Referrals from community optometrists to the hospital eye service in England.

PURPOSE: In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES. METHODS: Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. RESULTS: A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR. CONCLUSIONS: In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

Making health a shared value: Lessons from nurse-designed models of care.

BACKGROUND: Nurse-designed models of community-based care reflect a broad definition of health; family- and community-centricity; relationships; and group and public health approaches. PURPOSE: To examine how nurse-designed models of care have addressed "making health a shared value" based on the framework of the Culture of Health. METHOD: A mixed-methods design included an online survey completed by 37 of 41 of "Edge Runners" (American Academy of Nursing-designated nurse innovators) and telephone interviews with 13 of the 37. Data were analyzed using descriptive statistics and standard content analysis. FINDINGS: Two main areas of "making health a shared value" were increasing the perceptions that individual health is interdependent with the health of the community and community health promotion. Themes were the value of social support (interventions that engage an individual's inner circle and a group environment to reveal shared experiences); messaging (a holistic definition of health, the value of both culturally- and medically-accurate information, and the business case); and building trust (expertise sits locally and trust takes time). DISCUSSION: Refinement of the COH framework may be warranted and can provide strategies for making health a shared value within a community. Shifting the orientation of healthcare organizations must be a long-term, deliberate goal.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

[Value of shared electronic health records for the management of homeless people]. / Prise en charge des personnes sans chez-soi : intérêt du dossier médical partagé ?

AIM: To assess the acceptability for GPS to use the French shared Electronic Health Record (Dossier Médical Partagé, "DMP") when caring for Homeless People (HP). METHODS: Mixed, sequential, qualitative-quantitative study. The qualitative phase consisted of semi-structured interviews with GPs involved in the care of HP. During the quantitative phase, questionnaires were sent to 150 randomized GPs providing routine healthcare in Marseille. Social and practical acceptability was studied by means of a Likert Scale. RESULTS: 19 GPs were interviewed during the qualitative phase, and 105 GPs answered the questionnaire during the quantitative phase (response rate: 73%). GPs had a poor knowledge about DMP. More than half (52.5%) of GPs were likely to effectively use DMP for HP. GPs felt that the "DMP" could improve continuity, quality, and security of care for HP. They perceived greater benefits of the use the DMP for HP than for the general population, notably in terms of saving time (p = 0.03). However, GPs felt that HP were vulnerable and wanted to protect their patients; they worried about security of data storage. GPs identified specific barriers for HP to use DMP: most of them concerned practical access for HP to DMP (lack of social security card, or lack of tool for accessing internet). CONCLUSION: A shared electronic health record, such as the French DMP, could improve continuity of care for HP in France. GPs need to be better informed, and DMP functions need to be optimized and adapted to HP, so that it can be effectively used by GPs for HP.

Telepathology Impacts and Implementation Challenges: A Scoping Review.

CONTEXT: Telepathology is a particular form of telemedicine that fundamentally alters the way pathology services are delivered. Prior reviews in this area have mostly focused on 2 themes, namely technical feasibility issues and diagnosis accuracy. OBJECTIVES: To synthesize the literature on telepathology implementation challenges and broader organizational and societal impacts and to propose a research agenda to guide future efforts in this domain. DATA SOURCES: Two complementary databases were systematically searched: MEDLINE (PubMed) and ABI/INFORM (ProQuest). Peer-reviewed articles and conference proceedings were considered. The final sample consisted of 159 papers published between 1992 and 2013. CONCLUSIONS: This review highlights the diversity of telepathology networks and the importance of considering these distinctions when interpreting research findings. Various network structures are associated with different benefits. Although the dominant rationale in single-site projects is financial, larger centralized and decentralized telepathology networks are targeting a more diverse set of benefits, including extending access to pathology to a whole region, achieving substantial economies of scale in workforce and equipment, and improving quality by standardizing care. Importantly, our synthesis reveals that the nature and scale of encountered implementation challenges also varies depending on the network structure. In smaller telepathology networks, organizational concerns are less prominent, and implementers are more focused on usability issues. As the network scope widens, organizational and legal issues gain prominence.

Outcome of shared care for pediatric cardiac transplantation between two nations with different health care systems.

BACKGROUND: No data are available for the outcome of children undergoing cardiac transplantation with shared care programs in different countries. We sought to investigate the outcome of a shared care transplant program between 2 countries given the complex immunologic, cardiac, and psychologic needs of these young people. METHODS: We investigated the results of a shared care program for children who underwent cardiac transplantation between our center in the Republic of Ireland and 2 centers in the United Kingdom over 2 decades. RESULTS: Between 1990 and 2013, 22 patients underwent 23 cardiac transplants. The median age at transplant was 3.2 years (range, 0.3-13.3 years), median age at listing was 30 months (range, 0.1-13.3 years), and the median waiting list time was 2.8 months (range, 0.3-14 months). The median time to return to the referral center from the time of transplant was 3 weeks (range, 2-8 weeks). The referral center treated 4 of 5 late rejection episodes. Angiography was undertaken in the transplant center at annual or biannual review. Outcomes for rejection, coronary vasculopathy, and survival were comparable between the referral and transplant centers. CONCLUSIONS: This report of shared care for pediatric transplant patients between 2 sovereign nations demonstrates good results, with comparable outcomes to the specialist transplant center. These data may encourage liberalization of follow-up in other centers.

Cooperation for a competitive position: The impact of hospital cooperation behavior on organizational performance.

BACKGROUND: Several public policy initiatives, particularly those involving managed care, aim to enhance cooperation between partners in the health care sector because it is expected that such cooperation will reduce costs and generate additional revenue. However, empirical evidence regarding the effects of cooperation on hospital performance is scarce, particularly with respect to creating a comprehensive measure of cooperation behavior. PURPOSE: The aim of this study is to investigate the impact of hospital cooperation behavior on organizational performance. We differentiate between horizontal and vertical cooperation using two alternative measures-cooperation depth and cooperation breadth-and include the interaction effects between both cooperation directions. METHODOLOGY: Data are derived from a survey of German hospitals and combined with objective performance information from annual financial statements. Generalized linear regression models are used. FINDINGS: The study findings provide insight into the nature of hospitals' cooperation behavior. In particular, we show that there are negative synergies between horizontal administrative cooperation behavior and vertical cooperation behavior. Whereas the depth and breadth of horizontal administrative cooperation positively affect financial performance (when there is no vertical cooperation), vertical cooperation positively affects financial performance (when there is no horizontal administrative cooperation) only when cooperation is broad (rather than deep). PRACTICAL IMPLICATIONS: Horizontal cooperation is generally more effective than vertical cooperation at improving financial performance. Hospital managers should consider the negative interaction effect when making decisions about whether to recommend a cooperative relationship in a horizontal or vertical direction. In addition, managers should be aware of the limited financial benefit of cooperation behavior.

[Concept for a department of intensive care]. / Konzept einer Klinik für Intensivmedizin.

BACKGROUND: Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital. PREREQUISITES: To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources. GOAL: Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.

Telemedicine:'If you aren't doing anything now, you're way behind'.

Any health care provider that's not taking advantange of the many advances in audiovisual tools to connect with patients is woefully behind the curve, experts warn. Here's what some hospitals are up to in both rural communities and urban areas.

[Management by objectives: an experience by transfusion and immunology service in Rabat]. / Contractualisation interne : expérience du service de transfusion et d'immunologie de Rabat.

The management by objectives method has become highly used in health management. In this context, the blood transfusion and haemovigilance service has been chosen for a pilot study by the Head Department of the Ibn Sina Hospital in Rabat. This study was conducted from 2009 to 2011, in four steps. The first one consisted in preparing human resources (information and training), identifying the strengths and weaknesses of the service and the identification and classification of the service's users. The second step was the elaboration of the terms of the contract, which helped to determine two main strategic objectives: to strengthen the activities of the service and move towards the "status of reference." Each strategic objective had been declined in operational objectives, then in actions and the means required for the implementation of each action. The third step was the implementation of each action (service, head department) so as to comply with the terms of the contract as well as to meet the deadlines. Based on assessment committees, the last step consisted in the evaluation process. This evaluation was performed using monitoring indicators and showed that management by objectives enabled the Service to reach the "clinical governance level", to optimize its human and financial resources and to reach the level of "national laboratory of reference in histocompatibility". The scope of this paper is to describe the four steps of this pilot study and to explain the usefulness of the management by objectives method in health management.

Decision support for hospital bed management using adaptable individual length of stay estimations and shared resources.

BACKGROUND: Elective patient admission and assignment planning is an important task of the strategic and operational management of a hospital and early on became a central topic of clinical operations research. The management of hospital beds is an important subtask. Various approaches have been proposed, involving the computation of efficient assignments with regard to the patients' condition, the necessity of the treatment, and the patients' preferences. However, these approaches are mostly based on static, unadaptable estimates of the length of stay and, thus, do not take into account the uncertainty of the patient's recovery. Furthermore, the effect of aggregated bed capacities have not been investigated in this context. Computer supported bed management, combining an adaptable length of stay estimation with the treatment of shared resources (aggregated bed capacities) has not yet been sufficiently investigated. The aim of our work is: 1) to define a cost function for patient admission taking into account adaptable length of stay estimations and aggregated resources, 2) to define a mathematical program formally modeling the assignment problem and an architecture for decision support, 3) to investigate four algorithmic methodologies addressing the assignment problem and one base-line approach, and 4) to evaluate these methodologies w.r.t. cost outcome, performance, and dismissal ratio. METHODS: The expected free ward capacity is calculated based on individual length of stay estimates, introducing Bernoulli distributed random variables for the ward occupation states and approximating the probability densities. The assignment problem is represented as a binary integer program. Four strategies for solving the problem are applied and compared: an exact approach, using the mixed integer programming solver SCIP; and three heuristic strategies, namely the longest expected processing time, the shortest expected processing time, and random choice. A baseline approach serves to compare these optimization strategies with a simple model of the status quo. All the approaches are evaluated by a realistic discrete event simulation: the outcomes are the ratio of successful assignments and dismissals, the computation time, and the model's cost factors. RESULTS: A discrete event simulation of 226,000 cases shows a reduction of the dismissal rate compared to the baseline by more than 30 percentage points (from a mean dismissal ratio of 74.7% to 40.06% comparing the status quo with the optimization strategies). Each of the optimization strategies leads to an improved assignment. The exact approach has only a marginal advantage over the heuristic strategies in the model's cost factors (≤3%). Moreover,this marginal advantage was only achieved at the price of a computational time fifty times that of the heuristic models (an average computing time of 141 s using the exact method, vs. 2.6 s for the heuristic strategy). CONCLUSIONS: In terms of its performance and the quality of its solution, the heuristic strategy RAND is the preferred method for bed assignment in the case of shared resources. Future research is needed to investigate whether an equally marked improvement can be achieved in a large scale clinical application study, ideally one comprising all the departments involved in admission and assignment planning.