Koller, Claudia; Levi, Christopher R

2016-04-08

Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke. Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted. Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05). In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.

Transformation of the Urban Health Care Safety Net: The Devolution of a Public Responsibility.

PubMed

Kulesher, Robert

2015-01-01

Reduced spending in both federal and state programs and the closure of public hospitals have serious consequences for the health of urban dwellers, especially the poor and uninsured. Through a combination of economic factors, many municipalities have formed public-private partnerships and launched community initiatives to preserve some of the elements of the health care safety net. What once was a responsibility of municipal governments, the provision of health care to poor and uninsured populations, is now posing challenges for private-sector providers. This article identifies several factors that have contributed to the incremental demise of the publicly funded urban health care safety net and how local entities and the federal government are responding to the care of the poor and uninsured.

Optimizing the care model for an uncomplicated acute pain episode in sickle cell disease.

PubMed

Telfer, Paul; Kaya, Banu

2017-12-08

The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model. © 2016 by The American Society of Hematology. All rights reserved.

The Aged Residential Care Healthcare Utilization Study (ARCHUS): a multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.

PubMed

Connolly, Martin J; Boyd, Michal; Broad, Joanna B; Kerse, Ngaire; Lumley, Thomas; Whitehead, Noeline; Foster, Susan

2015-01-01

To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities. Cluster randomized controlled trial. RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control. A total of 1998 residents of 18 intervention facilities and 18 control facilities. A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria. Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months. The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85-1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76-1.61; P = .62). This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging. Australian and New Zealand Clinical Trials Registry (ACTRN12611000187943). Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Chinese health care system and clinical epidemiology

PubMed Central

Sun, Yuelian; Gregersen, Hans; Yuan, Wei

2017-01-01

China has gone through a comprehensive health care insurance reform since 2003 and achieved universal health insurance coverage in 2011. The new health care insurance system provides China with a huge opportunity for the development of health care and medical research when its rich medical resources are fully unfolded. In this study, we review the Chinese health care system and its implication for medical research, especially within clinical epidemiology. First, we briefly review the population register system, the distribution of the urban and rural population in China, and the development of the Chinese health care system after 1949. In the following sections, we describe the current Chinese health care delivery system and the current health insurance system. We then focus on the construction of the Chinese health information system as well as several existing registers and research projects on health data. Finally, we discuss the opportunities and challenges of the health care system in regard to clinical epidemiology research. China now has three main insurance schemes. The Urban Employee Basic Medical Insurance (UEBMI) covers urban employees and retired employees. The Urban Residence Basic Medical Insurance (URBMI) covers urban residents, including children, students, elderly people without previous employment, and unemployed people. The New Rural Cooperative Medical Scheme (NRCMS) covers rural residents. The Chinese Government has made efforts to build up health information data, including electronic medical records. The establishment of universal health care insurance with linkage to medical records will provide potentially huge research opportunities in the future. However, constructing a complete register system at a nationwide level is challenging. In the future, China will demand increased capacity of researchers and data managers, in particular within clinical epidemiology, to explore the rich resources. PMID:28356772

Poverty and palliative care in the US: issues facing the urban poor.

PubMed

Hughes, Anne

2005-01-01

Poverty is a significant public health and social problem in the US. The urban poor living with life-limiting illnesses are a particularly vulnerable population. The literature related to the experiences of the urban poor at the end of life is sparse. Most relates to the experiences of patients with cancer. The purpose of this literature review is to describe the problem of poverty in the US, to identify challenges in providing palliative care to the urban poor, and lastly, to articulate implications for nursing practice and nursing research.

Multidisciplinary acute care research organization (MACRO): if you build it, they will come.

PubMed

Early, Barbara J; Huang, David T; Callaway, Clifton W; Zenati, Mazen; Angus, Derek C; Gunn, Scott R; Yealy, Donald M; Unikel, Daniel; Billiar, Timothy R; Peitzman, Andrew B; Sperry, Jason L

2013-07-01

Clinical research will increasingly play a core role in the evolution and growth of acute care surgery program development across the country. What constitutes an efficient and effective clinical research infrastructure in the current fiscal and academic environment remains obscure. We sought to characterize the effects of implementation of a multidisciplinary acute care research organization (MACRO) at a busy tertiary referral university setting. In 2008, to minimize redundancy and cost as well as to maximize existing resources promoting acute care research, MACRO was created, unifying clinical research infrastructure among the Departments of Critical Care Medicine, Emergency Medicine, and Surgery. During the periods 2008 to 2012, we performed a retrospective analysis and determined volume of clinical studies, patient enrollment for both observational and interventional trials, and staff growth since MACRO's origination and characterized changes over time. From 2008 to 2011, the volume of patients enrolled in clinical studies, which MACRO facilitates has significantly increased more than 300%. The percentage of interventional/observational trials has remained stable during the same period (50-60%). Staff has increased from 6 coordinators to 10, with an additional 15 research associates allowing 24/7 service. With this significant growth, MACRO has become financially self-sufficient, and additional outside departments now seek MACRO's services. Appropriate organization of acute care clinical research infrastructure minimizes redundancy and can promote sustainable, efficient growth in the current academic environment. Further studies are required to determine if similar models can be successful at other acute care surgery programs.

General surgery 2.0: the emergence of acute care surgery in Canada

PubMed Central

Hameed, S. Morad; Brenneman, Frederick D.; Ball, Chad G.; Pagliarello, Joe; Razek, Tarek; Parry, Neil; Widder, Sandy; Minor, Sam; Buczkowski, Andrzej; MacPherson, Cailan; Johner, Amanda; Jenkin, Dan; Wood, Leanne; McLoughlin, Karen; Anderson, Ian; Davey, Doug; Zabolotny, Brent; Saadia, Roger; Bracken, John; Nathens, Avery; Ahmed, Najma; Panton, Ormond; Warnock, Garth L.

2010-01-01

Over the past 5 years, there has been a groundswell of support in Canada for the development of organized, focused and multidisciplinary approaches to caring for acutely ill general surgical patients. Newly forged acute care surgery (ACS) services are beginning to provide prompt, evidence-based and goal-directed care to acutely ill general surgical patients who often present with a diverse range of complex pathologies and little or no pre- or postoperative planning. Through a team-based structure with attention to processes of care and information sharing, ACS services are well positioned to improve outcomes, while finding and developing efficiencies and reducing costs of surgical and emergency health care delivery. The ACS model also offers enhanced opportunities for surgical education for students, residents and practicing surgeons, and it will provide avenues to strengthen clinical and academic bonds between the community and academic surgical centres. In the near future, cooperation of ACS services from community and academic hospitals across the country will lead to the formation of systems of acute surgical care whose development will be informed by rigorous data collection and research and evidence-based quality-improvement initiatives. In an era of increasing subspecialization, ACS is a strong unifying force in general surgery and a platform for collective advocacy for an important patient population. PMID:20334738

Impact of double counting and transfer bias on estimated rates and outcomes of acute myocardial infarction.

PubMed

Westfall, J M; McGloin, J

2001-05-01

Ischemic heart disease is the leading cause of death in the United States. Recent studies report inconsistent findings on the changes in the incidence of hospitalizations for ischemic heart disease. These reports have relied primarily on hospital discharge data. Preliminary data suggest that a significant percentage of patients suffering acute myocardial infarction (MI) in rural communities are transferred to urban centers for care. Patients transferred to a second hospital may be counted twice for one episode of ischemic heart disease. To describe the impact of double counting and transfer bias on the estimation of incidence rates and outcomes of ischemic heart disease, specifically acute MI, in the United States. Analysis of state hospital discharge data from Kansas, Colorado (State Inpatient Database [SID]), Nebraska, Arizona, New Jersey, Michigan, Pennsylvania, and Illinois (SID) for the years 1995 to 1997. A matching algorithm was developed for hospital discharges to determine patients counted twice for one episode of ischemic heart disease. Validation of our matching algorithm. Patients reported to have suffered ischemic heart disease (ICD9 codes 410-414, 786.5). Number of patients counted twice for one episode of acute MI. It is estimated that double count rates range from 10% to 15% for all states and increased over the 3 years. Moderate sized rural counties had the highest estimated double count rates at 15% to 20% with a few counties having estimated double count rates a high as 35% to 50%. Older patients and females were less likely to be double counted (P <0.05). Double counting patients has resulted in a significant overestimation in the incidence rate for hospitalization for acute MI. Correction of this double counting reveals a significantly lower incidence rate and a higher in-hospital mortality rate for acute MI. Transferred patients differ significantly from nontransferred patients, introducing significant bias into MI outcome studies. Double counting and transfer bias should be considered when conducting and interpreting research on ischemic heart disease, particularly in rural regions.

Lack of existing guidelines for a large group of patients in Sweden: a national survey across the acute surgical care delivery chain.

PubMed

Muntlin Athlin, Åsa; Juhlin, Claes; Jangland, Eva

2017-02-01

Evidence-informed healthcare is the fundament for practice, whereby guidelines based on the best available evidence should assist health professionals in managing patients. Patients seeking care for acute abdominal pain form a common group in acute care settings worldwide, for whom decision-making and timely treatment are of paramount importance. There is ambiguity about the existence, use and content of guidelines for patients with acute abdomen. The objective was to describe and compare guidelines and management of patients with acute abdomen in different settings across the acute care delivery chain in Sweden. A national cross-sectional design was used. Twenty-nine ambulance stations, 17 emergency departments and 33 surgical wards covering all six Swedish health regions were included, and 23 guidelines were quality appraised using the validated Appraisal of Guidelines for Research & Evaluation II tool. There is a lack of guidelines in use for the management of this large group of patients between and within different healthcare areas across the acute care delivery chain. The quality appraisal identified that several guidelines were of poor quality, especially the in-hospital ones. Further, range orders for analgesics are common in the ambulance services and the surgical wards, but are seldom present in the emergency departments. Also, education in pain management is more common in the ambulance services. These findings are noteworthy as, hypothetically, the same patient could be treated in three different ways during the same care episode. There is an urgent need to develop high-quality evidence-based clinical guidelines for this patient group, with the entire care process in focus. © 2016 John Wiley & Sons, Ltd.

Perception of health care providers toward geriatric oral health in Belgaum district: A cross-sectional study.

PubMed

Mehta, Nishant; Rajpurohit, Ladusingh; Ankola, Anil; Hebbal, Mamata; Setia, Priyanka

2015-05-01

To access knowledge and practices related to the oral health of geriatrics among the health care providers practicing in urban and rural areas. Older adults have identified a number of barriers that contribute to lack of dental service use. However, barriers that clinicians encounter in providing dental treatment to older adults are not as clear-cut. 236 health professionals (of allopathy, ayurveda, and homeopathy) from urban and rural areas were assessed by means of structured questionnaire related to oral health practices and beliefs. Doctors practicing in urban areas assessed dental care needs more frequently (P = 0.038) and performed greater practices related to oral health of geriatrics (P = 0.043) than the doctors practicing in primary health care (PHC) centers (rural) (P = 0.038). Owing to the relative lack of knowledge among rural practitioners, there is a need to integrate primary health care with oral care in rural areas.

The Feasibility of Digital Pen and Paper Technology for Vital Sign Data Capture in Acute Care Settings

PubMed Central

Dykes, Patricia C.; Benoit, Angela; Chang, Frank; Gallagher, Joan; Li, Qi; Spurr, Cindy; McGrath, E. Jan; Kilroy, Susan M.; Prater, Marita

2006-01-01

The transition from paper to electronic documentation systems in acute care settings is often gradual and characterized by a period in which paper and electronic processes coexist. Intermediate technologies are needed to “bridge” the gap between paper and electronic systems as a means to improve work flow efficiency through data acquisition at the point of care in structured formats to inform decision support and facilitate reuse. The purpose of this paper is to report on the findings of a study conducted on three acute care units at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston, MA to evaluate the feasibility of digital pen and paper technology as a means to capture vital sign data in the context of acute care workflows and to make data available in a flow sheet in the electronic medical record. PMID:17238337

The feasibility of digital pen and paper technology for vital sign data capture in acute care settings.

PubMed

Dykes, Patricia C; Benoit, Angela; Chang, Frank; Gallagher, Joan; Li, Qi; Spurr, Cindy; McGrath, E Jan; Kilroy, Susan M; Prater, Marita

2006-01-01

The transition from paper to electronic documentation systems in acute care settings is often gradual and characterized by a period in which paper and electronic processes coexist. Intermediate technologies are needed to "bridge" the gap between paper and electronic systems as a means to improve work flow efficiency through data acquisition at the point of care in structured formats to inform decision support and facilitate reuse. The purpose of this paper is to report on the findings of a study conducted on three acute care units at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, MA to evaluate the feasibility of digital pen and paper technology as a means to capture vital sign data in the context of acute care workflows and to make data available in a flow sheet in the electronic medical record.

Frequency and Reasons for Return to Acute Care in Leukemia Patients Undergoing Inpatient Rehabilitation

PubMed Central

Fu, Jack Brian; Lee, Jay; Smith, Dennis W.; Bruera, Eduardo

2012-01-01

Objective To assess the frequency and reasons for return to the primary acute care service among leukemia patients undergoing inpatient rehabilitation. Design Retrospective study of all patients with leukemia, myelodysplastic syndrome, aplastic anemia, or myelofibrosis admitted to inpatient rehabilitation at a tertiary referral-based cancer center between January 1, 2005, and April 10, 2012. Items analyzed from patient records included return to the primary acute care service with demographic information, leukemia characteristics, medications, hospital admission characteristics, and laboratory values. Results 225 patients were admitted a total of 255 times. 93/255 (37%) of leukemia inpatient rehabilitation admissions returned to the primary acute care service. 18/93 (19%) and 42/93 (45%) of these patients died in the hospital and were discharged home respectively. Statistically significant factors (p<.05) associated with return to the primary acute care service include peripheral blast percentage and the presence of an antifungal agent on the day of inpatient rehabilitation transfer. Using an additional two factors (platelet count and the presence of an antiviral agent both with a p<.11), a Return To Primary (RTP) - Leukemia index was formulated. Conclusions Leukemia patients with the presence of circulating peripheral blasts and/or antifungal agent may be at increased risk of return to the primary acute care service. The RTP-Leukemia index should be tested in prospective studies to determine its usefulness. PMID:23117267

Where did the acute medical trainees go? A review of the career pathways of acute care common stem acute medical trainees in London.

PubMed

Gowland, Emily; Ball, Karen Le; Bryant, Catherine; Birns, Jonathan

2016-10-01

Acute care common stem acute medicine (ACCS AM) training was designed to develop competent multi-skilled acute physicians to manage patients with multimorbidity from 'door to discharge' in an era of increasing acute hospital admissions. Recent surveys by the Royal College of Physicians have suggested that acute medical specialties are proving less attractive to trainees. However, data on the career pathways taken by trainees completing core acute medical training has been lacking. Using London as a region with a 100% fill rate for its ACCS AM training programme, this study showed only 14% of trainees go on to higher specialty training in acute internal medicine and a further 10% to pursue higher medical specialty training with dual accreditation with internal medicine. 16% of trainees switched from ACCS AM to emergency medicine or anaesthetics during core ACCS training, and intensive care medicine proved to be the most popular career choice for ACCS AM trainees (21%). The ACCS AM training programme therefore does not appear to be providing what it was set out to do and this paper discusses the potential causes and effects. © Royal College of Physicians 2016. All rights reserved.

Characteristics of Pesticide Poisoning in Rural and Urban Settings in Uganda.

PubMed

Pedersen, Bastian; Ssemugabo, Charles; Nabankema, Victoria; Jørs, Erik

2017-01-01

Pesticide poisoning is a significant burden on health care systems in many low-income countries. This study evaluates cases of registered pesticide poisonings treated in selected rural (N = 101) and urban (N = 212) health facilities in Uganda from January 2010 to August 2016. In the urban setting, pesticides were the most prevalent single poison responsible for intoxications (N = 212 [28.8%]). Self-harm constituted a significantly higher proportion of the total number of poisonings in urban (63.3%) compared with rural areas (25.6%) where unintentional poisonings prevailed. Men were older than women and represented a majority of around 60% of the cases in both the urban and rural settings. Unintentional cases were almost the only ones seen below the age of 10, whereas self-harm dominated among adolescents and young persons from 10 to 29 years of age. Organophosphorus insecticides accounted for 73.0% of the poisonings. Urban hospitals provided a more intensive treatment and had registered fever complications than rural health care settings. To minimize self-harm with pesticides, a restriction of pesticide availability as shown to be effective in other low-income countries is recommended. Training of health care workers in proper diagnosis and treatment of poisonings and improved equipment in the health care settings should be strengthened.

Characteristics of Pesticide Poisoning in Rural and Urban Settings in Uganda

PubMed Central

Pedersen, Bastian; Ssemugabo, Charles; Nabankema, Victoria; Jørs, Erik

2017-01-01

Pesticide poisoning is a significant burden on health care systems in many low-income countries. This study evaluates cases of registered pesticide poisonings treated in selected rural (N = 101) and urban (N = 212) health facilities in Uganda from January 2010 to August 2016. In the urban setting, pesticides were the most prevalent single poison responsible for intoxications (N = 212 [28.8%]). Self-harm constituted a significantly higher proportion of the total number of poisonings in urban (63.3%) compared with rural areas (25.6%) where unintentional poisonings prevailed. Men were older than women and represented a majority of around 60% of the cases in both the urban and rural settings. Unintentional cases were almost the only ones seen below the age of 10, whereas self-harm dominated among adolescents and young persons from 10 to 29 years of age. Organophosphorus insecticides accounted for 73.0% of the poisonings. Urban hospitals provided a more intensive treatment and had registered fever complications than rural health care settings. To minimize self-harm with pesticides, a restriction of pesticide availability as shown to be effective in other low-income countries is recommended. Training of health care workers in proper diagnosis and treatment of poisonings and improved equipment in the health care settings should be strengthened. PMID:28615953

Hiring appropriate providers for different populations: acute care nurse practitioners.

PubMed

Haut, Cathy; Madden, Maureen

2015-06-01

Acute care nurse practitioners, prepared as providers for a variety of populations of patients, continue to make substantial contributions to health care. Evidence indicates shorter stays, higher satisfaction among patients, increased work efficiency, and higher quality outcomes when acute care nurse practitioners are part of unit- or service-based provider teams. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education outlines detailed guidelines for matching nurse practitioners' education with certification and practice by using a population-focused algorithm. Despite national support for the model, nurse practitioners and employers continue to struggle with finding the right fit. Nurse practitioners often use their interest and previous nursing experience to apply for an available position, and hospitals may not understand preparation or regulations related to matching the appropriate provider to the work environment. Evidence and regulatory guidelines indicate appropriate providers for population-focused positions. This article presents history and recommendations for hiring acute care nurse practitioners as providers for different populations of patients. ©2015 American Association of Critical-Care Nurses.

32 CFR 199.2 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... may have periodic acute episodes and may require intermittent inpatient hospital care. However, a... patients. Hospital, acute care (general and special). An institution that meets the criteria as set forth...

32 CFR 199.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... may have periodic acute episodes and may require intermittent inpatient hospital care. However, a... patients. Hospital, acute care (general and special). An institution that meets the criteria as set forth...

32 CFR 199.2 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... may have periodic acute episodes and may require intermittent inpatient hospital care. However, a... patients. Hospital, acute care (general and special). An institution that meets the criteria as set forth...

32 CFR 199.2 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... periodic acute episodes and may require intermittent inpatient hospital care. However, a chronic medical... patients. Hospital, acute care (general and special). An institution that meets the criteria as set forth...

32 CFR 199.2 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... may have periodic acute episodes and may require intermittent inpatient hospital care. However, a... patients. Hospital, acute care (general and special). An institution that meets the criteria as set forth...

Impact of vehicular networks on emergency medical services in urban areas.

PubMed

Lee, Chun-Liang; Huang, Chung-Yuan; Hsiao, Tzu-Chien; Wu, Chun-Yen; Chen, Yaw-Chung; Wang, I-Cheng

2014-10-31

The speed with which emergency personnel can provide emergency treatment is crucial to reducing death and disability among acute and critically ill patients. Unfortunately, the rapid development of cities and increased numbers of vehicles are preventing emergency vehicles from easily reaching locations where they are needed. A significant number of researchers are experimenting with vehicular networks to address this issue, but in most studies the focus has been on communication technologies and protocols, with few efforts to assess how network applications actually support emergency medical care. Our motivation was to search the literature for suggested methods for assisting emergency vehicles, and to use simulations to evaluate them. Our results and evidence-based studies were cross-referenced to assess each method in terms of cumulative survival ratio (CSR) gains for acute and critically ill patients. Simulation results indicate that traffic light preemption resulted in significant CSR increases of between 32.4% and 90.2%. Route guidance was found to increase CSRs from 14.1% to 57.8%, while path clearing increased CSRs by 15.5% or less. It is our hope that this data will support the efforts of emergency medical technicians, traffic managers, and policy makers.

Impact of Vehicular Networks on Emergency Medical Services in Urban Areas

PubMed Central

Lee, Chun-Liang; Huang, Chung-Yuan; Hsiao, Tzu-Chien; Wu, Chun-Yen; Chen, Yaw-Chung; Wang, I.-Cheng

2014-01-01

The speed with which emergency personnel can provide emergency treatment is crucial to reducing death and disability among acute and critically ill patients. Unfortunately, the rapid development of cities and increased numbers of vehicles are preventing emergency vehicles from easily reaching locations where they are needed. A significant number of researchers are experimenting with vehicular networks to address this issue, but in most studies the focus has been on communication technologies and protocols, with few efforts to assess how network applications actually support emergency medical care. Our motivation was to search the literature for suggested methods for assisting emergency vehicles, and to use simulations to evaluate them. Our results and evidence-based studies were cross-referenced to assess each method in terms of cumulative survival ratio (CSR) gains for acute and critically ill patients. Simulation results indicate that traffic light preemption resulted in significant CSR increases of between 32.4% and 90.2%. Route guidance was found to increase CSRs from 14.1% to 57.8%, while path clearing increased CSRs by 15.5% or less. It is our hope that this data will support the efforts of emergency medical technicians, traffic managers, and policy makers. PMID:25365059

Pacifier Use and its Association with Breastfeeding and Acute Respiratory Infection (ARI) in Children Below 2 Years Old.

PubMed

Z M, Siti; S, Joanita; J, Khairun Nisa; M N, Balkish; A, Tahir

2013-04-01

Extensive literature reviews showed that pacifier usage is associated with early cessation of breast feeding, as well as respiratory infection. This cross sectional study was a part of the bigger study of The Third National Health Morbidity Survey conducted throughout Malaysia in 2006. Survival and pearson cox regression was done to find association between pacifier user and breast feeding duration. Logistic Regression was done to find association between variables of interest. The prevalence of pacifier use was 32.9%. Chinese children reported significantly higher usage of pacifier (95% CI; 47.5, 58.7) as well as those resided in urban area (95% CI;32.5,37.7). One third of pacifier user had stopped breastfeeding at 6 months of age. Those with pacifier users were significantly shorter in breast feeding duration and significantly associated with non exclusivity in breastfeeding. Those without pacifier user were significantly associated with ever breast fed.(p value=0.001). There was no significant association between pacifier use with acute respiratory infection. Factors such as ethnicity and residential are non modifiable whereas modifiable factor such as pacifier use is certainly needed to be addressed at maternal and child health care level.

Medical emergency response in a sub-acute hospital: improving the model of care for deteriorating patients.

PubMed

Visser, Philip; Dwyer, Alison; Moran, Juli; Britton, Mary; Heland, Melodie; Ciavarella, Filomena; Schutte, Sandy; Jones, Daryl

2014-05-01

To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a sub-acute hospital setting. The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran's mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives. What is known about this topic? Rapid response team (RRT) activation has been well described in the acute hospital setting. Although the impact on survival benefit to patients remains controversial, it has been widely adopted as a model of care to respond to deteriorating ward patients. This is particularly relevant in Australia at present with the implementation of the new National Safety and Quality Health Service Standards. What does this paper add? There have not been any previous papers published on rapid response systems in a sub-acute hospital. This paper describes some of the changes and challenges associated with increasing RRT activations in a sub-acute health care facility. What are the implications for practitioners? For clinicians in a sub-acute setting, the study reinforces the importance of pre-emptively documenting and communicating advance care directives. In addition, it is important to identify patients with reversible pathology likely to benefit from transfer and acute care, and to avoid the transfer of those who will not and, instead, provide appropriate palliation. For practitioners involved in models of care for deteriorating patients, the study provides information on where problems occurred in our system and the strategies used to address these issues.

Translating evidence into policy for cardiovascular disease control in India

PubMed Central

2011-01-01

Cardiovascular diseases (CVD) are leading causes of premature mortality in India. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors-smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care. PMID:21306620

Psychological first aid training for the faith community: a model curriculum.

PubMed

McCabe, O Lee; Lating, Jeffrey M; Everly, George S; Mosley, Adrian M; Teague, Paula J; Links, Jonathan M; Kaminsky, Michael J

2007-01-01

Traditionally faith communities have served important roles in helping survivors cope in the aftermath of public health disasters. However, the provision of optimally effective crisis intervention services for persons experiencing acute or prolonged emotional trauma following such incidents requires specialized knowledge, skills, and abilities. Supported by a federally-funded grant, several academic health centers and faith-based organizations collaborated to develop a training program in Psychological First Aid (PFA) and disaster ministry for members of the clergy serving urban minorities and Latino immigrants in Baltimore, Maryland. This article describes the one-day training curriculum composed of four content modules: Stress Reactions of Mind-Body-Spirit, Psychological First Aid and Crisis Intervention, Pastoral Care and Disaster Ministry, and Practical Resources and Self Care for the Spiritual Caregiver Detailed descriptions of each module are provided, including its purpose; rationale and background literature; learning objectives; topics and sub-topics; and educational methods, materials and resources. The strengths, weaknesses, and future applications of the training template are discussed from the vantage points of participants' subjective reactions to the training.

Addressing Unmet Need for HIV Testing in Emergency Care Settings: A Role for Computer-facilitated Rapid HIV Testing?

PubMed Central

Kurth, Ann E.; Severynen, Anneleen; Spielberg, Freya

2014-01-01

HIV testing in emergency departments (EDs) remains underutilized. We evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned non-acute adult ED patients to computer tool (‘CARE’) and rapid HIV testing before standard visit (n=258) or to standard visit (n=259) with chart access. Assessed intervention acceptability and compared noted HIV risks. Participants were 56% non-white, 58% male; median age 37 years. In the CARE arm nearly all (251/258) completed the session and received HIV results; 4 declined test consent. HIV risks were reported by 54% of users and there was one confirmed HIV-positive and 2 false-positives (seroprevalence 0.4%, 95% CI 0.01–2.2%). Half (55%) preferred computerized, over face-to-face, counseling for future HIV testing. In standard arm, one HIV test and 2 referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches. PMID:23837807

[Endemic channel of acute respiratory disease and acute diarrheal disease in children under 5 years of age in a district of Bogotá].

PubMed

Rodríguez-Morales, Fabio; Suárez-Cuartas, Miguel R; Ramos-Ávila, Ana C

2016-04-01

Objective Developing a useful tool for planning health care for children under 5 years of age in the Ciudad Bolivar locality of Bogotá, developing an endemic channel for acute respiratory disease and acute diarrheal disease in children under 5 years of age for the period of 2008 to 2012. Methodology Descriptive study with a focus on public health surveillance for the preparation of an endemic channel for children under 5 years receiving care services in the Vista Hermosa Hospital Level I. Results The incidence of acute respiratory disease for a period of five years was identified with a monthly average of 1265 + 79 cases, showing two annual peak periods. Acute diarrheal disease, a monthly average of 243 cases was obtained with a period of higher incidence. Conclusion The correct preparation of the endemic channels in primary health care can provide alerts in a timely manner from the first level of care and guide decision-making in health and help achieve better network management services.

An Ecological Examination of an Urban Sixth Grade Physical Education Class

ERIC Educational Resources Information Center

James, Alisa R.; Collier, Douglas

2011-01-01

Background: There are several factors that influence teaching urban physical education. Violence, poverty and irrelevant curricula influence the teaching-learning environment in urban physical education. One approach to urban physical education is to look carefully at the ecology that exists within an urban physical education class. This ecology…

Assessment of Pharmacists' Perception of Patient Care Competence and Need for Training in Rural and Urban Areas in North Dakota

ERIC Educational Resources Information Center

Scott, David M.

2010-01-01

Context: Few studies have examined pharmacists' level of patient care competence and need for continuous professional development in rural areas. Purpose: To assess North Dakota pharmacists' practice setting, perceived level of patient care competencies, and the need for professional development in urban and rural areas. Methods: A survey was…

The Influence of Rural Location on Utilization of Formal Home Care: The Role of Medicaid

ERIC Educational Resources Information Center

McAuley, William J.; Spector, William D.; Van Nostrand, Joan; Shaffer, Tom

2004-01-01

Purpose: This research examines the impact of rural-urban residence on formal home-care utilization among older people and determines whether and how Medicaid coverage influences the association between, rural-urban location and risk of formal home-care use. Design and Methods: We combined data from the 1998 consolidated file of the Medical…

Cluster Analysis of Vulnerable Groups in Acute Traumatic Brain Injury Rehabilitation.

PubMed

Kucukboyaci, N Erkut; Long, Coralynn; Smith, Michelle; Rath, Joseph F; Bushnik, Tamara

2018-01-06

To analyze the complex relation between various social indicators that contribute to socioeconomic status and health care barriers. Cluster analysis of historical patient data obtained from inpatient visits. Inpatient rehabilitation unit in a large urban university hospital. Adult patients (N=148) receiving acute inpatient care, predominantly for closed head injury. Not applicable. We examined the membership of patients with traumatic brain injury in various "vulnerable group" clusters (eg, homeless, unemployed, racial/ethnic minority) and characterized the rehabilitation outcomes of patients (eg, duration of stay, changes in FIM scores between admission to inpatient stay and discharge). The cluster analysis revealed 4 major clusters (ie, clusters A-D) separated by vulnerable group memberships, with distinct durations of stay and FIM gains during their stay. Cluster B, the largest cluster and also consisting of mostly racial/ethnic minorities, had the shortest duration of hospital stay and one of the lowest FIM improvements among the 4 clusters despite higher FIM scores at admission. In cluster C, also consisting of mostly ethnic minorities with multiple socioeconomic status vulnerabilities, patients were characterized by low cognitive FIM scores at admission and the longest duration of stay, and they showed good improvement in FIM scores. Application of clustering techniques to inpatient data identified distinct clusters of patients who may experience differences in their rehabilitation outcome due to their membership in various "at-risk" groups. The results identified patients (ie, cluster B, with minority patients; and cluster D, with elderly patients) who attain below-average gains in brain injury rehabilitation. The results also suggested that systemic (eg, duration of stay) or clinical service improvements (eg, staff's language skills, ability to offer substance abuse therapy, provide appropriate referrals, liaise with intensive social work services, or plan subacute rehabilitation phase) could be beneficial for acute settings. Stronger recruitment, training, and retention initiatives for bilingual and multiethnic professionals may also be considered to optimize gains from acute inpatient rehabilitation after traumatic brain injury. Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Use of outsourced nurses in long-term acute care hospitals: outcomes and leadership preferences.

PubMed

Alvarez, M Raymond; Kerr, Bernard J; Burtner, Joan; Ledlow, Gerald; Fulton, Larry V

2011-02-01

When staffing effectiveness is not maintained over time, the likelihood of negative outcomes increases. This challenge is particularly problematic in long-term acute care hospitals (LTACHs) where use of outsourced temporary nurses is common when providing safe, sufficient care to medically complex patients who require longer hospital stays than normally would occur. To assess this issue, the authors discuss the outcomes of their survey of LTACH chief nursing officers that demonstrated LTACH quality indicators and overall patient satisfaction were within nationally accepted benchmarks even with higher levels of outsourced nurses used in this post-acute care setting.

The SocioDemographic Characteristics of the Communities Served by Retail Clinics

PubMed Central

Rudavsky, Rena; Mehrotra, Ateev

2010-01-01

PURPOSE As a rapidly growing new health care delivery model in the United States, retail clinics have been the subject of much debate and controversy. Located physically within a retail store, retail clinics provide simple acute and preventive services for a fixed price and without an appointment. Some hope that retail clinics can be a new safety-net provider for the poor and those without a primary care physician. To better understand the potential for retail clinics to achieve this goal, we describe the socio-demographic characteristics of the communities in which they operate. METHODS We created an inventory of all retail clinics in the United States and determined the proportion that are in Health Profession Shortage Area (HPSA). We defined each retail clinic’s catchment area as all census blocks that were less than a five-minute driving distance from the clinic. We compared the socio-demographic characteristics of the population within and outside of these retail clinic catchment areas. RESULTS Of the 982 clinics in 32 states, 88.4% were in an urban area and 12.5% were in a HPSA (20.9% of the US population lives within a HPSA). Compared to the rest of the urban population, the population living within a retail clinic catchment area has a higher median household income ($52,849 vs. $46,080), is better educated (32.6% vs. 24.9% with a college degree), and is as likely to be uninsured (17.7% vs. 17.0%). In a multivariate model, the census block’s median household income had the strongest association with whether the census block was in a retail clinic catchment area (OR 3.63 (95% CI 3.26–4.05) median income ≥$54,779 vs. median income –003C;$30,781) CONCLUSIONS We find that relatively few retail clinics are located in HPSAs and compared to the rest of the urban population, the population living in close proximity to a retail clinic has a higher income. PMID:20051541

Facilitating earlier transfer of care from acute stroke services into the community.

PubMed

Robinson, Jennifer

This article outlines an initiative to reduce length of stay for stroke patients within an acute hospital and to facilitate earlier transfer of care. Existing care provision was remodelled and expanded to deliver stroke care to patients within a community bed-based intermediate care facility or intermediate care at home. This new model of care has improved the delivery of rehabilitation through alternative and innovative ways of addressing service delivery that meet the needs of the patients.

From Alaska: A 21st Century Story of Indigenous Self-Determination in Urban American Public Education

ERIC Educational Resources Information Center

Weinstein, Gail L. Israel

2014-01-01

For Alaskan Indigenous people, an acute clash of cultures occurs daily in U.S. public school education. The dynamics used to implement and improve the well-being and graduation outcomes for Alaska Native youth in urban public school are presented. A partnership between Cook Inlet Tribal Council, Inc., an Alaska Native social service nonprofit, and…

Routine HIV screening in two health-care settings--New York City and New Orleans, 2011-2013.

PubMed

Lin, Xia; Dietz, Patricia M; Rodriguez, Vanessa; Lester, Deborah; Hernandez, Paloma; Moreno-Walton, Lisa; Johnson, Grant; Van Handel, Michelle M; Skarbinski, Jacek; Mattson, Christine L; Stratford, Dale; Belcher, Lisa; Branson, Bernard M

2014-06-27

Approximately 16% of the estimated 1.1 million persons living with human immunodeficiency virus (HIV) in the United States are unaware of their infection and thus unable to benefit from effective treatment that improves health and reduces transmission risk. Since 2006, CDC has recommended that health-care providers screen for HIV all patients aged 13-64 years unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. This report describes novel HIV screening programs at the Urban Health Plan (UHP), Inc. in New York City and the Interim Louisiana Hospital (ILH) in New Orleans. Data were provided by the two programs. UHP screened a monthly average of 986 patients for HIV during January 2011-September 2013. Of the 32,534 patients screened, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received their test result and 43 (29%) were newly diagnosed. None of the 148 patients with HIV infection were previously receiving medical care, and 120 (81%) were linked to HIV medical care. The ILH emergency department (ED) and the urgent-care center (UCC) screened a monthly average of 1,323 patients from mid-March to December 2013. Of the 12,568 patients screened, 102 (0.81%) tested HIV-positive, of whom 100 (98%) received their test result, 77 (75%) were newly diagnosed, and five (5%) had acute HIV infection. Linkage to HIV medical care was successful for 67 (74%) of 91 patients not already in care. Routine HIV screening identified patients with new and previously diagnosed HIV infection and facilitated their linkage to medical care. The two HIV screening programs highlighted in this report can serve as models that could be adapted by other health-care settings.

Urban and agricultural sources of pyrethroid insecticides to the Sacramento-San Joaquin Delta of California.

PubMed

Weston, Donald P; Lydy, Michael J

2010-03-01

While studies have documented the presence of pyrethroid insecticides at acutely toxic concentrations in sediments, little quantitative data on sources exist. Urban runoff, municipal wastewater treatment plants and agricultural drains in California's Sacramento-San Joaquin River Delta were sampled to understand their importance as contributors of these pesticides to surface waters. Nearly all residential runoff samples were toxic to the amphipod, Hyalella azteca, and contained pyrethroids at concentrations exceeding acutely toxic thresholds, in many cases by 10-fold. Toxicity identification evaluation data were consistent with pyrethroids, particularly bifenthrin and cyfluthrin, as the cause of toxicity. Pyrethroids passed through secondary treatment systems at municipal wastewater treatment facilities and were commonly found in the final effluent, usually near H. azteca 96-h EC(50) thresholds. Agricultural discharges in the study area only occasionally contained pyrethroids and were also occasional sources of toxicity related to the organophosphate insecticide chlorpyrifos. Discharge of the pyrethroid bifenthrin via urban stormwater runoff was sufficient to cause water column toxicity in two urban creeks, over at least a 30 km reach of the American River, and at one site in the San Joaquin River, though not in the Sacramento River.

Expanding health insurance to increase health care utilization: will it have different effects in rural vs. urban areas?

PubMed

Erlyana, Erlyana; Damrongplasit, Kannika Kampanya; Melnick, Glenn

2011-05-01

This study investigates the importance of medical fee and distance to health care provider on individual's decision to seek care in developing countries. The estimation method used a mixed logit model applied to data from the third wave of the Indonesian family life survey (2000). The key variables of interest include medical fee and distance to different types of health care provider and individual characteristic variables. Urban dweller's decision to choose health care providers are sensitive to the monetary cost of medical care as measured by medical fee but they are not sensitive to distance. For those who reside in rural area, they are sensitive to the non-medical component cost of care as measured by travel distance but they are not sensitive to medical fee. As a result of those findings, policy makers should consider different sets of policy instruments when attempting to expand health service's usage in urban and rural areas of Indonesia. To increase access in urban areas, we recommend expansion of health insurance coverage in order to lower out-of-pocket medical expenditures. As for rural areas, expansion of medical infrastructures to reduce commuting distance and costs will be needed to increase utilization. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Accountable Care Collaboratives: The Drive to High-Value Healthcare

DTIC Science & Technology

2011-01-01

optional) f2 HEDIS: Breast Cancer Screening, females 40 ‐ 69 NCQA Claims  f3 HEDIS:  Flu   Shot  for Older Adults, adults 65+ NCQA CAHPS Survey (Medicare) f4...Physician Outpatient Inpatient Long Term Inpatient Skilled Nursing Home Health Hospital and Acute Care Acute Care Rehab Facility Care ASCs Care RBRVS APC

The Guy’s and St Thomas’s NHS Foundation Trust @home service: an overview of a new service

PubMed Central

Lee, Geraldine A.; Titchener, Karen

2017-01-01

Hospital in the home is a relatively new concept within the UK healthcare system. The Guy’s and St Thomas’s NHS Foundation Trust (GSTT) @home service ‘Bringing hospital care to your home’ was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients’ place of residence by facilitating rapid discharge from hospital. The service is designed for 260–280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data. PMID:28356923

The Guy's and St Thomas's NHS Foundation Trust @home service: an overview of a new service.

PubMed

Lee, Geraldine A; Titchener, Karen

2017-03-01

Hospital in the home is a relatively new concept within the UK healthcare system. The Guy's and St Thomas's NHS Foundation Trust (GSTT) @home service 'Bringing hospital care to your home' was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients' place of residence by facilitating rapid discharge from hospital. The service is designed for 260-280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data.

Specialized stroke services: a meta-analysis comparing three models of care.

PubMed

Foley, Norine; Salter, Katherine; Teasell, Robert

2007-01-01

Using previously published data, the purpose of this study was to identify and discriminate between three different forms of inpatient stroke care based on timing and duration of treatment and to compare the results of clinically important outcomes. Randomized controlled trials, including a recent review of inpatient stroke unit/rehabilitation care, were identified and grouped into three models of care as follows: (a) acute stroke unit care (patients admitted within 36 h of stroke onset and remaining for up to 2 weeks; n = 5), (b) units combining acute and rehabilitative care (combined; n = 4), and (c) rehabilitation units where patients were transferred onto the service approximately 2 weeks following stroke (post-acute; n = 5). Pooled analyses for the outcomes of mortality, combined death and dependency and length of hospital stay were calculated for each model of care, compared to conventional care. All three models of care were associated with significant reductions in the odds of combined death and dependency; however, acute stroke units were not associated with significant reductions in mortality when this outcome was analyzed separately (OR 0.80; 95% CI: 0.61-1.03). Post-acute stroke units were associated with the greatest reduction in the odds of mortality (OR 0.60; 95% CI: 0.44-0.81). Significant reductions in length of hospital stay were associated with combined stroke units only (weighted mean difference -14 days; 95% CI: -27 to -2). Overall, specialized stroke services were associated with significant reductions in mortality, death and dependency and length of hospital stay although not every model of care was associated with equal benefit.

Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care: exploratory study.

PubMed

O'Brien, Kathryn; Stanton, Naomi; Edwards, Adrian; Hood, Kerenza; Butler, Christopher C

2011-03-01

Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown. To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI. Exploratory, observational study. Four general practices in South Wales. A total of 99 sequential attendees with acute illness aged less than five years. UTI defined by >10(5) organisms/ml on laboratory culture of urine. Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections. Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.

Infection prevention and control practices related to Clostridium difficile infection in Canadian acute and long-term care institutions.

PubMed

Wilkinson, Krista; Gravel, Denise; Taylor, Geoffrey; McGeer, Allison; Simor, Andrew; Suh, Kathryn; Moore, Dorothy; Kelly, Sharon; Boyd, David; Mulvey, Michael; Mounchili, Aboubakar; Miller, Mark

2011-04-01

Clostridium difficile is an important pathogen in Canadian health care facilities, and infection prevention and control (IPC) practices are crucial to reducing C difficile infections (CDIs). We performed a cross-sectional study to identify CDI-related IPC practices in Canadian health care facilities. A survey assessing facility characteristics, CDI testing strategies, CDI contact precautions, and antimicrobial stewardship programs was sent to Canadian health care facilities in February 2005. Responses were received from 943 (33%) facilities. Acute care facilities were more likely than long-term care (P < .001) and mixed care facilities (P = .03) to submit liquid stools from all patients for CDI testing. Physician orders were required before testing for CDI in 394 long-term care facilities (66%)-significantly higher than the proportions in acute care (41%; P < .001) and mixed care sites (49%; P < .001). A total of 841 sites (93%) had an infection control manual, 639 (76%) of which contained CDI-specific guidelines. Antimicrobial stewardship programs were reported by 40 (29%) acute care facilities; 19 (54%) of these sites reported full enforcement of the program. Canadian health care facilities have widely varying C difficile IPC practices. Opportunities exist for facilities to take a more active role in IPC policy development and implementation, as well as antimicrobial stewardship. Copyright © 2011 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.

The impact and effectiveness of nurse-led care in the management of acute and chronic pain: a review of the literature.

PubMed

Courtenay, Molly; Carey, Nicola

2008-08-01

To identify, summarise and critically appraise the current evidence regarding the impact and effectiveness of nurse-led care in acute and chronic pain. A diverse range of models of care exist within the services available for the management of acute and chronic pain. Primary studies have been conducted evaluating these models, but, review and synthesis of the findings from these studies has not been undertaken. Literature review. Searches of Pubmed (NLM) Medline, CINAHL, Web of Knowledge (Science Index, Social Science index), British Nursing Index from January 1996-March 2007 were conducted. The searches were supplemented by an extensive hand search of the literature through references identified from retrieved articles and by contact with experts in the field. Twenty-one relevant publications were identified and included findings from both primary and secondary care. The areas, in which nurses, caring for patients in pain are involved, include assessment, monitoring, evaluation of pain, interdisciplinary collaboration and medicines management. Education programmes delivered by specialist nurses can improve the assessment and documentation of acute and chronic pain. Educational interventions and the use of protocols by specialist nurses can improve patients understanding of their condition and improve pain control. Acute pain teams, led by nurses, can reduce pain intensity and are cost effective. Nurses play key roles in the diverse range of models of care that exist in acute and chronic pain. However, there are methodological weaknesses across this body of research evidence and under researched issues that point to a need for further rigorous evaluation. Nurse-led care is an integral element of the pain services offered to patients. This review highlights the effect of this care and the issues that require consideration by those responsible for the development of nurse-led models in acute and chronic pain.

Using discrete event computer simulation to improve patient flow in a Ghanaian acute care hospital.

PubMed

Best, Allyson M; Dixon, Cinnamon A; Kelton, W David; Lindsell, Christopher J; Ward, Michael J

2014-08-01

Crowding and limited resources have increased the strain on acute care facilities and emergency departments worldwide. These problems are particularly prevalent in developing countries. Discrete event simulation is a computer-based tool that can be used to estimate how changes to complex health care delivery systems such as emergency departments will affect operational performance. Using this modality, our objective was to identify operational interventions that could potentially improve patient throughput of one acute care setting in a developing country. We developed a simulation model of acute care at a district level hospital in Ghana to test the effects of resource-neutral (eg, modified staff start times and roles) and resource-additional (eg, increased staff) operational interventions on patient throughput. Previously captured deidentified time-and-motion data from 487 acute care patients were used to develop and test the model. The primary outcome was the modeled effect of interventions on patient length of stay (LOS). The base-case (no change) scenario had a mean LOS of 292 minutes (95% confidence interval [CI], 291-293). In isolation, adding staffing, changing staff roles, and varying shift times did not affect overall patient LOS. Specifically, adding 2 registration workers, history takers, and physicians resulted in a 23.8-minute (95% CI, 22.3-25.3) LOS decrease. However, when shift start times were coordinated with patient arrival patterns, potential mean LOS was decreased by 96 minutes (95% CI, 94-98), and with the simultaneous combination of staff roles (registration and history taking), there was an overall mean LOS reduction of 152 minutes (95% CI, 150-154). Resource-neutral interventions identified through discrete event simulation modeling have the potential to improve acute care throughput in this Ghanaian municipal hospital. Discrete event simulation offers another approach to identifying potentially effective interventions to improve patient flow in emergency and acute care in resource-limited settings. Copyright © 2014 Elsevier Inc. All rights reserved.

The costs and service implications of substituting intermediate care for acute hospital care.

PubMed

Mayhew, Leslie; Lawrence, David

2006-05-01

Intermediate care is part of a package of initiatives introduced by the UK Government mainly to relieve pressure on acute hospital beds and reduce delayed discharge (bed blocking). Intermediate care involves caring for patients in a range of settings, such as in the home or community or in nursing and residential homes. This paper considers the scope of intermediate care and its role in relation to acute hospital services. In particular, it develops a framework that can be used to inform decisions about the most cost-effective care pathways for given clinical situations, and also for wider planning purposes. It does this by providing a model for evaluating the costs of intermediate care services provided by different agencies and techniques for calibrating the model locally. It finds that consistent application of the techniques over a period of time, coupled with sound planning and accounting, should result in savings to the health economy.

Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score.

PubMed

Coyte, P C; Young, W; Croxford, R

2000-11-01

We estimated the impact of alternative discharge strategies, following joint replacement (JR) surgery, on acute care readmission rates and the total cost of a continuum of care. Following surgery, patients were discharged to one of four destinations. Propensity scores were used to adjust costs and outcomes for potential bias in the assignment of discharge destinations. We demonstrated that the use of rehabilitation hospitals may lower readmission rates, but at a prohibitive incremental cost of each saved readmission, that patients discharged with home care had longer acute care stays than other patients, that the provision of home care services increased health system costs, and that acute care readmission rates were greatest among patients discharged with home care. Our study should be seen as one important stepping stone towards a full economic evaluation of the continuum of care for patients.

Investigation of Eligible Picture Categories for Use as Environmental Cues in Dementia-Sensitive Environments.

PubMed

Motzek, Tom; Bueter, Kathrin; Marquardt, Gesine

2017-07-01

Environmental cues, such as pictures, could be helpful in improving room-finding and wayfinding abilities among older patients. The aim of this study was to identify picture categories that are preferred and easily remembered by older patients and cognitively impaired patients and which therefore might be suitable for use as environmental cues in acute care settings. Twelve pictures were presented to a sample of older patients ( n = 37). The pictures represented different categories: familiarity (familiar vs. unfamiliar), type of shot (close-up vs. wide shot), and picture content (nature vs. animal vs. urban). We tested the patients' votes of preference and abilities to identify and immediately recall pictures. Cognitively impaired patients ( n = 14) were assessed by the abbreviated mental test and the mini mental state examination and were compared with patients without cognitive impairments ( n = 23) using a repeated measures analysis of variance. The results showed a main effect of familiarity on positive vote and recall of pictures. The absence of interaction effects of familiarity and group indicated an overall impact of familiarity on the sample. Within cognitively impaired patients, a significant difference in recall of picture content between urban (20%) and animal (9%) was found. Pictures, which patients were able to relate to in terms of familiarity and the characteristics urban and nature, seem to be suitable for use as environmental cues. Besides functioning as such, we assume, based on literature, that pictures could further enhance the ambiance or serve as prompts for communication and interaction.

Characteristics of elderly patients admitted to an urban tertiary care hospital with osteoporotic fractures: correlations with risk factors, fracture type, gender and ethnicity.

PubMed

Becker, Carolyn; Crow, Scott; Toman, Jared; Lipton, Carter; McMahon, Don J; Macaulay, William; Siris, Ethel

2006-01-01

Osteoporosis is a major public health problem in the United States of America and around the world, largely due to the morbidity and mortality associated with osteoporotic fractures. In the past decade, large epidemiologic studies have contributed greatly to our understanding of patients who fracture. However, most studies are limited to postmenopausal white women. In this retrospective review, we analyze data from 185 men and women with acute fragility fractures who received osteoporosis consultations during admission to a single urban hospital between 2001 and 2003. Men and women differed in terms of risk factors for falls and osteoporosis but had areal bone mineral density (BMD) measurements remarkably similar, except at the total hip. Black and Hispanic subjects with fractures were significantly younger than whites yet were much more likely to have serious co-morbidities, such as diabetes mellitus and hypertension. In spite of significantly higher BMD measurements, black patients had the highest rates of vitamin D deficiency and secondary hyperparathyroidism. Patients admitted with hip fractures differed from those with non-hip fractures on a number of important variables. Based on these data, we conclude that elderly subjects admitted to an urban hospital with osteoporotic fractures are a heterogeneous group, with features that vary according to fracture type, gender and ethnicity. Future studies of patients with clinical fragility fractures should include ample numbers of men and ethnic minorities, since differences in underlying risk factors may suggest alternative strategies for fracture prevention.

Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association.

PubMed

Schiele, Francois; Gale, Chris P; Bonnefoy, Eric; Capuano, Frederic; Claeys, Marc J; Danchin, Nicolas; Fox, Keith Aa; Huber, Kurt; Iakobishvili, Zaza; Lettino, Maddalena; Quinn, Tom; Rubini Gimenez, Maria; Bøtker, Hans E; Swahn, Eva; Timmis, Adam; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zeymer, Uwe; Bueno, Hector

2017-02-01

Evaluation of quality of care is an integral part of modern healthcare, and has become an indispensable tool for health authorities, the public, the press and patients. However, measuring quality of care is difficult, because it is a multifactorial and multidimensional concept that cannot be estimated solely on the basis of patients' clinical outcomes. Thus, measuring the process of care through quality indicators (QIs) has become a widely used practice in this context. Other professional societies have published QIs for the evaluation of quality of care in the context of acute myocardial infarction (AMI), but no such indicators exist in Europe. In this context, the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) has reflected on the measurement of quality of care in the context of AMI (ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)) and created a set of QIs, with a view to developing programmes to improve quality of care for the management of AMI across Europe. We present here the list of QIs defined by the ACCA, with explanations of the methodology used, scientific justification and reasons for the choice for each measure.

Clinical Telemedicine Utilization in Ontario over the Ontario Telemedicine Network.

PubMed

O'Gorman, Laurel D; Hogenbirk, John C; Warry, Wayne

2016-06-01

Northern Ontario is a region in Canada with approximately 775,000 people in communities scattered across 803,000 km(2). The Ontario Telemedicine Network (OTN) facilitates access to medical care in areas that are often underserved. We assessed how OTN utilization differed throughout the province. We used OTN medical service utilization data collected through the Ontario Health Insurance Plan and provided by the Ministry of Health and Long Term Care. Using census subdivisions grouped by Northern and Southern Ontario as well as urban and rural areas, we calculated utilization rates per fiscal year and total from 2008/2009 to 2013/2014. We also used billing codes to calculate utilization by therapeutic area of care. There were 652,337 OTN patient visits in Ontario from 2008/2009 to 2013/2014. Median annual utilization rates per 1,000 people were higher in northern areas (rural, 52.0; urban, 32.1) than in southern areas (rural, 6.1; urban, 3.1). The majority of usage in Ontario was in mental health and addictions (61.8%). Utilization in other areas of care such as surgery, oncology, and internal medicine was highest in the rural north, whereas primary care use was highest in the urban south. Utilization was higher and therapeutic areas of care were more diverse in rural Northern Ontario than in other parts of the province. Utilization was also higher in urban Northern Ontario than in Southern Ontario. This suggests that telemedicine is being used to improve access to medical care services, especially in sparsely populated regions of the province.

The variability of critical care bed numbers in Europe.

PubMed

Rhodes, A; Ferdinande, P; Flaatten, H; Guidet, B; Metnitz, P G; Moreno, R P

2012-10-01

To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product. Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds. We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP (r(2) = 0.16, p = 0.05), numbers of acute care beds corrected for population (r(2) = 0.12, p = 0.05) and the percentage of acute care beds designated as critical care (r(2) = 0.59, p < 0.0001). They were not correlated with the proportion of GDP expended on healthcare. Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.

Development of a resource model for infection prevention and control programs in acute, long term, and home care settings: conference proceedings of the Infection Prevention and Control Alliance.

PubMed

Morrison, Judith

2004-02-01

There is mounting concern about the impact of health care restructuring on the provision of infection prevention services across the health care continuum. In response to this, Health Canada hosted two meetings of Canadian infection control experts to develop a model upon which the resources required to support an effective, integrated infection prevention and control program across the health care continuum could be based. The final models project the IPCP needs as three full time equivalent infection control professionals/500 beds in acute care hospitals and one full time equivalent infection control professional/150-250 beds in long term care facilities. Non human resource requirements are also described for acute, long term, community, and home care settings.

Hospitalization of childhood rotavirus infection from Kuala Lumpur, Malaysia.

PubMed

Lee, W S; Veerasingam, P D; Goh, A Y T; Chua, K B

2003-01-01

To determine the epidemiology of rotavirus gastroenteritis in children admitted to an urban hospital in a developing country from South-East Asia. Retrospective review of cases of acute gastroenteritis admitted to the children's ward of the University of Malaya Medical Centre, Kuala Lumpur, Malaysia, between 1996 and 1999. During the study period, 333 cases (24%) of 1362 stool samples, obtained from children admitted with acute diarrhoea, were positive for rotavirus. Acute gastroenteritis constituted 8.2%, and rotavirus infection 1.6% of all the paediatric admissions each year. Of the 271 cases analysed, 72% of the affected population were less than 2 years of age. Peak incidence of admissions was between January to March, and September to October. Dehydration was common (92%) but electrolyte disturbances, lactose intolerance (5.2%), prolonged diarrhoea (2.6%) and cow's milk protein intolerance was uncommon. No deaths were recorded. Rotavirus infection was a common cause of childhood diarrhoea that required hospital admission in an urban setting in Malaysia.

Rural-urban differences in end-of-life nursing home care: facility and environmental factors.

PubMed

Temkin-Greener, Helena; Zheng, Nan Tracy; Mukamel, Dana B

2012-06-01

This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents. We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location. We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas. This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.

American College of Cardiology (ACC)'s PINNACLE India Quality Improvement Program (PIQIP)-Inception, progress and future direction: A report from the PIQIP Investigators.

PubMed

Kalra, Ankur; Glusenkamp, Nathan; Anderson, Karen; Kalra, Ram N; Kerkar, Prafulla G; Kumar, Ganesh; Maddox, Thomas M; Oetgen, William J; Virani, Salim S

2016-12-01

Cardiovascular diseases have surpassed infectious disorders to become the leading cause of morbidity and mortality in India. 1 A national-level registry comprehensively documenting the current-day prevalence of cardiovascular risk factors and disease burden among patients seeking care in the outpatient setting in India is currently non-existent. With a burgeoning urban population, the cardiovascular disease burden in India is set to skyrocket, with an estimated 18 million productive years of life lost by 2030. 2 While there are limited quality improvement registries in India, for example, the Kerala acute coronary syndrome and Trivandrum heart failure registries, their focus is on in-patient care quality improvement, while the vast majority of patients with cardiovascular diseases worldwide, including India, interact with the health care system in the outpatient setting. 3,4 Recognizing this unmet need, the American College of Cardiology partnered with local stakeholders in India to establish India's first outpatient cardiovascular disease performance measurement initiative in 2011, the PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP). 5 This manuscript discusses the inception of the PIQIP registry, the progress it has made and challenges thus far, and its future direction and the promise it holds for cardiovascular care quality improvement in India. Copyright © 2016. Published by Elsevier B.V.

Prevalence of graduated compression stocking-associated pressure injuries in surgical intensive care units.

PubMed

Hobson, Deborah B; Chang, Tracy Y; Aboagye, Jonathan K; Lau, Brandyn D; Shihab, Hasan M; Fisher, Betsy; Young, Samantha; Sujeta, Nancy; Shaffer, Dauryne L; Popoola, Victor O; Kraus, Peggy S; Knorr, Gina; Farrow, Norma E; Streiff, Michael B; Haut, Elliott R

2017-08-01

This study aimed to determine the prevalence of static graduated compression stocking (sGCS)-associated pressure injury among patients in surgical intensive care units (ICUs). We retrospectively reviewed data from wound care rounds between April 2011 and June 2012 at 3 surgical ICUs at an urban, tertiary care hospital. Patients with sGCS-associated pressure injury were identified and descriptive analysis was performed on their demographic, perioperative, and postoperative characteristics. We examined 1787 individual patients during 2391 patient encounters. A total of 129 (7.2%) of patients developed pressure injuries. Forty patients (2.2%) developed sGCS-associated pressure injury. Static GCS-associated pressure injury accounted for 31% (40/129) of all pressure injuries and 74% (40/54) of all medical device-related pressure injury. Eighteen (45%) and 6 (15%) developed stage 1 and 2 pressure injury, respectively, and 16 (40%) developed deep tissue injuries. The mean age of our patients was 64.7 years, about half (47.5%) were male, and their mean Acute Physiology and Chronic Health Evaluation II score was 18.8. Many had comorbid conditions, including obesity (44.5%) and diabetes (42.5%), and required mechanical ventilation (45%). Pressure injuries are a notable complication of sGCS in surgical ICU patients. Appropriate measures are required to help avoid this potentially preventable harm. Copyright © 2017 Elsevier Inc. All rights reserved.

The utility of outpatient commitment: acute medical care access and protecting health.

PubMed

Segal, Steven P; Hayes, Stephania L; Rimes, Lachlan

2018-06-01

This study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment-community treatment orders (CTOs) in Victoria Australia-are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness. For years 2000 to 2010, the study compared acute medical care access of 27,585  severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care. Validating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis. Mental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.

Referral Regions for Time-Sensitive Acute Care Conditions in the United States.

PubMed

Wallace, David J; Mohan, Deepika; Angus, Derek C; Driessen, Julia R; Seymour, Christopher M; Yealy, Donald M; Roberts, Mark M; Kurland, Kristen S; Kahn, Jeremy M

2018-03-24

Regional, coordinated care for time-sensitive and high-risk medical conditions is a priority in the United States. A necessary precursor to coordinated regional care is regions that are actionable from clinical and policy standpoints. The Dartmouth Atlas of Health Care, the major health care referral construct in the United States, uses regions that cross state and county boundaries, limiting fiscal or political ownership by key governmental stakeholders in positions to create incentive and regulate regional care coordination. Our objective is to develop and evaluate referral regions that define care patterns for patients with acute myocardial infraction, acute stroke, or trauma, yet also preserve essential political boundaries. We developed a novel set of acute care referral regions using Medicare data in the United States from 2011. For acute myocardial infraction, acute stroke, or trauma, we iteratively aggregated counties according to patient home location and treating hospital address, using a spatial algorithm. We evaluated referral political boundary preservation and spatial accuracy for each set of referral regions. The new set of referral regions, the Pittsburgh Atlas, had 326 distinct regions. These referral regions did not cross any county or state borders, whereas 43.1% and 98.1% of all Dartmouth Atlas hospital referral regions crossed county and state borders. The Pittsburgh Atlas was comparable to the Dartmouth Atlas in measures of spatial accuracy and identified larger at-risk populations for all 3 conditions. A novel and straightforward spatial algorithm generated referral regions that were politically actionable and accountable for time-sensitive medical emergencies. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents.

PubMed

Shah, Manish N; Wasserman, Erin B; Wang, Hongyue; Gillespie, Suzanne M; Noyes, Katia; Wood, Nancy E; Nelson, Dallas; Dozier, Ann; McConnochie, Kenneth M

2016-03-01

The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents. We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use. We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different. High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

Changing trends and predictors of outcome in patients with acute poisoning admitted to the intensive care.

PubMed

Jayashree, M; Singhi, S

2011-10-01

Acute poisoning in children is a medical emergency and preventable cause of morbidity and mortality. Knowledge about the nature, magnitude, outcome and predictors of outcome is necessary for management and allocation of scant resources. This is a retrospective study conducted in the Pediatric Intensive Care Unit (PICU) of an urban multi speciality teaching and referral hospital in North India from January 1993 to June 2008 to determine the epidemiology, clinical profile, outcome and predictors of outcome in children with acute poisoning. Data of 225 children with acute poisoning was retrieved from case records with respect to demographic profile, time to presentation, PRISM score, clinical features, investigations, therapeutic measures, complications and outcome in terms of survival or death. Survivors and non-survivors were compared to determine the predictors of mortality. Acute poisoning constituted 3.9% of total PICU admissions; almost all (96.9%) were accidental. The mean age of study patient's was 3.3 ± 3.1 (range 0.10-12) years with majority (61.3%) being toddlers (1-3 years). In the overall cohort, kerosene (27.1%) and prescription drugs (26.7%) were the most common causative agents followed by organophosphates (16.0%), corrosives (7.6%), carbamates (4.9%) and aluminum phosphide (4.9%). However the trends of the three 5-year interval (1993 till the end of 1997, 1998 till the end of 2002 and 2003 till the end of June 2008) revealed a significant decrease in kerosene, aluminum phosphide and iron with increase in organophosphate compound poisoning. Ninety nine (44%) patients required supplemental oxygen, of which nearly half (n = 42; 42.4%) needed mechanical ventilation. Twenty (8.9%) died; cause of death being iron poisoning in five; aluminum phosphide in four; organophosphates in three and one each because of kerosene, diesel, carbamate, corrosive, sewing machine lubricant, isoniazid, salicylate and maduramycin poisoning. There has been a significant decrease in the mortality over the years. The non-survivors were older, had a higher PRISM score and hypotension at admission and higher need for oxygen and ventilation. On multiple logistic regression analysis hypotension at admission was the most significant predictor of death (adjusted odds ratio: 5.59; 95% confidence interval: 1.38-22.63; p = 0.016). Acute poisoning in children over the past 15 years has shown a changing trend with significant decrease in kerosene, iron and aluminum phosphide and an increase in organophosphate and prescription drugs. The overall mortality has decreased significantly. Hypotension at admission was the most significant predictor of death.

Children with Health Issues

ERIC Educational Resources Information Center

Schuster, Mark A.; Chung, Paul J.; Vestal, Katherine D.

2011-01-01

All children, even the healthiest, have preventive and acute health care needs. Moreover, a growing number of children are chronically ill, with preventive, acute, and ongoing care needs that may be much more demanding than those for healthy children. Because children are unable to care for themselves, their parents are expected to provide a range…

Spatial Accessibility to Health Care Services: Identifying under-Serviced Neighbourhoods in Canadian Urban Areas

PubMed Central

Shah, Tayyab Ikram; Bell, Scott; Wilson, Kathi

2016-01-01

Background Urban environments can influence many aspects of health and well-being and access to health care is one of them. Access to primary health care (PHC) in urban settings is a pressing research and policy issue in Canada. Most research on access to healthcare is focused on national and provincial levels in Canada; there is a need to advance current understanding to local scales such as neighbourhoods. Methods This study examines spatial accessibility to family physicians using the Three-Step Floating Catchment Area (3SFCA) method to identify neighbourhoods with poor geographical access to PHC services and their spatial patterning across 14 Canadian urban settings. An index of spatial access to PHC services, representing an accessibility score (physicians-per-1000 population), was calculated for neighborhoods using a 3km road network distance. Information about primary health care providers (this definition does not include mobile services such as health buses or nurse practitioners or less distributed services such as emergency rooms) used in this research was gathered from publicly available and routinely updated sources (i.e. provincial colleges of physicians and surgeons). An integrated geocoding approach was used to establish PHC locations. Results The results found that the three methods, Simple Ratio, Neighbourhood Simple Ratio, and 3SFCA that produce City level access scores are positively correlated with each other. Comparative analyses were performed both within and across urban settings to examine disparities in distributions of PHC services. It is found that neighbourhoods with poor accessibility scores in the main urban settings across Canada have further disadvantages in relation to population high health care needs. Conclusions The results of this study show substantial variations in geographical accessibility to PHC services both within and among urban areas. This research enhances our understanding of spatial accessibility to health care services at the neighbourhood level. In particular, the results show that the low access neighbourhoods tend to be clustered in the neighbourhoods at the urban periphery and immediately surrounding the downtown area. PMID:27997577

Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.

PubMed

Lind, S; Wallin, L; Brytting, T; Fürst, C J; Sandberg, J

2017-11-01

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care. Copyright © 2017 Elsevier B.V. All rights reserved.

Patient Nonadherence to Guideline-Recommended Care in Acute Low Back Pain.

PubMed

Bier, Jasper D; Kamper, Steven J; Verhagen, Arianne P; Maher, Christopher G; Williams, Christopher M

2017-12-01

To describe the magnitude of patient-reported nonadherence with guideline-recommended care for acute low back pain. Secondary analysis of data from participants enrolled in the Paracetamol for Acute Low Back Pain study trial, a randomized controlled trial evaluating the effectiveness of paracetamol for acute low back pain. Primary care, general practitioner. Data from participants with acute low back pain (N=1643). Guideline-recommended care, including reassurance, simple analgesia, and the advice to stay active and avoid bed rest. Also, advice against additional treatments and referral for imaging. Proportion of nonadherence with guideline-recommended care. Nonadherence was defined as (1) failure to consume the advised paracetamol dose, or (2) receipt of additional health care, tests, or medication during the trial treatment period (4wk). Multivariable logistic regression analysis was performed to determine the factors associated with nonadherence. In the first week of treatment, 39.7% of participants were classified as nonadherent. Over the 4-week treatment period, 70.0% were nonadherent, and 57.5% did not complete the advised paracetamol regimen. Higher perceived risk of persistent pain, lower level of disability, and not claiming workers' compensation were associated with nonadherence, with odds ratios ranging from .46 to 1.05. Adherence to guideline-recommended care for acute low back pain was poor. Most participants do not complete the advised paracetamol regimen. Higher perceived risk of persistence of complaints, lower baseline disability, and participants not claiming workers' compensation were independently associated with nonadherence. Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Antibiotic use among older adults on an acute care general surgery service

PubMed Central

Pollmann, André S.; Bailey, Jon G.; Davis, Philip J.B.; Johnson, Paul M.

2017-01-01

Background Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. Methods Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. Results During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. Conclusion Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment. PMID:28930045

Development and Validation of a Simplified Renal Replacement Therapy Suitable for Prolonged Field Care in a Porcine (Sus scrofa) Model of Acute Kidney Injury

DTIC Science & Technology

2018-03-01

of a Simplified Renal Replacement Therapy Suitable for Prolonged Field Care in a Porcine (Sus scrofa) Model of Acute Kidney Injury. PRINCIPAL...and methods, results - include tables/figures, and conclusions/applications.) Objectives/Background: Acute kidney injury (AKI) is a serious

47 CFR 54.605 - Determining the urban rate.

Code of Federal Regulations, 2010 CFR

2010-10-01

....605 Telecommunication FEDERAL COMMUNICATIONS COMMISSION (CONTINUED) COMMON CARRIER SERVICES (CONTINUED) UNIVERSAL SERVICE Universal Service Support for Health Care Providers § 54.605 Determining the urban rate. (a) If a rural health care provider requests an eligible service to be provided over a distance that...

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study.

PubMed

Sacco, Ralph L; Gardener, Hannah; Wang, Kefeng; Dong, Chuanhui; Ciliberti-Vargas, Maria A; Gutierrez, Carolina M; Asdaghi, Negar; Burgin, W Scott; Carrasquillo, Olveen; Garcia-Rivera, Enid J; Nobo, Ulises; Oluwole, Sofia; Rose, David Z; Waters, Michael F; Zevallos, Juan Carlos; Robichaux, Mary; Waddy, Salina P; Romano, Jose G; Rundek, Tatjana

2017-02-14

Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals. Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) ( P <0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Quality and rural-urban comparison of tuberculosis care in Rivers State, Nigeria.

PubMed

Tobin-West, Charles Ibiene; Isodje, Anastasia

2016-01-01

Nigeria ranks among countries with the highest burden of tuberculosis. Yet evidence continues to indicate poor treatment outcomes which have been attributed to poor quality of care. This study aims to identify some of the systemic problems in order to inform policy decisions for improved quality of services and treatment outcomes in Nigeria. A comparative assessment of the quality of TB care in rural and urban health facilities was carried out between May and June 2013, employing the Donabedian model of quality assessment. Data was analysed using the SPSS software package version 20.0. The level of significance was set at p < 0.05. Health facility infrastructures were more constrained in the urban than rural settings. Both the urban and rural facilities lacked adequate facilities for infection control such as, running water, air filter respirators, hand gloves and extractor fans. Health education and HIV counselling and testing (HCT) were limited in rural facilities compared to urban facilities. Although anti-TB drugs were generally available in both settings, the DOTS strategy in patient care was completely ignored. Finally, laboratory support for diagnosis and patient monitoring was limited in the rural facilities. The study highlights suboptimal quality of TB care in Rivers State with limitations in health education and HCT of patients for HIV as well as laboratory support for TB care in rural health facilities. We, therefore, recommend that adequate infection control measures, strict observance of the DOTS strategy and sufficient laboratory support be provided to TB clinics in the State.

A Technical Guide to Urban Community Forestry: Urban and Community Forestry: Improving Our Quality of Life

Treesearch

USDA Forest Service

1993-01-01

Trees growing within cities and towns form a forest-an urban forest. But urban trees require special attention, because they are expected to exist within the urban environment. With its infrastructure of streets, sidewalks, curbs, buried utilities, overhead power lines and buildings, the urban environment places tremendous stresses on trees. With proper care, trees...

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics

ERIC Educational Resources Information Center

Grace, Christopher; Kutzko, Deborah; Alston, W. Kemper; Ramundo, Mary; Polish, Louis; Osler, Turner

2010-01-01

Context: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. Purpose: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. Methods: This was a retrospective cohort study. Findings: Over an 11-year period 363 new…

Fear and the Pedagogy of Care: An Exploratory Study of Veteran White Female Teachers' Emotional Resilience in Urban Schools

ERIC Educational Resources Information Center

Hafiz-Wahid-Muid, Fatima

2010-01-01

This dissertation poses the question, "Who cares and who does not care for poor, black, brown, red and economically disadvantaged children in urban school settings?" The study takes a deeper look at some of the underlying human dynamics that inform teacher retention and student academic achievement as an education problem, specifically related to…

THE PANC 3 SCORE PREDICTING SEVERITY OF ACUTE PANCREATITIS.

PubMed

Beduschi, Murilo Gamba; Mello, André Luiz Parizi; VON-Mühlen, Bruno; Franzon, Orli

2016-03-01

About 20% of cases of acute pancreatitis progress to a severe form, leading to high mortality rates. Several studies suggested methods to identify patients that will progress more severely. However, most studies present problems when used on daily practice. To assess the efficacy of the PANC 3 score to predict acute pancreatitis severity and its relation to clinical outcome. Acute pancreatitis patients were assessed as to sex, age, body mass index (BMI), etiology of pancreatitis, intensive care need, length of stay, length of stay in intensive care unit and mortality. The PANC 3 score was determined within the first 24 hours after diagnosis and compared to acute pancreatitis grade of the Revised Atlanta classification. Out of 64 patients diagnosed with acute pancreatitis, 58 met the inclusion criteria. The PANC 3 score was positive in five cases (8.6%), pancreatitis progressed to a severe form in 10 cases (17.2%) and five patients (8.6%) died. Patients with a positive score and severe pancreatitis required intensive care more often, and stayed for a longer period in intensive care units. The PANC 3 score showed sensitivity of 50%, specificity of 100%, accuracy of 91.4%, positive predictive value of 100% and negative predictive value of 90.6% in prediction of severe acute pancreatitis. The PANC 3 score is useful to assess acute pancreatitis because it is easy and quick to use, has high specificity, high accuracy and high predictive value in prediction of severe acute pancreatitis.

THE PANC 3 SCORE PREDICTING SEVERITY OF ACUTE PANCREATITIS

PubMed Central

BEDUSCHI, Murilo Gamba; MELLO, André Luiz Parizi; VON-MÜHLEN, Bruno; FRANZON, Orli

2016-01-01

Background : About 20% of cases of acute pancreatitis progress to a severe form, leading to high mortality rates. Several studies suggested methods to identify patients that will progress more severely. However, most studies present problems when used on daily practice. Objective : To assess the efficacy of the PANC 3 score to predict acute pancreatitis severity and its relation to clinical outcome. Methods : Acute pancreatitis patients were assessed as to sex, age, body mass index (BMI), etiology of pancreatitis, intensive care need, length of stay, length of stay in intensive care unit and mortality. The PANC 3 score was determined within the first 24 hours after diagnosis and compared to acute pancreatitis grade of the Revised Atlanta classification. Results : Out of 64 patients diagnosed with acute pancreatitis, 58 met the inclusion criteria. The PANC 3 score was positive in five cases (8.6%), pancreatitis progressed to a severe form in 10 cases (17.2%) and five patients (8.6%) died. Patients with a positive score and severe pancreatitis required intensive care more often, and stayed for a longer period in intensive care units. The PANC 3 score showed sensitivity of 50%, specificity of 100%, accuracy of 91.4%, positive predictive value of 100% and negative predictive value of 90.6% in prediction of severe acute pancreatitis. Conclusion : The PANC 3 score is useful to assess acute pancreatitis because it is easy and quick to use, has high specificity, high accuracy and high predictive value in prediction of severe acute pancreatitis. PMID:27120730

Methodology for a Community Based Stroke Preparedness Intervention: The ASPIRE Study

PubMed Central

Boden-Albala, Bernadette; Edwards, Dorothy F.; Clair, Shauna St; Wing, Jeffrey J; Fernandez, Stephen; Gibbons, Chris; Hsia, Amie W.; Morgenstern, Lewis B.; Kidwell, Chelsea S.

2014-01-01

Background and Purpose Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. Methods The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multi-level program utilizing a community engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia (DC). This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue plasminogen activator (IV tPA) utilization for acute ischemic stroke. Results Phase 1 included: 1) enhancement of EMS focus on acute stroke; 2) hospital collaborations to implement and/or enrich acute stroke protocols and transition DC hospitals toward Primary Stroke Center certification; and 3) pre-intervention acute stroke patient data collection in all 7 acute care DC hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted with over 10,256 participants reached; 3289 intervention evaluations were performed, and 19,000 preparedness bracelets and 14,000 stroke warning magnets were distributed. Phase 3 included an evaluation of EMS and hospital processes for acute stroke care and a yearlong post-intervention acute stroke data collection period to assess changes in IV tPA utilization. Conclusions We report the methods, feasibility, and pre-intervention data collection efforts of the ASPIRE intervention. PMID:24876243

Validating diagnostic information on the Minimum Data Set in Ontario Hospital-based long-term care.

PubMed

Wodchis, Walter P; Naglie, Gary; Teare, Gary F

2008-08-01

Over 20 countries currently use the Minimum Data Set Resident Assessment Instrument (MDS) in long-term care settings for care planning, policy, and research purposes. A full assessment of the quality of the diagnostic information recorded on the MDS is lacking. The primary goal of this study was to examine the quality of diagnostic coding on the MDS. Subjects for this study were admitted to Ontario Complex Continuing Care Hospitals (CCC) directly from acute hospitals between April 1, 1997 and March 31, 2005 (n = 80,664). Encrypted unique identifiers, common across acute and CCC administrative databases, were used to link administrative records for patients in the sample. After linkage, each resident had 2 sources of diagnostic information: the acute discharge abstract database and the MDS. Using the discharge abstract database as the reference standard, we calculated the sensitivity for each of 43 MDS diagnoses. Compared with primary diagnoses coded in acute care abstracts, 12 of 43 MDS diagnoses attained a sensitivity of at least 0.80, including 7 of the 10 diagnoses with the highest prevalence as an acute care primary diagnosis before CCC admission. Although the sensitivity was high for many of the most prevalent conditions, important diagnostic information is missed increasing the potential for suboptimal clinical care. Emphasis needs to be put on improving information flow across care settings during patient transitions. Researchers should exercise caution when using MDS diagnoses to identify patient populations, particularly those shown to have low sensitivity in this study.

Oral hygiene and mouth care for older people in acute hospitals: part 1.

PubMed

Steel, Ben J

2017-10-31

The oral health of older people in acute hospitals has rarely been studied. Hospital admission provides a prime opportunity for identification and rectification of problems, and oral health promotion. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presents the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. Searches of electronic databases and the websites of relevant professional health service bodies in the UK were undertaken to identify articles and guidelines. The literature shows a high prevalence of oro-dental disease in this population, with many known detrimental effects, combined with suboptimal oral hygiene and mouth care provision in acute hospitals. Several guidelines exist, although the emphasis on oral health is weaker than other aspects of hospital care. Older adults admitted to acute hospitals have a high burden of oro-dental disease and oral and mouth care needs, but care provision tends to be suboptimal. The literature is growing, but this area is still relatively neglected. Great potential exists to develop oral and mouth care in this context. The second part of this article explores clinical recommendations. ©2012 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Clinicians’ views on improving inter-organizational care transitions

PubMed Central

2013-01-01

Background Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians’ perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations. Methods A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. Results Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients’ readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. Conclusion Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient’s status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients. PMID:23899326

Knowledge translation: An interprofessional approach to integrating a pain consult team within an acute care unit.

PubMed

Feldman, Kira; Berall, Anna; Karuza, Jurgis; Senderovich, Helen; Perri, Giulia-Anna; Grossman, Daphna

2016-11-01

Management of pain in the frail elderly presents many challenges in both assessment and treatment, due to the presence of multiple co-morbidities, polypharmacy, and cognitive impairment. At Baycrest Health Sciences, a geriatric care centre, pain in its acute care unit had been managed through consultations with the pain team on a case-by-case basis. In an intervention informed by knowledge translation (KT), the pain specialists integrated within the social network of the acute care team for 6 months to disseminate their expertise. A survey was administered to staff on the unit before and after the intervention of the pain team to understand staff perceptions of pain management. Pre- and post-comparisons of the survey responses were analysed by using t-tests. This study provided some evidence for the success of this interprofessional education initiative through changes in staff confidence with respect to pain management. It also showed that embedding the pain team into the acute care team supported the KT process as an effective method of interprofessional team building. Incorporating the pain team into the acute care unit to provide training and ongoing decision support was a feasible strategy for KT and could be replicated in other clinical settings.

New indices for home nursing care resource disparities in rural and urban areas, based on geocoding and geographic distance barriers: a cross-sectional study.

PubMed

Lin, Shyang-Woei; Yen, Chia-Feng; Chiu, Tzu-Ying; Chi, Wen-Chou; Liou, Tsan-Hon

2015-10-08

Aging in place is the crucial object of long-term care policy worldwide. Approximately 15.6-19.4% of people aged 15 or above live with a disability, and 15.3% of them have moderate or severe disabilities. The allocation of home nursing care services is therefore an important issue. Service providers in Taiwan vary substantially across regions, and between rural and urban areas. There are no appropriate indices for describing the capacity of providers that it is due to the distances from care recipients. This study therefore aimed to describe and compare distance barriers for home nursing care providers using indices of the "profit willing distance" and the "tolerance limited distance". This cross-sectional study was conducted during 2012 and 2013 using geocoding and a geographic information system to identify the distance from the providers' locations to participants' homes in urban (Taipei City) and rural (Hualien County) areas in Taiwan. Data were collected in-person by professionals in Taiwanese hospitals using the World Health Organization Disability Assessment Schedule 2.0. The indices were calculated using regression curves, and the first inflection points were determined as the points on the curves where the first and second derivatives equaled 0. There were 5627 participants from urban areas and 956 from rural areas. In urban areas, the profit willing distance was 550-600 m, and we were unable to identify them in rural areas. This demonstrates that providers may need to supply services even when there is little profit. The tolerance limited distance were 1600-1650 m in urban areas and 1950-2000 m in rural areas. In rural areas, 33.3% of those living inside the tolerance limited distance and there was no provider within this distance, but this figure fell to just 13.9% in urban areas. There were strong disparities between urban and rural areas in home nursing care resource allocation. Our new "profit willing distance" and the "tolerance limited distance" are considered to be clearer and more equitable than other evaluation indices. They have practical application in considering resource distribution issues around the world, and in particular the rural-urban disparities for public resource.

A transitional care service for elderly chronic disease patients at risk of readmission.

PubMed

Brand, Caroline A; Jones, Catherine T; Lowe, Adrian J; Nielsen, David A; Roberts, Carol A; King, Bellinda L; Campbell, Donald A

2004-12-13

Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. A quasi-experimental controlled trial. A large tertiary metropolitan teaching hospital. 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

[Detection of palliative care needs in an acute care hospital unit. Pilot study].

PubMed

Rodríguez-Calero, Miguel Ángel; Julià-Mora, Joana María; Prieto-Alomar, Araceli

2016-01-01

Previous to wider prevalence studies, we designed the present pilot study to assess concordance and time invested in patient evaluations using a palliative care needs assessment tool. We also sought to estimate the prevalence of palliative care needs in an acute care hospital unit. A cross-sectional study was carried out, 4 researchers (2 doctors and 2 nurses) independently assessed all inpatients in an acute care hospital unit in Manacor Hospital, Mallorca (Spain), using the validated tool NECPAL CCOMS-ICO©, measuring time invested in every case. Another researcher revised clinical recordings to analise the sample profile. Every researcher assessed 29 patients, 15 men and 14 women, mean age 74,03 ± 10.25 years. 4-observer concordance was moderate (Kappa 0,5043), tuning out to be higher between nurses. Mean time per patient evaluation was 1.9 to 7.72 minutes, depending on researcher. Prevalence of palliative care needs was 23,28%. Moderate concordance lean us towards multidisciplinary shared assessments as a method for future research. Avarage of time invested in evaluations was less than 8 minutes, no previous publications were identified regarding this variable. More than 20% of inpatients of the acute care unit were in need of palliative care. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Care provider allocation on admissions to acute mental health wards: The development and validation of the Admission Team Score List.

PubMed

van den Berg, Sjobha R N; Stringer, Barbara; van de Sande, Roland; Draisma, Stasja

2018-05-18

Currently, support tools are lacking to prioritize steps in the care coordination process to enable safe practice and effective clinical pathways in the first phase of acute psychiatric admissions. This study describes the development, validity, and reliability of an acute care coordination support tool, the Admission Team Score List (ATSL). The ATSL assists in care provider allocation during admissions. Face validity and feasibility of the ATSL were tested in 77 acute admissions. Endscores of filled out ATSL's were translated to recommended team compositions. These ATSL team (ATSL-T) compositions were compared to the actually present team (AP-T) and the most preferred team (MP-T) composition in hindsight. Consistency between the ATSL-T and the MP-T was substantial; K w  = 0.70, P < 0.001, 95% CI [0.55-0.84]. The consistency between the ATSL-T and AP-T was moderate; K w  = 0.43, P < 0.001, 95% CI [0.23-0.62]. The ATSL has an adequate (inter-rater) reliability; ICC = 0.90, P < 0.001, 95% CI [0.65-0.91]. The ATSL study is an important step to promote safety and efficient care based on care provider allocation, for service users experiencing an acute admission. The ATSL may stimulate structured clinical decision-making during the hectic process around acute psychiatric admissions. © 2018 Australian College of Mental Health Nurses Inc.

Persistent Super-Utilization of Acute Care Services Among Subgroups of Veterans Experiencing Homelessness.

PubMed

Szymkowiak, Dorota; Montgomery, Ann Elizabeth; Johnson, Erin E; Manning, Todd; O'Toole, Thomas P

2017-10-01

Acute health care utilization often occurs among persons experiencing homelessness. However, knowing which individuals will be persistent super-utilizers of acute care is less well understood. The objective of the study was to identify those more likely to be persistent super-utilizers of acute care services. We conducted a latent class analysis of secondary data from the Veterans Health Administration Corporate Data Warehouse, and Homeless Operations Management and Evaluation System. The study sample included 16,912 veterans who experienced homelessness and met super-utilizer criteria in any quarter between July 1, 2014 and December 31, 2015. The latent class analysis included veterans' diagnoses and acute care utilization. Medical, mental health, and substance use morbidity rates were high. More than half of the sample utilized Veterans Health Administration Homeless Programs concurrently with their super-utilization of acute care. There were 7 subgroups of super-utilizers, which varied considerably on the degree to which their super-utilization persisted over time. Approximately a third of the sample met super-utilizer criteria for ≥3 quarters; this group was older and disproportionately male, non-Hispanic white, and unmarried, with lower rates of post-9/11 service and higher rates of rural residence and service-connected disability. They were much more likely to be currently homeless with more medical, mental health, and substance use morbidity. Only a subset of homeless veterans were persistent super-utilizers, suggesting the need for more targeted interventions.

Acute medical bed usage by nursing home residents.

PubMed

Beringer, T R; Flanagan, P

1999-05-01

An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people.

Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis▿

PubMed Central

Colgan, Richard; Johnson, James R.; Kuskowski, Michael; Gupta, Kalpana

2008-01-01

Emerging antimicrobial resistance among uropathogens makes the management of acute uncomplicated cystitis increasingly challenging. Few prospective data are available on the risk factors for resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the drug of choice in most settings. In order to evaluate this, we prospectively enrolled women 18 to 50 years of age presenting to an urban primary care practice with symptoms of cystitis. Potentially eligible women provided a urine sample for culture and completed a questionnaire regarding putative risk factors for TMP-SMX resistance. Escherichia coli isolates were tested for clonal group A (CGA) membership by a fumC-specific PCR. Of 165 women with cystitis symptoms, 103 had a positive urine culture and were eligible for participation. E. coli was the predominant uropathogen (86%). Fifteen (14.6%) women had a TMP-SMX-resistant (TMP-SMXr) organism (all of which were E. coli). Compared with the women who had a TMP-SMX-susceptible organism, women in the TMP-SMXr group were more likely to have traveled (odds ratio [OR], 15.4; 95% confidence interval [CI], 4.4 to 54.3; P < 0.001) and to be Asian (OR, 6.1; 95% CI, 1.0 to 36.4; P = 0.048). CGA was also independently associated with TMP-SMX resistance (OR, 105; 95% CI, 6.3 to 1,777.6; P = 0.001). No association with TMP-SMX resistance was demonstrated for the use of either TMP-SMX or another antibiotic in the past 3 months or with having a child in day care. Among these women with acute uncomplicated cystitis, Asian race and recent travel were independently associated with TMP-SMX resistance. TMP-SMXr isolates were more likely to belong to CGA. Knowledge of these risk factors for TMP-SMX resistance could facilitate the accurate selection of empirical therapy. PMID:18086847

Pediatric stroke: clinical characteristics, acute care utilization patterns, and mortality.

PubMed

Statler, Kimberly D; Dong, Li; Nielsen, Denise M; Bratton, Susan L

2011-04-01

Acute care utilization patterns are not well described but may help inform care coordination and treatment for pediatric stroke. The Kids Inpatient Database was queried to describe demographics and clinical characteristics of children with stroke, compare acute care utilization for hemorrhagic vs. ischemic stroke and Children's vs. non-Children's Hospitals, and identify factors associated with aggressive care and in-hospital mortality. Using a retrospective cohort of children hospitalized with stroke, demographics, predisposing conditions, and intensive (mechanical ventilation, advanced monitoring, and blood product administration) or aggressive (pharmacological therapy and/or invasive interventions) care were compared by stroke and hospital types. Factors associated with aggressive care or in-hospital mortality were explored using logistic regression. Hemorrhagic stroke comprised 43% of stroke discharges, was more common in younger children, and carried greater mortality. Ischemic stroke was more common in older children and more frequently associated with a predisposing condition. Rates of intensive and aggressive care were low (30% and 15%), similar by stroke type, and greater at Children's Hospitals. Older age, hemorrhagic stroke, predisposing condition, and treatment at a Children's Hospital were associated with aggressive care. Hemorrhagic stroke and aggressive care were associated with in-hospital mortality. Acute care utilization is similar by stroke type but both intensive and aggressive care are more common at Children's Hospitals. Mortality remains relatively high after pediatric stroke. Widespread implementation of treatment guidelines improved outcomes in adult stroke. Adoption of recently published treatment recommendations for pediatric stroke may help standardize care and improve outcomes.

Components of nurse innovation: a model from acute care hospitals.

PubMed

Neidlinger, S H; Drews, N; Hukari, D; Bartleson, B J; Abbott, F K; Harper, R; Lyon, J

1992-12-01

Components that promote nurse innovation in acute care hospitals are explicated in the Acute Care Nursing Innovation Model. Grounded in nursing care delivery systems and excellent management-organizations perspectives, nurse executives and 30 nurse "intrapreneurs" from 10 innovative hospitals spanning the United States shared their experiences and insights through semistructured, tape-recorded telephone interviews. Guided by interpretive interactionist strategies, the essential components, characteristics, and interrelationships are conceptualized and described so that others may be successful in their innovative endeavors. Successful innovation is dependent on the fit between and among the components; the better the fit, the more likely the innovation will succeed.

Mild traumatic brain injury in children: management practices in the acute care setting.

PubMed

Kool, Bridget; King, Vivienne; Chelimo, Carol; Dalziel, Stuart; Shepherd, Michael; Neutze, Jocelyn; Chambers, Nikki; Wells, Susan

2014-08-01

Accurate diagnosis, treatment and follow up of children suffering mild traumatic brain injury (MTBI) is important as post-concussive symptoms and long-term disability might occur. This research explored the decisions clinicians make in their assessment and management of children with MTBI in acute care settings, and identified barriers and enablers to the delivery of best-practice care. A purposeful sample of 29 clinicians employed in two metropolitan paediatric EDs and one Urgent Care clinic was surveyed using a vignette-based questionnaire that also included domains of guideline awareness, attitudes to MTBI care, use of clinical decision support systems, and knowledge and skills for practising evidence-based healthcare. Overall, the evaluation and management of children presenting acutely with MTBI generally followed best-practice guidelines, particularly in relation to identifying intracranial injuries that might require surgical intervention, observation for potential deterioration, adequate pain management and the provision of written head injury advice on discharge. Larger variation emerged in regard to follow-up care and referral pathways. Potential barriers to best- practice were lack of guideline awareness, attitudes to MTBI, and lack of time or other priorities. Opportunities exist to improve care for children who present in acute care settings following mild traumatic brain injury. These include having up-to-date guidelines that are consistent across acute care settings; providing clearer pathways for referral and follow up; targeting continuing medical education towards potential complications; and providing computerised decision support so that assessment and management are conducted systematically. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Use of reproductive health care services among urban migrant women in Bangladesh.

PubMed

Islam, Mohammad Mainul; Gagnon, Anita J

2016-03-09

Recent internal migration flows from rural to urban areas pose challenges to women using reproductive health care services in their migratory destinations. No studies were found which examined the relationship between migration, migration-associated indicators and reproductive health care services in Bangladesh. We analyzed the 2006 Bangladesh Urban Health Survey (data made publically available in June 2013) of 14,191 ever-married women aged 10-59 years. Cross tabulations and logistic regression were conducted. Migrants and non-migrants did not differ significantly in their use of modern contraceptives and treatment for STI but were less likely to receive ANC even after controlling for a range of variables. Compared to non-migrants, more migrants had home births, did not take vitamin A after delivery, and had no medical exam post-birth. Migrant women being village-born (rather than urban-born) were associated with risk of diminished: use of ANC; treatment for STI; medical exam post-birth; vitamin A post-birth. Migrating for work or education (rather than other reasons) was associated with risk of diminished: use of ANC; use of modern facilities for birth; and medical exam post-birth. Each additional year lived in urban areas was associated with a greater likelihood of receiving ANC. Women who migrated to urban areas in Bangladesh were significantly less likely than non-migrants to use reproductive health care services related to pregnancy care. Pro-actively identifying migrant women, especially those who originated from villages or migrated for work or education may be warranted to ensure optimal use of pregnancy-related services.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis.

PubMed

Palmer, Karen S; Agoritsas, Thomas; Martin, Danielle; Scott, Taryn; Mulla, Sohail M; Miller, Ashley P; Agarwal, Arnav; Bresnahan, Andrew; Hazzan, Afeez Abiola; Jeffery, Rebecca A; Merglen, Arnaud; Negm, Ahmed; Siemieniuk, Reed A; Bhatnagar, Neera; Dhalla, Irfan A; Lavis, John N; You, John J; Duckett, Stephen J; Guyatt, Gordon H

2014-01-01

Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care. We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication. Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk  = 1.24, 95% CI 1.18-1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences. Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Urban-Rural Comparisons in Hospital Admission, Treatments, and Outcomes for ST-Segment-Elevation Myocardial Infarction in China From 2001 to 2011: A Retrospective Analysis From the China PEACE Study (Patient-Centered Evaluative Assessment of Cardiac Events).

PubMed

Li, Xi; Murugiah, Karthik; Li, Jing; Masoudi, Frederick A; Chan, Paul S; Hu, Shuang; Spertus, John A; Wang, Yongfei; Downing, Nicholas S; Krumholz, Harlan M; Jiang, Lixin

2017-11-01

In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available. We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P =0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P =0.04) and early β-blockers (56% versus 60%; P =0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011. Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883. © 2017 American Heart Association, Inc.

Creating Learning Momentum through Overt Teaching Interactions during Real Acute Care Episodes

ERIC Educational Resources Information Center

Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R.

2015-01-01

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand…

Vertical integration and diversification of acute care hospitals: conceptual definitions.

PubMed

Clement, J P

1988-01-01

The terms vertical integration and diversification, although used quite frequently, are ill-defined for use in the health care field. In this article, the concepts are defined--specifically for nonuniversity acute care hospitals. The resulting definitions are more useful than previous ones for predicting the effects of vertical integration and diversification.

77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-17

... [CMS-1588-F2] RIN 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for...

Healthcare Resource Availability, Quality of Care, and Acute Ischemic Stroke Outcomes.

PubMed

O'Brien, Emily C; Wu, Jingjing; Zhao, Xin; Schulte, Phillip J; Fonarow, Gregg C; Hernandez, Adrian F; Schwamm, Lee H; Peterson, Eric D; Bhatt, Deepak L; Smith, Eric E

2017-02-03

Healthcare resources vary geographically, but associations between hospital-based resources and acute stroke quality and outcomes remain unclear. Using Get With The Guidelines-Stroke and Dartmouth Atlas of Health Care data, we examined associations between healthcare resource availability, stroke care, and outcomes. We categorized hospital referral regions with high-, medium-, or low-resource levels based on the 2006 national per-capita availability median of 6 relevant acute stroke care resources. Using multivariable logistic regression, we examined healthcare resource level and in-hospital quality and outcomes. Of 1 480 308 admitted ischemic stroke patients (2006-2013), 28.8% were hospitalized in low-, 44.4% in medium-, and 26.9% in high-resource hospital referral regions. Quality-of-care/timeliness metrics, adjusted length of stay, and in-hospital mortality were similar across all resource levels. Significant variation exists in regional availability of healthcare resources for acute ischemic stroke treatment, yet among Get With the Guidelines-Stroke hospitals, quality of care and in-hospital outcomes did not differ by regional resource availability. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

The prevailing winds of oppression: understanding the new graduate experience in acute care.

PubMed

Duchscher, Judy Boychuk; Myrick, Florence

2008-01-01

The experience of new graduates in acute care. The majority of newly graduated nurses make their initial professional role transition in acute care. Being socialized into the dynamic culture of today's hospitals creates significant challenges not only for the nurses themselves but also for institutions of higher education, healthcare administrators, and policy makers across this country. Demanding workloads for hospital nurses, an aging nursing workforce, and the high level of stress inherent in workplaces across North America are factors contributing to an exodus of both new and seasoned nurses out of acute care. This article outlines the implicit and explicit factors that may be contributing to the dissatisfaction and distress in nursing graduates entering professional practice through hospital nursing. CINAHL, MEDLINE, Sociolit, and PubMed. Discussion is focused on the oppressive context in which hospital nursing continues to be situated and explores the ideological, structural, and relational aspects of domination that continue to surface in the work experiences of novice as well as seasoned nurses. Suggestions for addressing the issues that plague the acute care environment are integrated throughout the article, and a detailed framework of empowerment for this nursing context is offered.

Hospitals ineligible for federal meaningful-use incentives have dismally low rates of adoption of electronic health records.

PubMed

Wolf, Larry; Harvell, Jennie; Jha, Ashish K

2012-03-01

The US government has dedicated substantial resources to help certain providers, such as short-term acute care hospitals and physicians, adopt and meaningfully use electronic health record (EHR) systems. We used national data to determine adoption rates of EHR systems among all types of inpatient providers that were ineligible for these same federal meaningful-use incentives: long-term acute care hospitals, rehabilitation hospitals, and psychiatric hospitals. Adoption rates for these institutions were dismally low: less than half of the rate among short-term acute care hospitals. Specifically, 12 percent of short-term acute care hospitals have at least a basic EHR system, compared with 6 percent of long-term acute care hospitals, 4 percent of rehabilitation hospitals, and 2 percent of psychiatric hospitals. To advance the creation of a nationwide health information technology infrastructure, federal and state policy makers should consider additional measures, such as adopting health information technology standards and EHR system certification criteria appropriate for these ineligible hospitals; including such hospitals in state health information exchange programs; and establishing low-interest loan programs for the acquisition and use of certified EHR systems by ineligible providers.

[Implementation of a palliative care concept in a geriatric acute care hospital].

PubMed

Hagg-Grün, U; Lukas, A; Sommer, B-N; Klaiber, H-R; Nikolaus, T

2010-12-01

To integrate palliative care patients into an acute geriatric ward requires extensive and continuous education and preparation of all participating professionals. It can be a lengthy process to integrate palliative care concepts despite cooperation of the hospital administration. The group of patients to be integrated differs from the patients of regular geriatric wards because of a higher percentage of relatively young oncologic patients and they differ from a regular palliative ward because about 50% are non-oncologic patients, while the average age is much higher than in normal palliative care. It is possible to integrate specialized palliative care into a regular geriatric ward. Patients admitted without palliative intention will benefit the most from ward-integrated palliative care if the treatment aim turns this way. Ward-integrated palliative care can be an integral part of treating geriatric patients in addition to acute geriatric medicine, rehabilitation, and prevention. It can also provide caretakers and patients with the benefits from continuity of treatment and care.

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou, China

PubMed Central

Zeng, Jiazhi; Shi, Leiyu; Zou, Xia; Chen, Wen; Ling, Li

2015-01-01

Objectives China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China. Methods The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores. Results After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001). Conclusions This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care. PMID:26474161

Perioperative and acute care outcomes in morbidly obese patients with acetabular fractures at a Level 1 trauma center

PubMed Central

Vincent, Heather K.; Haupt, Edward; Tang, Sonya; Egwuatu, Adaeze; Vlasak, Richard; Horodyski, MaryBeth; Carden, Donna; Sadisivan, Kalia K.

2014-01-01

Background Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma. Purpose The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture. Methods This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2; N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups. Conclusions Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture. PMID:25104886

The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm.

PubMed

Kim, Kelvin; Iorio, Richard

2017-06-01

Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms. We summarize a number of experiences and lessons learned since the implementation of Bundled Payments for Care Improvement at our institution. Our experience has led to the development of more refined clinical pathways and coordination of care through evidence-based approaches. We have established that the success of the bundled payment program rests on the following 5 main clinical pillars: (1) optimizing patient selection and comorbidities; (2) optimizing care coordination, patient education, shared decision making, and patient expectations; (3) using a multimodal pain management protocol and minimizing narcotic use to facilitate rapid rehabilitation; (4) optimizing blood management, and standardizing venous thromboembolic disease prophylaxis treatment by risk standardizing patients and minimizing the use of aggressive anticoagulation; and (5) minimizing post-acute facility and resource utilization, and maximizing home resources for patient recovery. From our extensive experience with bundled payment models, we have established 5 clinical pillars of value for bundled payments. Our hope is that these principles will help ease the transition to value-based care for less-experienced healthcare systems. Copyright © 2017 Elsevier Inc. All rights reserved.

Learning from death: a hospital mortality reduction programme

PubMed Central

Wright, John; Dugdale, Bob; Hammond, Ian; Jarman, Brian; Neary, Maria; Newton, Duncan; Patterson, Chris; Russon, Lynne; Stanley, Philip; Stephens, Rose; Warren, Erica

2006-01-01

Problem: There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care. Setting: A large acute hospital in an urban district in the North of England. Design: Before and after evaluation of a hospital mortality reduction programme. Strategies for change: Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control. Effects: Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002-2005. Lessons learnt: Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality. PMID:16738373

Introducing Namaste Care to the hospital environment: a pilot study.

PubMed

St John, Kimberley; Koffman, Jonathan

2017-10-01

The rising prevalence of dementia is impacting on acute hospitals and placing increased expectations on health and social care professionals to improve the support and services they are delivering. It has been recommended that good practice in dementia care relies on adopting a palliative approach to care and meeting people's physical, psychological, social and spiritual needs. Increased dementia training for staff that includes initiatives that promote dignity; enhancing communication skills and recognizing that a person with dementia may be approaching the end of their lives are needed. Our study aim was to explore whether Namaste Care is an acceptable and effective service for people with advanced dementia being cared for on an acute hospital ward. This was an exploratory qualitative interview, pilot study. Individual, semi-structured, face-to-face interviews were conducted with hospital healthcare staff working in an area of the hospital where Namaste Care had been implemented. Data were analysed using the framework approach. Eight interviews were completed with members of the multidisciplinary ward team. Two themes were identified: (I) difficulties establishing relationships with people with dementia in hospital (subthemes: lack of time and resources, lack of confidence leading to fear and anxiety); (II) the benefits of a Namaste Care service in an acute hospital setting (subthemes: a reduction in agitated behavior; connecting and communicating with patients with dementia using the senses; a way of showing people with dementia they are cared for and valued). This small-scale study indicates that Namaste Case has the potential to improve the quality of life of people with advanced dementia being cared for in an acute hospital setting. However, further research is required to explore more specifically its benefits in terms of improved symptom management and wellbeing of people with dementia on acute hospitals wards.

Traumatic stress in parents of children admitted to the pediatric intensive care unit.

PubMed

Balluffi, Andrew; Kassam-Adams, Nancy; Kazak, Anne; Tucker, Michelle; Dominguez, Troy; Helfaer, Mark

2004-11-01

To measure the prevalence of parental acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) and to examine the relationship between ASD symptoms and PTSD symptoms in parents of infants and children admitted to the pediatric intensive care unit (PICU). To examine the correlation between parental perceptions of illness severity and objective measures. To assess the association among demographic, situational, and illness factors and the severity of ASD and PTSD. Prospective cohort study. Thirty-eight bed PICU at an urban children's hospital. The parents of 272 children admitted to the PICU for >48 hrs. ASD symptoms were assessed using the Acute Stress Disorder Scale during the child's admission. PTSD symptoms were assessed using the PTSD Checklist at least 2 months after discharge. The severity of illness was measured using the Pediatric Risk of Mortality (PRISM III) score. Of the 272 parents completing the initial assessment, 87 (32%) met symptom criteria for ASD. Of the 161 parents completing follow-up, 33 (21%) met symptom criteria for PTSD. PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU, unexpected admission, parent's degree of worry that the child might die, and the occurrence of another hospital admission or other traumatic event subsequent to the index admission. Neither ASD nor PTSD responses were associated with objective measures of a child's severity of illness (PRISM III score). Traumatic stress symptoms are common among parents in the PICU and may persist long after discharge. There is strong support from these data for continued attention to supporting parents both during and after a child's PICU admission.

Effects of outsourced nursing on quality outcomes in long-term acute-care hospitals.

PubMed

Alvarez, M Raymond; Kerr, Bernard J; Burtner, Joan; Ledlow, Gerald; Fulton, Larry V

2011-03-01

Use of outsourced nurses is often a stop-gap measure for unplanned vacancies in smaller healthcare facilities such as long-term acute-care hospitals (LTACHs). However, the relationship of utilization levels (low, medium, or high percentages) of nonemployees covering staff schedules often is perceived to have negative relationships with quality outcomes. To assess this issue, the authors discuss the outcomes of their national study of LTACH hospitals that indicated no relationship existed between variations in percentage of staffing by contracted nurses and selected outcomes in this post-acute-care setting.

Coding Accuracy of the Ambulatory Data System: A Study of Coding Accuracy Within the General Internal Medicine Clinic, Walter Reed Army Medical Center

DTIC Science & Technology

1998-04-17

concerns center around its ultimate goal to maximize appropriate care and minimize or eliminate inappropriate care (DoD UM Policy , 1996). While the...uasp cncd . GCK Tobacco taw disorder tr’O: Anemia ID: Acute bronchial ID: A«Jtt]ihiir<rtiK*i» 10: Acute refft iafection ID: Acute xinucm ID...181-187. Department of Defense (DoD) Ultilization Management Policy for the Direct Care System (Draft) (1996). Duncan, D.G. & Servais, C.S., (1996

Optimizing Safety, Fidelity and Usability of an Intelligent Clinical Support Tool (ICST) For Acute Hospital Care: an Australian Case Study Using a Multi-Method Delphi Process.

PubMed

Botti, Mari; Redley, Bernice; Nguyen, Lemai; Coleman, Kimberley; Wickramasinghe, Nilmini

2015-01-01

This research focuses on a major health priority for Australia by addressing existing gaps in the implementation of nursing informatics solutions in healthcare. It serves to inform the successful deployment of IT solutions designed to support patient-centered, frontline acute healthcare delivery by multidisciplinary care teams. The outcomes can guide future evaluations of the contribution of IT solutions to the efficiency, safety and quality of care delivery in acute hospital settings.

Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema.

PubMed

Hubble, Michael W; Richards, Michael E; Wilfong, Denise A

2008-01-01

To estimate the cost-effectiveness of continuous positive airway pressure (CPAP) in managing prehospital acute pulmonary edema in an urban EMS system. Using estimates from published reports on prehospital and emergency department CPAP, a cost-effectiveness model of implementing CPAP in a typical urban EMS system was derived from the societal perspective as well as the perspective of the implementing EMS system. To assess the robustness of the model, a series of univariate and multivariate sensitivity analyses was performed on the input variables. The cost of consumables, equipment, and training yielded a total cost of $89 per CPAP application. The theoretical system would be expected to use CPAP 4 times per 1000 EMS patients and is expected to save 0.75 additional lives per 1000 EMS patients at a cost of $490 per life saved. CPAP is also expected to result in approximately one less intubation per 6 CPAP applications and reduce hospitalization costs by $4075 per year for each CPAP application. Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. Previous studies have demonstrated the clinical effectiveness of CPAP in the management of acute pulmonary edema. Through a theoretical analysis which modeled the costs and clinical benefits of implementing CPAP in an urban EMS system, prehospital CPAP appears to be a cost-effective treatment.

Chiropractic Use by Urban and Rural Residents with Insurance Coverage

ERIC Educational Resources Information Center

Lind, Bonnie K.; Diehr, Paula K.; Grembowski, David E.; Lafferty, William E.

2009-01-01

Purpose: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use…

Alcohol Consumption among Urban, Suburban, and Rural Veterans Affairs Outpatients

ERIC Educational Resources Information Center

Williams, Emily C.; McFarland, Lynne V.; Nelson, Karin M.

2012-01-01

Purpose: United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care-based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol…

Post–Acute Care Use and Hospital Readmission after Sepsis

PubMed Central

Jones, Tiffanie K.; Fuchs, Barry D.; Small, Dylan S.; Halpern, Scott D.; Hanish, Asaf; Umscheid, Craig A.; Baillie, Charles A.; Kerlin, Meeta Prasad; Gaieski, David F.

2015-01-01

Rationale: The epidemiology of post–acute care use and hospital readmission after sepsis remains largely unknown. Objectives: To examine the rate of post–acute care use and hospital readmission after sepsis and to examine risk factors and outcomes for hospital readmissions after sepsis. Methods: In an observational cohort study conducted in an academic health care system (2010–2012), we compared post–acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations with 108,958 nonsepsis hospitalizations. We used three validated, claims-based approaches to identify sepsis and severe sepsis. Measurements and Main Results: Post–acute care use at discharge was more likely after sepsis, driven by skilled care facility placement (35.4% after sepsis vs. 15.8%; P < 0.001), with the highest rate observed after severe sepsis. Readmission rates at 7, 30, and 90 days were higher postsepsis (P < 0.001). Compared with nonsepsis hospitalizations (15.6% readmitted within 30 d), the increased readmission risk was present regardless of sepsis severity (27.3% after sepsis and 26.0–26.2% after severe sepsis). After controlling for presepsis characteristics, the readmission risk was found to be 1.51 times greater (95% CI, 1.38–1.66) than nonsepsis hospitalizations. Readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P < 0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, malignancy diagnosis, hospitalizations in the year prior to the index hospitalization, nonelective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red cell distribution width at discharge. Conclusions: Post–acute care use and hospital readmissions were common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with adverse readmission outcomes. PMID:25751120

Who Are the High-Cost Users? A Method for Person-Centred Attribution of Health Care Spending.

PubMed

Guilcher, Sara J T; Bronskill, Susan E; Guan, Jun; Wodchis, Walter P

2016-01-01

To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE. Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11. This study is a retrospective cohort study. A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year. Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year. Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.

Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial.

PubMed

Levine, David M; Ouchi, Kei; Blanchfield, Bonnie; Diamond, Keren; Licurse, Adam; Pu, Charles T; Schnipper, Jeffrey L

2018-05-01

Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking. Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience. Randomized controlled trial. Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma. Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing. Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience. Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups. The use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial. Trial Registration NCT02864420.

Hospital-level changes in adult ICU bed supply in the United States

PubMed Central

Wallace, David J.; Seymour, Christopher W.; Kahn, Jeremy M.

2017-01-01

Objective Although the number of intensive care beds in the United States is increasing, little is known about the hospitals responsible for this growth. We sought to better characterize national growth in intensive care beds by identifying hospital-level factors associated with increasing numbers of intensive care beds over time. Design We performed a repeated-measures time series analysis of hospital-level intensive care bed supply using data from Centers for Medicare and Medicaid Services. Setting All United States acute care hospitals with adult intensive care beds over the years 1996 to 2011. Measurements & Main Results We described the number of beds, teaching status, ownership, intensive care occupancy and urbanicity for each hospital in each year of the study. We then examined the relationship between increasing intensive care beds and these characteristics, controlling for other factors. The study included 4,457 hospitals and 55,865 hospital-years. Overall, the majority of intensive care bed growth occurred in teaching hospitals (net +13,471 beds, 72.1% of total growth), hospitals with 250 or more beds (net +18,327 beds, 91.8% of total growth) and hospitals in the highest quartile of occupancy (net +10,157 beds, 54.0% of total growth). In a longitudinal multivariable model, larger hospital size, teaching status, and high intensive care occupancy were associated with subsequent-year growth. Furthermore, the effects of hospital size and teaching status were modified by occupancy: the greatest odds of increasing intensive care unit beds were in hospitals with 500 or more beds in the highest quartile of occupancy (adjusted OR: 18.9; 95% CI: 14.0 – 25.5; p<0.01) and large teaching hospitals in the highest quartile of occupancy (adjusted OR: 7.3; 95% CI: 5.3 – 9.9; p<0.01). Conclusions Increasingly, intensive care bed expansion in the United States is occurring in larger hospitals and teaching centers, particularly following a year with high intensive care unit occupancy. PMID:27661861

Oral Health Inequalities between Rural and Urban Populations of the African and Middle East Region.

PubMed

Ogunbodede, E O; Kida, I A; Madjapa, H S; Amedari, M; Ehizele, A; Mutave, R; Sodipo, B; Temilola, S; Okoye, L

2015-07-01

Although there have been major improvements in oral health, with remarkable advances in the prevention and management of oral diseases, globally, inequalities persist between urban and rural communities. These inequalities exist in the distribution of oral health services, accessibility, utilization, treatment outcomes, oral health knowledge and practices, health insurance coverage, oral health-related quality of life, and prevalence of oral diseases, among others. People living in rural areas are likely to be poorer, be less health literate, have more caries, have fewer teeth, have no health insurance coverage, and have less money to spend on dental care than persons living in urban areas. Rural areas are often associated with lower education levels, which in turn have been found to be related to lower levels of health literacy and poor use of health care services. These factors have an impact on oral health care, service delivery, and research. Hence, unmet dental care remains one of the most urgent health care needs in these communities. We highlight some of the conceptual issues relating to urban-rural inequalities in oral health, especially in the African and Middle East Region (AMER). Actions to reduce oral health inequalities and ameliorate rural-urban disparity are necessary both within the health sector and the wider policy environment. Recommended actions include population-specific oral health promotion programs, measures aimed at increasing access to oral health services in rural areas, integration of oral health into existing primary health care services, and support for research aimed at informing policy on the social determinants of health. Concerted efforts must be made by all stakeholders (governments, health care workforce, organizations, and communities) to reduce disparities and improve oral health outcomes in underserved populations. © International & American Associations for Dental Research 2015.

Formal Home Care Utilization Patterns by Rural–Urban Community Residence

PubMed Central

Spector, William; Van Nostrand, Joan

2009-01-01

Background We examined formal home care utilization among civilian adults across metro and nonmetro residential categories before and after adjustment for predisposing, enabling, and need variables. Methods Two years of the Medical Expenditure Panel Survey (MEPS) were combined to produce a nationally representative sample of adults who resided in the community for a calendar year. We established 6 rural–urban categories based upon Urban Influence Codes and examined 2 dependent variables: (a) likelihood of using any formal home care and (b) number of provider days received by users. The Area Resource File provided county-level information. Logistic and negative binomial regression analyses were employed, with adjustments for the MEPS complex sampling design and the combined years. Results Under controls for predisposing, enabling, and need variables, differences in likelihood of any formal home care use disappear, but differences in number of provider days received by users emerged, with fewer provider days in remote areas than in metro and several other nonmetro types. Conclusions It is important to fully account for predisposing, enabling, and need factors when assessing rural and urban home care utilization patterns. The limited provider days in remote counties under controls suggest a possible access problem for adults in these areas. PMID:19196690

Mortality following stroke during and after acute care according to neighbourhood deprivation: a disease registry study.

PubMed

Grimaud, Olivier; Leray, Emmanuelle; Lalloué, Benoit; Aghzaf, Radouane; Durier, Jérôme; Giroud, Maurice; Béjot, Yannick

2014-12-01

Neighbourhood deprivation has been shown to be inversely associated with mortality 1 month after stroke. Whether this disadvantage begins while patients are still receiving acute care is unclear. We aimed to study mortality after stroke specifically in the period while patients are under acute care and the ensuing period when they are discharged to home or other care settings. Our sample includes 1760 incident strokes (mean age 75, 48% men, 86% ischaemic) identified between 1998 and 2010 by the population-based stroke registry of Dijon (France). We used Cox regression to study all-cause mortality up to 90 days after stroke occurrence. Overall, 284 (16.1%) patients died during the 90 days following stroke. Prior to stroke, risk factors prevalence (eg, high blood pressure and diabetes) and acute care management did not vary across deprivation levels. There was no association between deprivation and mortality while patients were in acute care (HR comparing the highest to the lowest tertiles of deprivation: 1.01, 95% CI 0.71 to 1.43). After discharge, however, age and gender adjusted mortality gradually increased with deprivation (HR 2.08, 95% CI 1.07 to 4.02). This association was not modified when stroke type and severity were accounted for. The gradient of higher poststroke mortality with increasing neighbourhood deprivation was noticeable only after acute hospital discharge. Quality of postacute care and social support are potential determinants of these variations. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Patient factors associated with increased acute care costs of hip fractures: a detailed analysis of 402 patients.

PubMed

Aigner, R; Meier Fedeler, T; Eschbach, D; Hack, J; Bliemel, C; Ruchholtz, S; Bücking, B

2016-12-01

The aim of the present study was to identify patient factors associated with higher costs in hip fracture patients. The mean costs of a prospectively observed sample of 402 patients were 8853 €. The ASA score, Charlson comorbidity index, and fracture location were associated with increased costs. Fractures of the proximal end of the femur (hip fractures) are of increasing incidence due to demographic changes. Relevant co-morbidities often present in these patients cause high complication rates and prolonged hospital stays, thus leading to high costs of acute care. The aim of this study was to perform a precise cost analysis of the actual hospital costs of hip fractures and to identify patient factors associated with increased costs. The basis of this analysis was a prospectively observed single-center trial, which included 402 patients with fractures of the proximal end of the femur. All potential cost factors were recorded as accurately as possible for each of the 402 patients individually, and statistical analysis was performed to identify associations between pre-existing patient factors and acute care costs. The mean total acute care costs per patient were 8853 ± 5676 € with ward costs (5828 ± 4294 €) and costs for surgical treatment (1972 ± 956 €) representing the major cost factors. The ASA score, Charlson comorbidity index, and fracture location were identified as influencing the costs of acute care for hip fracture treatment. Hip fractures are associated with high acute care costs. This study underlines the necessity of sophisticated risk-adjusted payment models based on specific patient factors. Economic aspects should be an integral part of future hip fracture research due to limited health care resources.

Health seeking behaviour and health awareness among rural and urban adolescents in Dehradun District, Uttarakhand, India.

PubMed

Kumar, Tuhin; Pal, Piyalee; Kaur, Prabhdeep

2017-04-01

Adolescents constituted 19% population of India in 2011. Adolescents have health seeking behaviour different from that of adults. We estimated the utilisation of available health care services by adolescents and awareness regarding various health issues in the urban and rural Dehradun District, Uttarakhand, India. We also described knowledge and practices of public sector health care providers. We conducted a cross-sectional survey among adolescents 10-19 years in the urban Dehradun and rural Chakrata block of the Dehradun District. We used cluster sampling with sample size 680 each in urban and rural areas. We collected data from adolescents using semi structured questionnaire on health awareness and utilisation of health care services. Public sector health care providers were surveyed about their knowledge and practices regarding adolescents health. We surveyed 1463 adolescents. The overall mean age was 14.4 (2.6) years, about half being females. Half of the adolescents who had any illness used the public sector. Awareness about anaemia was 48% in urban and 12% in rural areas. A higher proportion of females (Rural: 89%, Urban: 76%) were aware of condoms as contraceptives than males (Rural: 68%, Urban: 12%). Only 62% of doctors and 49% of paramedical staff had knowledge regarding services under Adolescents Reproductive and Sexual Health (ARSH). Awareness regarding various health issues was low among males as compared to females, especially in rural areas. School based health promotion programs should be carried out to increase awareness among adolescents. Health facilities should be strengthened to provide adolescent friendly health services to enhance utilisation.

Moving toward holistic wellness, empowerment and self-determination for Indigenous peoples in Canada: Can traditional Indigenous health care practices increase ownership over health and health care decisions?

PubMed

Auger, Monique; Howell, Teresa; Gomes, Tonya

2016-12-27

This study aimed to understand the role that traditional Indigenous health care practices can play in increasing individual-level self-determination over health care and improving health outcomes for urban Indigenous peoples in Canada. This project took place in Vancouver, British Columbia and included the creation and delivery of holistic workshops to engage community members (n = 35) in learning about aspects of traditional health care practices. Short-term and intermediate outcomes were discussed through two gatherings involving focus groups and surveys. Data were transcribed, reviewed, thematically analyzed, and presented to the working group for validation. When participants compared their experiences with traditional health care to western health care, they described barriers to care that they had experienced in accessing medical doctors (e.g., racism, mistrust), as well as the benefits of traditional healing (e.g., based on relationships, holistic approach). All participants also noted that they had increased ownership over their choices around, and access to, health care, inclusive of both western and traditional options. They stressed that increased access to traditional health care is crucial within urban settings. Self-determination within Indigenous urban communities, and on a smaller scale, ownership for individuals, is a key determinant of health for Indigenous individuals and communities; this was made clear through the analysis of the research findings and is also supported within the literature. This research also demonstrates that access to traditional healing can enhance ownership for community members. These findings emphasize that there is a continued and growing need for support to aid urban Indigenous peoples in accessing traditional health care supports.

Use of chest sonography in acute-care radiology☆

PubMed Central

De Luca, C.; Valentino, M.; Rimondi, M.R.; Branchini, M.; Baleni, M. Casadio; Barozzi, L.

2008-01-01

Diagnosis of acute lung disease is a daily challenge for radiologists working in acute-care areas. It is generally based on the results of chest radiography performed under technically unfavorable conditions. Computed tomography (CT) is undoubtedly more accurate in these cases, but it cannot always be performed on critically ill patients who need continuous care. The use of thoracic ultrasonography (US) has recently been proposed for the study of acute lung disease. It can be carried out rapidly at the bedside and does not require any particularly sophisticated equipment. This report analyzes our experience with chest sonography as a supplement to chest radiography in an Emergency Radiology Unit. We performed chest sonography – as an adjunct to chest radiography – on 168 patients with acute chest pathology. Static and dynamic US signs were analyzed in light of radiographic findings and, when possible, CT. The use of chest US improved the authors' ability to provide confident diagnoses of acute disease of the chest and lungs. PMID:23397048

Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting.

PubMed

Bridgeman, Mary Barna; Abazia, Daniel T

2017-03-01

The authors review the historical use of medicinal cannabis and discuss the agent's pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.

Art, music, story: The evaluation of a person-centred arts in health programme in an acute care older persons' unit.

PubMed

Ford, Karen; Tesch, Leigh; Dawborn, Jacqueline; Courtney-Pratt, Helen

2018-06-01

To evaluate the impact of an arts in health programme delivered by a specialised artist within an acute older person's unit. Acute hospitals must meet the increasingly complex needs of older people who experience multiple comorbidities, often including cognitive impairment, either directly related to their admission or longer term conditions, including dementia. A focus on physical illness, efficiency and tasks within an acute care environment can all divert attention from the psychosocial well-being of patients. This focus also decreases capacity for person-centred approaches that acknowledge and value the older person, their life story, relationships and the care context. The importance of arts for health and wellness, including responsiveness to individual need, is well established: however, there is little evidence about its effectiveness for older people in acute hospital settings. We report on a collaborative arts in health programme on an acute medical ward for older people. The qualitative study used collaborative enquiry underpinned by a constructivist approach to evaluate an arts programme that involved participatory art-making activities, customised music, song and illustration work, and enlivening the unit environment. Data sources included observation of art activities, semi-structured interviews with patients and family members, and focus groups with staff. Data were transcribed and thematically analysed using a line by line approach. The programme had positive impacts for the environment, patients, families and staff. The environment exhibited changes as a result of programme outputs; patients and families were engaged and enjoyed activities that aided recovery from illness; and staff also enjoyed activities and importantly learnt new ways of working with patients. An acute care arts in health programme is a carefully nuanced programme where the skills of the arts health worker are critical to success. Utilising such skill, continued focus on person-centeredness and openness to creativity demonstrated positive impacts for patients, families, staff and the ward environment. This study affirms the contribution of an arts in health program for older persons in an acute care setting in challenging the dominance of a task based medical model and emphasising person-centred care and outcomes. © 2018 John Wiley & Sons Ltd.

Quality and rural-urban comparison of tuberculosis care in Rivers State, Nigeria

PubMed Central

Tobin-West, Charles Ibiene; Isodje, Anastasia

2016-01-01

Introduction Nigeria ranks among countries with the highest burden of tuberculosis. Yet evidence continues to indicate poor treatment outcomes which have been attributed to poor quality of care. This study aims to identify some of the systemic problems in order to inform policy decisions for improved quality of services and treatment outcomes in Nigeria. Methods A comparative assessment of the quality of TB care in rural and urban health facilities was carried out between May and June 2013, employing the Donabedian model of quality assessment. Data was analysed using the SPSS software package version 20.0. The level of significance was set at p < 0.05. Results Health facility infrastructures were more constrained in the urban than rural settings. Both the urban and rural facilities lacked adequate facilities for infection control such as, running water, air filter respirators, hand gloves and extractor fans. Health education and HIV counselling and testing (HCT) were limited in rural facilities compared to urban facilities. Although anti-TB drugs were generally available in both settings, the DOTS strategy in patient care was completely ignored. Finally, laboratory support for diagnosis and patient monitoring was limited in the rural facilities. Conclusion The study highlights suboptimal quality of TB care in Rivers State with limitations in health education and HCT of patients for HIV as well as laboratory support for TB care in rural health facilities. We, therefore, recommend that adequate infection control measures, strict observance of the DOTS strategy and sufficient laboratory support be provided to TB clinics in the State. PMID:27642401

Missed Nursing Care and Unit-Level Nurse Workload in the Acute and Post-Acute Settings.

PubMed

Orique, Sabrina B; Patty, Christopher M; Woods, Ellen

2016-01-01

This study replicates previous research on the nature and causes of missed nursing care and adds an explanatory variable: unit-level nurse workload (patient turnover percentage). The study was conducted in California, which legally mandates nurse staffing ratios. Findings demonstrated no significant relationship between patient turnover and missed nursing care.

The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada.

PubMed

Wang, Li; Grignon, Michel; Perry, Sheril; Chen, Xi-Kuan; Ytsma, Alison; Allin, Sara; Gapanenko, Katerina

2018-04-17

To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier. Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013. We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression. Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB. On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients. The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains. © Health Research and Educational Trust.

Needlestick and other potential blood and body fluid exposures among health care workers in British Columbia, Canada.

PubMed

Alamgir, Hasanat; Cvitkovich, Yuri; Astrakianakis, George; Yu, Shicheng; Yassi, Annalee

2008-02-01

Health care workers have high risk of exposure to human blood and body fluids (BBF) from patients in acute care and residents in nursing homes or personal homes. This analysis examined the epidemiology for BBF exposure across health care settings (acute care, nursing homes, and community care). Detailed analysis of BBF exposure among the health care workforce in 3 British Columbian health regions was conducted by Poisson regression modeling, with generalized estimating equations to determine the relative risk associated with various occupations. Acute care had the majority of needlestick, sharps, and splash events with the BBF exposure rate in acute care 2 to 3 times higher compared with nursing home and community care settings. Registered nurses had the highest frequency of needlestick, sharps, and splash events. Laboratory assistants had the highest exposure rates from needlestick injuries and splashes, whereas licensed practical nurses had the highest exposure rate from sharps. Most needlestick injuries (51.3%) occurred at the patient's bedside. Sharps incidents occurred primarily in operating rooms (26.9%) and at the patient's bedside (20.9%). Splashes occurred most frequently at the patient's bedside (46.1%) and predominantly affected the eyes or face/mouth. The majority of needlestick/sharps injuries occurred during use for registered nurses, during disposal for licensed practical nurses, and after disposal for care aides. The high risk of BBF exposure for some occupations indicates there is room for improvement to reduce BBF exposure by targeting high-risk groups for prevention strategies.

Day hospital versus admission for acute psychiatric disorders

PubMed Central

Marshall, Max; Crowther, Ruth; Sledge, William Hurt; Rathbone, John; Soares-Weiser, Karla

2014-01-01

Background Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. Objectives To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders. Search methods We searched the Cochrane Schizophrenia Group Trials Register (June 2010) which is based on regular searches of MEDLINE, EMBASE, CINAHL and PsycINFO. We approached trialists to identify unpublished studies. Selection criteria Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder. Data collection and analysis Two review authors independently extracted and cross-checked data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data. We calculated weighted or standardised means for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. We therefore sought individual patient data so that we could re-analyse outcomes in a common format. Main results Ten trials (involving 2685 people) met the inclusion criteria. We obtained individual patient data for four trials (involving 646 people). We found no difference in the number lost to follow-up by one year between day hospital care and inpatient care (5 RCTs, n = 1694, RR 0.94 CI 0.82 to 1.08). There is moderate evidence that the duration of index admission is longer for patients in day hospital care than inpatient care (4 RCTs, n = 1582, WMD 27.47 CI 3.96 to 50.98). There is very low evidence that the duration of day patient care (adjusted days/month) is longer for patients in day hospital care than inpatient care (3 RCTs, n = 265, WMD 2.34 days/month CI 1.97 to 2.70). There is no difference between day hospital care and inpatient care for the being readmitted to in/day patient care after discharge (5 RCTs, n = 667, RR 0.91 CI 0.72 to 1.15). It is likely that there is no difference between day hospital care and inpatient care for being unemployed at the end of the study (1 RCT, n = 179, RR 0.88 CI 0.66 to 1.19), for quality of life (1 RCT, n = 1117, MD 0.01 CI −0.13 to 0.15) or for treatment satisfaction (1 RCT, n = 1117, MD 0.06 CI −0.18 to 0.30). Authors’ conclusions Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients. However, further data are still needed on the cost effectiveness of day hospitals. PMID:22161384

Fluid accumulation during acute kidney injury in the intensive care unit.

PubMed

Berthelsen, R E; Perner, A; Jensen, A K; Jensen, J-U; Bestle, M H

2018-07-01

Fluid therapy is a ubiquitous intervention in patients admitted to the intensive care unit, but positive fluid balance may be associated with poor outcomes and particular in patients with acute kidney injury. Studies describing this have defined fluid overload either at specific time points or considered patients with a positive mean daily fluid balance as fluid overloaded. We wished to detail this further and performed joint model analyses of the association between daily fluid balance and outcome represented by mortality and renal recovery in patients admitted with acute kidney injury. We did a retrospective cohort study of patients admitted to the intensive care unit with acute kidney injury during a 2-year observation period. We used serum creatinine measurements to identify patients with acute kidney injury and collected sequential daily fluid balance during the first 5 days of admission to the intensive care unit. We used joint modelling techniques to correlate the development of fluid overload with survival and renal recovery adjusted for age, gender and disease severity. The cohort contained 863 patients with acute kidney injury of whom 460 (53%) and 254 (29%) developed 5% and 10% fluid overload, respectively. We found that both 5% and 10% fluid overload was correlated with reduced survival and renal recovery. Joint model analyses of fluid accumulation in patients admitted to the intensive care unit with acute kidney injury confirm that even a modest degree of fluid overload (5%) may be negatively associated with both survival and renal recovery. © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Hospital performance recognition with the Get With The Guidelines Program and mortality for acute myocardial infarction and heart failure.

PubMed

Heidenreich, Paul A; Lewis, William R; LaBresh, Kenneth A; Schwamm, Lee H; Fonarow, Gregg C

2009-10-01

Many hospitals enrolled in the American Heart Association's Get With The Guidelines (GWTG) Program achieve high levels of recommended care for heart failure, acute myocardial infarction (MI) and stroke. However, it is unclear if outcomes are better in those hospitals recognized by the GWTG program for their processes of care. We compared hospitals enrolled in GWTG and receiving achievement awards for high levels of recommended processes of care with other hospitals using data on risk-adjusted 30-day survival for heart failure and acute MI reported by the Center for Medicare and Medicaid Services. Among the 3,909 hospitals with 30-day data reported by Center for Medicare and Medicaid Services 355 (9%) received GWTG achievement awards. Risk-adjusted mortality for hospitals receiving awards was lower for both heart failure (11.0% vs 11.2%, P = .0005) and acute MI (16.1% vs 16.5%, P < .0001) compared to those not receiving awards. After additional adjustment for hospital characteristics and noncardiac performance measures, the reduction in mortality remained significantly lower for GWTG award hospitals for acute myocardial infraction (-0.19%, 95% CI -0.33 to -0.05), but not for heart failure (-0.11%, 95% CI -0.25 to 0.02). Additional adjustment for cardiac processes of care reduced the benefit of award hospitals by 28% for heart failure mortality and 43% for acute MI mortality. Hospitals receiving achievement awards from the GWTG program have modestly lower risk adjusted mortality for acute MI and to a lesser extent, heart failure, explained in part by better process of care.

Promoting patient-centred fundamental care in acute healthcare systems.

PubMed

Feo, Rebecca; Kitson, Alison

2016-05-01

Meeting patients' fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this re-conceptualisation and subsequent action, poor quality, depersonalised fundamental care will prevail. Copyright © 2016 Elsevier Ltd. All rights reserved.

Retail clinic visits and receipt of primary care.

PubMed

Reid, Rachel O; Ashwood, J Scott; Friedberg, Mark W; Weber, Ellerie S; Setodji, Claude M; Mehrotra, Ateev

2013-04-01

An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. To assess the association between retail clinic use and receipt of key primary care functions. We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.

Evaluation and management of patients in the acute phase of myocardial infarction - the role of nuclear medicine in the coronary care unit

DOE Office of Scientific and Technical Information (OSTI.GOV)

Palac, R.T.; Gray, L.; Brown, P.H.

1988-09-01

This is the third article in a four-part continuing education series relating to patient care and management. After completing the article, the reader should be able to: 1) understand the application, potential, and problems of nuclear cardiology in the coronary care unit; 2) recognize the utilization of nuclear cardiology in acute coronary care management; and 3) appreciate the important role of nuclear cardiology in cardiac patient care.

Short-term outcome and differences between rural and urban trauma patients treated by mobile intensive care units in Northern Finland: a retrospective analysis.

PubMed

Raatiniemi, Lasse; Liisanantti, Janne; Niemi, Suvi; Nal, Heini; Ohtonen, Pasi; Antikainen, Harri; Martikainen, Matti; Alahuhta, Seppo

2015-11-05

Emergency medical services are an important part of trauma care, but data comparing urban and rural areas is needed. We compared 30-day mortality and length of intensive care unit (ICU) stay for trauma patients injured in rural and urban municipalities and collected basic data on trauma care in Northern Finland. We examined data from all trauma patients treated by the Finnish Helicopter Emergency Medical Services in 2012 and 2013. Only patients surviving to hospital were included in the analysis but all pre-hospital deaths were recorded. All data was retrieved from the national Helicopter Emergency Medical Services database, medical records, and the Finnish Causes of Death Registry. Patients were defined as urban or rural depending on the type of municipality where the injury occurred. A total of 472 patients were included. Age and Injury Severity Score did not differ between rural and urban patients. The pre-hospital time intervals and distances to trauma centers were longer for rural patients and a larger proportion of urban patients had intentional injuries (23.5% vs. 9.3%, P <0.001). The 30-day mortality for severely injured patients (Injury Severity Score >15) was 23.9% in urban and 13.3% in rural municipalities. In the multivariate regression analysis the odds ratio (OR) for 30-day mortality was 2.8 (95% confidence interval 1.0 to 7.9, P = 0.05) in urban municipalities. There was no difference in the length of ICU stay or scores. Twenty patients died on scene or during transportation and 56 missions were aborted because of pre-hospital death. The severely injured urban trauma patients had a trend toward higher 30-day mortality compared with patients injured in rural areas but the length of ICU stay was similar. However, more pre-hospital deaths occurred in rural municipalities. The time before mobile ICU arrival appears to be critical for trauma patients' survival, especially in rural areas.

Acute care costs of patients admitted for management of chronic obstructive pulmonary disease exacerbations: contribution of disease severity, infection and chronic heart failure.

PubMed

Hutchinson, A; Brand, C; Irving, L; Roberts, C; Thompson, P; Campbell, D

2010-05-01

In 2003, chronic obstructive pulmonary disease (COPD) accounted for 46% of the burden of chronic respiratory disease in the Australian community. In the 65-74-year-old age group, COPD was the sixth leading cause of disability for men and the seventh for women. To measure the influence of disease severity, COPD phenotype and comorbidities on acute health service utilization and direct acute care costs in patients admitted with COPD. Prospective cohort study of 80 patients admitted to the Royal Melbourne Hospital in 2001-2002 for an exacerbation of COPD. Patients were followed for 12 months and data were collected on acute care utilization. Direct hospital costs were derived using Transition II, an activity-based costing system. Individual patient costs were then modelled to ascertain which patient factors influenced total direct hospital costs. Direct costs were calculated for 225 episodes of care, the median cost per admission was AU$3124 (interquartile range $1393 to $5045). The median direct cost of acute care management per patient per year was AU$7273 (interquartile range $3957 to $14 448). In a multivariate analysis using linear regression modelling, factors predictive of higher annual costs were increasing age (P= 0.041), use of domiciliary oxygen (P= 0.008) and the presence of chronic heart failure (P= 0.006). This model has identified a number of patient factors that predict higher acute care costs and awareness of these can be used for service planning to meet the needs of patients admitted with COPD.

Assuring health coverage for all in India.

PubMed

Patel, Vikram; Parikh, Rachana; Nandraj, Sunil; Balasubramaniam, Priya; Narayan, Kavita; Paul, Vinod K; Kumar, A K Shiva; Chatterjee, Mirai; Reddy, K Srinath

2015-12-12

Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist. A large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care. Here we make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022--a fitting way to mark the 75th year of India's independence. Copyright © 2015 Elsevier Ltd. All rights reserved.