Change in health care use after coordinated care planning: a quasi-experimental study.

BACKGROUND: We sought to determine whether patients with a coordinated care plan developed using the Health Links model of care in the Hamilton Niagara Haldimand Brant Local Health Integration Network differed in their use of health care (no. of emergency department visits, inpatient admissions, length of inpatient stay) when compared with a matched control group of patients with no care plans. METHODS: We performed a propensity score-matched study of 12 months pre- and 12 months post-health care use. Patients who had a coordinated care plan that started between 2013 and 2015 were propensity score matched to patients in a control group. Patient information was obtained from Client Health and Related Information System, National Ambulatory Care Reporting System and Discharge Abstract Database. Differences in health care use pre- and post-index date were compared using the Wilcoxon signed-rank test. A negative binomial regression model was fit for each health care use outcome at 6 and 12 months post-index date. RESULTS: Six hundred coordinated care plan enrollees and 25 449 potential control patients were included in the matching algorithm, which resulted in 548 matched pairs (91.3%). Both groups showed decreases in health care use post-index date. Matched care plan enrollees had significantly fewer emergency department visits at 6 (incidence rate ratio [IRR] 0.81, 95% confidence interval [CI] 0.72-0.91, p < 0.01) and 12 months post-index date (IRR 0.88, 95% CI 0.79-0.99, p < 0.05) compared with the matched controls. Other use parameters were not significantly different between care plan enrollees and the control group. INTERPRETATION: Care plan enrollees show a decrease in the number of times they visit emergency departments, which may be attributed to integrated and coordinated care planning. This association should be examined to see whether these reductions persist for more than 1 year.

Online dissolved methane and total dissolved sulfide measurement in sewers.

Recent studies using short-term manual sampling of sewage followed by off-line laboratory gas chromatography (GC) measurement have shown that a substantial amount of dissolved methane is produced in sewer systems. However, only limited data has been acquired to date due to the low frequency and short span of this method, which cannot capture the dynamic variations of in-sewer dissolved methane concentrations. In this study, a newly developed online measuring device was used to monitor dissolved methane concentrations at the end of a rising main sewer network, over two periods of three weeks each, in summer and early winter, respectively. This device uses an online gas-phase methane sensor to measure methane under equilibrium conditions after being stripped from the sewage. The data are then converted to liquid-phase methane concentrations according to Henry's Law. The detection limit and range are suitable for sewer application and can be adjusted by varying the ratio of liquid-to-gas phase volume settings. The measurement presented good linearity (R² > 0.95) during field application, when compared to off-line measurements. The overall data set showed a wide variation in dissolved methane concentration of 5-15 mg/L in summer and 3.5-12 mg/L in winter, resulting in a significant average daily production of 24.6 and 19.0 kg-CH4/d, respectively, from the network with a daily average sewage flow of 2840 m³/day. The dissolved methane concentration demonstrated a clear diurnal pattern coinciding with flow and sulfide fluctuation, implying a relationship with the wastewater hydraulic retention time (HRT). The total dissolved sulfide (TDS) concentration in sewers can be determined simultaneously with the same principle.

Introduction and feasibility assessment of laundry use of recycled water in dual reticulation systems in Australia.

Laundry is a potential new end use of recycled water in dual reticulation systems. Generally, the community is willing to accept this new end use if it can meet the concerns on health issues, durability of washing machine, cloth quality and aesthetic appearance. This study addresses all these major concerns thereby assisting in the introduction and promotion of this new end use in the existing and proposed dual reticulation systems. Five representative cloth materials were selected for washing in tap water and in recycled water for up to 50 wash cycles for comparative studies. The tearing/tensile strength tests were used for the assessment of cloth durability. ANOVA one way test was applied for the significance analysis (Tukey's test p<0.05) which indicated that there is no significant change in the tensile/tearing strengths of washed cloth samples. Scanning electron microscope (SEM) images of the washed cloth samples found no distinct change in surface morphology. Textile colour analysis (CIEDE2000) analysed the variation in colour of the washed cloth samples and showed that the change in colour ∆E ranges from 0-1 revealing no visible difference in colour of cloth samples. Langelier Saturation Index (LSI) was used as the indicator for predicting corrosive/scaling potential of recycled water. The LSI values ranged from +0.5 to -0.5, indicating no corrosive or scaling potential of recycled water. The microbiological study of the cloth samples washed in recycled water indicated that there was no contamination with representative bacteria. As the recycled water has similar effects like tap water on cloth and washing machine, it is safe to use for laundry.

A comprehensive framework for the assessment of new end uses in recycled water schemes.

Nowadays, recycled water has provided sufficient flexibility to satisfy short-term freshwater needs and increase the reliability of long-term water supplies in many water scarce areas, which becomes an essential component of integrated water resources management. However, the current applications of recycled water are still quite limited that are mainly associated with non-potable purposes such as irrigation, industrial uses, toilet flushing and car washing. There is a large potential to exploit and develop new end uses of recycled water in both urban and rural areas. This can greatly contribute to freshwater savings, wastewater reduction and water sustainability. Consequently, the paper identified the potentials for the development of three recycled water new end uses, household laundry, livestock feeding and servicing, and swimming pool, in future water use market. To validate the strengths of these new applications, a conceptual decision analytic framework was proposed. This can be able to facilitate the optional management strategy selection process and thereafter provide guidance on the future end use studies within a larger context of the community, processes, and models in decision-making. Moreover, as complex evaluation criteria were selected and taken into account to narrow down the multiple management alternatives, the methodology can successfully add transparency, objectivity and comprehensiveness to the assessment. Meanwhile, the proposed approach could also allow flexibility to adapt to particular circumstances of each case under study.

Vision and perception of community on the use of recycled water for household laundry: a case study in Australia.

This study investigates the community perception of household laundry as a new end use of recycled water in three different locations of Australia through a face to face questionnaire survey (n=478). The study areas were selected based on three categories of (1) non-user, (2) perspective user and (3) current user of recycled water. The survey results indicate that significantly higher number (70%) of the respondents supported the use of recycled water for washing machines (χ(2)=527.40, df=3; p=0.000). Significant positive correlation between the overall support for the new end use and the willingness of the respondents to use recycled water for washing machine was observed among all users groups (r=0.43, p=0.000). However, they had major concerns regarding the effects of recycled water on the aesthetic appearance of cloth, cloth durability, machine durability, odour of the recycled water and cost along with the health issues. The perspective user group had comparatively more reservations and concerns about the effects of recycled water on washing machines than the non-users and the current users (χ(2)=52.73, df=6; p=0.000). Overall, community from all three study areas are willing to welcome this new end use as long as all their major concerns are addressed and safety is assured.

Dosing free nitrous acid for sulfide control in sewers: results of field trials in Australia.

Intermittent dosing of free nitrous acid (FNA), with or without the simultaneous dosing of hydrogen peroxide, is a new strategy developed recently for the control of sulfide production in sewers. Six-month field trials have been carried out in a rising main sewer in Australia (150 mm in diameter and 1080 m in length) to evaluate the performance of the strategy that was previously demonstrated in laboratory studies. In each trial, FNA was dosed at a pumping station for a period of 8 or 24 h, some with simultaneous hydrogen peroxide dosing. The sulfide control effectiveness was monitored by measuring, on-line, the dissolved sulfide concentration at a downstream location of the pipeline (828 m from the pumping station) and the gaseous H2S concentration at the discharge manhole. Effective sulfide control was achieved in all nine consecutive trials, with sulfide production reduced by more than 80% in 10 days following each dose. Later trials achieved better control efficiency than the first few trials possibly due to the disrupting effects of FNA on sewer biofilms. This suggests that an initial strong dose (more chemical consumption) followed by maintenance dosing (less chemical consumption) could be a very cost-effective way to achieve consistent control efficiency. It was also found that heavy rainfall slowed the recovery of sulfide production after dosing, likely due to the dilution effects and reduced retention time. Overall, intermittent dose of FNA or FNA in combination with H2O2 was successfully demonstrated to be a cost-effective method for sulfide control in rising main sewers.

Analysis of social attitude to the new end use of recycled water for household laundry in Australia by the regression models.

Recycled water for household laundry can be regarded as a promising strategy to alleviate the current demand on scarce water supplies. Public acceptability becomes fairly important to ensure the successful establishment and development of this new end use. To address the issue, this study conducted social surveys in two locations of Australia, Port Macquarie and Melbourne, where respondents were asked 17 questions. The regression models provide conclusions about which characteristics are more likely to lead to the acceptance of recycled water from society. Three attitudinal variables (RWAlterDW, Attitude and Cost) and three psychological variables (Odour, Reading and SmallUnit) were found to be the key driving forces behind domestic water reuse behaviour. These findings could drive the future research direction to achieve better public perception of this new end use of recycled water.

Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial.

BACKGROUND: Hospitalized patients frequently have urinary catheters inserted for inappropriate reasons. This can lead to urinary tract infections and other complications. OBJECTIVE: To assess whether stop orders for indwelling urinary catheters reduces the duration of inappropriate urinary catheterization and the incidence of urinary tract infections. DESIGN: A randomized controlled trial was conducted in three tertiary-care hospitals in Ontario, Canada. Patients with indwelling urinary catheters were randomized to prewritten orders for the removal of urinary catheters if specified criteria were not present or to usual care. PARTICIPANTS: Six hundred ninety-two hospitalized patients admitted to hospital with indwelling urinary catheters inserted for < or = 48 h. MEASUREMENTS: The main outcomes included days of inappropriate indwelling catheter use, total days of catheter use, frequency of urinary tract infection, and catheter reinsertions. RESULTS: There were fewer days of inappropriate and total urinary catheter use in the stop-order group than in the usual care group (difference -1.69 [95% CI -1.23 to -2.15], P < 0.001 and -1.34 days, [95% CI, -0.64 to -2.05 days], P < 0.001, respectively). Urinary tract infections occurred in 19.0% of the stop-order group and 20.2% of the usual care group, relative risk 0.94 (95% CI, 0.66 to 1.33), P = 0.71. Catheter reinsertion occurred in 8.6% of the stop-order group and 7.0% in the usual care group, relative risk 1.23 (95% CI, 0.72 to 2.11), P = 0.45. CONCLUSIONS: Stop orders for urinary catheterization safely reduced duration of inappropriate urinary catheterization in hospitalized patients but did not reduce urinary tract infections.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure--2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies.

Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers.

Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.