Prevalence of infections in long-term care facilities: how to read it?

PURPOSE: Prevalence surveys are mostly used in European countries for infection surveillance in long-term care facilities (LTCFs). The purpose of this paper is to document the prevalence of infections in LTCFs and to identify and discuss the potential sources of variation in the overall prevalence of infections. METHODS: Six repeated prevalence surveys were carried out over a period of 3 years in 11 LTCFs in the Emilia-Romagna region, involving a mean of 812 residents in each survey. In one facility, continuous surveillance was also conducted. McGeer's infection criteria were used. Observers undertook a 1-day training course and on-field training. RESULTS: The average prevalence of infected residents was 11.5/100 residents: respiratory tract infections were the most common (5.7/100 residents), followed by urinary tract infections (2.6%), skin infections (1.9%), and ocular infections (1.4%). In a multivariate model, the prevalence significantly varied by season (p < 0.001) and residents' case-mix index (CMI, p < 0.001). In individual homes, the case mix varied from 0.91 to 1.1 and the observed prevalence varied from 6.6 to 40.4%. One facility set up and maintained continuous surveillance: three clusters of lower respiratory tract infection were identified in 1.5 years by a temporal scan test. Cases belonging to one outbreak only were captured by the prevalence surveys conducted in the same periods. CONCLUSIONS: The prevalence of infections in LTCFs needs to be interpreted cautiously, given the effects of seasonality and case-mix variation. Repeated prevalence surveys may be a good start in individual facilities, but the identification of outbreaks requires a continuous surveillance system.

Emergence of ciprofloxacin resistance in Escherichia coli isolates from outpatient urine samples.

This study investigated the association between prescription of fluoroquinolones and emergence of ciprofloxacin resistance among Escherichia coli isolates in the urine of outpatients from whom a ciprofloxacin-sensitive E. coli strain had been isolated previously. Patients were identified and followed using the healthcare databases of Emilia-Romagna Region, Italy. The outcome of interest was the first isolation from urine of an E. coli strain resistant to ciprofloxacin. Prescription of fluoroquinolones during the previous 6 months was associated independently with the emergence of ciprofloxacin resistance; the strength of the association varied according to individual fluoroquinolone agents.

Impact of regionalisation of cardiac surgery in Emilia-Romagna, Italy.

STUDY OBJECTIVE: Assessment of the impact of the regionalisation of cardiac surgery through the organisational form of a hub&spoke model introduced in the year 2000. DESIGN: Case mix adjusted before (1998-1999)-after (2000-2002) comparison of: (a) in-hospital and 30 days mortality rates; (b) proportion of patients timely (within one day) referred for surgery from spoke to hub centres; (c) patients' waiting times to surgery. SETTING: Emilia-Romagna, an Italian region with four million residents. PATIENTS: 16,512 patients aged > or =18 years and referred to cardiac surgery over the period 1998-2002. MAIN RESULTS: Overall, taking into account differences in case mix across the whole study period, the implementation of the regionalisation policy was associated with a 22% reduction (OR: 0.79, 95%CI: 0.66 to 0.93) in in-hospital mortality rate. The corresponding figure for 30 day mortality was 18% (OR: 0.82: 95%CI: 0.69 to 0.98). The individual centres' volume of cases changed over the study period for all hospitals but two, and the biggest reduction in mortality was seen at the centre with the largest increase in caseload. CONCLUSIONS: This study provides additional evidence on the benefit of regionalisation of cardiac surgery interventions. The system allowed each centre to reach the minimum caseload required to assure good quality of care. These findings suggest that policies aimed at increasing cooperation rather than competition among health service providers have a positive impact on quality of care. Timely referrals for surgery increased by 21% (95%CI: 1.12 to 1.31), and mean waiting times were reduced by 7.5 average days (95%CI: -10.33 to -4.71).

Selective referrals in a 'hub and spoke' institutional setting: the case of coronary angioplasty procedures.

We analyse the highly-regulated cardiovascular sector of the health service in the Italian region of Emilia Romagna: this sector is characterised by strict regulatory control and a great emphasis on co-ordination and co-operation between public and private producers. These features have been even more marked since 2000, due to the adoption of the 'hub and spoke' organisational model, whereby a close relationship of selective referral from the network of satellite cardiology units (spokes) to the six Cardiac Surgical Centres (hubs) has been developed, so as to concentrate high risk procedures in highly specialised units. We focus on coronary angioplasty procedures (PTCA) and examine relations among centres before and after the official introduction of this hierarchical system completed the regionalisation of cardiovascular services. Secondly, since earlier regional efforts to reconfigure cardiovascular care by sending referrals to a few major centres may already have produced a high level of co-ordination among units, we investigate what happens to the volume-effect advantage across hospital categories with regard to the likelihood of adverse results for PTCA. We used descriptive statistics and logistic regression models to assess the existence of selective referrals and the concentration of clinical complexity in more specialised centres. Figures were taken from a regional administrative database based on hospital discharge abstracts (SDO) for the period 1998-2000.