COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

Trade union or trait d'union? Setting targets for general practitioners: A regional case study.

AIMS: The Italian general practitioners (GPs) are not directly employed by the National Health Service but work as independent contractors. Their activity and their salary are managed at the national, regional, and local level. This paper analyses the Tuscany Region case study to investigate if primary care's target-setting styles are associated with different GP perceptions, by comparing nine different local agreements to a survey on 102 GPs. We propose a classification of the different target-setting (ideal typical) styles, ranging from "financial governance" (FG), mainly based on financial targets, to "clinical governance" (CG), that mainly relies on clinical and quality targets. FINDINGS: Results show that GPs are more likely to have a more favourable attitude toward primary care managerial tools if they have certain characteristics, ie, quality measures. This suggest that target setting system might promote both the GPs' compliance to the targets set by the agreement and the involvement of the GPs in the LHA's governance processes too. CONCLUSIONS: The managerial tools could pave the way to overcome the classical "trade unionist" relationship between the regional and local authority and the GPs, working as a "trait d'union" between the two players.

Supporting the evaluation of public and patient engagement in health system organizations: Results from an implementation research study.

BACKGROUND: As citizens, patients and family members are participating in numerous and expanding roles in health system organizations, attention has turned to evaluating these efforts. The context-specific nature of engagement requires evaluation tools to be carefully designed for optimal use. We sought to address this need by assessing the appropriateness and feasibility of a generic tool across a range of health system organizations, engagement activities and patient groups. METHODS: We used a mixed-methods implementation research design to study the implementation of an engagement evaluation tool in seven health system organizations in Ontario, Canada focusing on two key implementation outcome variables: appropriateness and feasibility. Data were collected through respondent feedback questions (binary and open-ended) at the end of the tool's three questionnaires as well as interviews and debriefing discussions with engagement professionals and patient partners from collaborating organizations. RESULTS: The three questionnaires comprising the evaluation tool were collectively administered 29 times to 405 respondents yielding a 52% response rate (90% and 53% of respondents respectively assessed the survey's appropriateness and feasibility [quantitatively or qualitatively]). The questionnaires' basic properties were rated highly by all respondents. Concrete suggestions were provided for improving the appropriateness and feasibility of the questionnaires (or components within) for different engagement activity and organization types, and for enhancing the timing of implementation. DISCUSSION AND CONCLUSIONS: Our study findings offer guidance for health system organizations and evaluators to support the optimal use of engagement evaluation tools across a variety of health system settings, engagement activities and respondent groups.

Exploration and practice of the "1 + 10 + 1100000" model.

The exploration and practice of the "1 + 10 + 1100000" model of local medical consortium includes three aspects: graded diagnosis and treatment, two-way referral, and dynamic flow; seamless connection between general practice and specialty to realize health management; and establishment of the "community health center-East Hospital-Tongji University" teaching platform.

Administrators, health service providers, and consumers perspectives of functions of district health-care systems in Oromia region, Ethiopia: A qualitative study.

The practice of functions of district health-care systems in Ethiopia is not clear. The aim of this study was to investigate the perspectives of administrators, health service providers, and health-care consumers regarding functions of district health-care systems as currently practiced. Grounded theory approach was applied using interviews and desk review of documents. This study was set up in Oromia National Regional State, Ethiopia. Inductive analysis of interviews was done. Interviews and document reviews were mirrored. Eleven functions of district health-care systems emerged in this study organized by level with relationships and commonality of few activities. The 11 functions of district health-care systems were creating capacity of health centers and health professionals for the provision of health care; creating access for the provision of health care; ensuring equitable access to health care; regulation of private health-care providers; disaster preparedness; monitoring risk factors and diseases in the district; provision of health promotive, preventive, and curative health care for communicable diseases and maternal health conditions; monitoring intermediate outcomes of care; developing capacity of health post and villagers toward demand creation for health care; provision of maternal and child health services; and helping health posts in reaching mothers and sick individuals.

A spatio-temporal cluster analysis of technical efficiency in the production of outpatient maternal health services and its structural correlates in México.

OBJECTIVE: To analyze the formation of spatial clusters of technical efficiency (TE) in the production of outpatient maternal health services in México for the period 2008 to 2015. METHODS: We performed a longitudinal analysis of administrative and structural data related to the 243 Mexican health jurisdictions. We use window data envelopment analysis and spatial and econometric techniques. Structural correlates of each TE cluster obtained were identified estimating a pooled multinomial logit model. RESULTS: We observed an increase in the overall TE, accompanied by a reduction in its standard deviation. Furthermore, we identified positive TE spatial dependence both globally and locally. Multiple regression analysis showed that the maximum-performance TE cluster was composed of health jurisdictions located in the North of México and characterized by social marginalization, a reduced indigenous population, and a low demand for maternal health services. CONCLUSIONS: The identification of TE clusters can provide elements to induce decision makers to innovative in ways of allocating resources and manage their utilization. In México as other low- and middle-income countries, it is key to develop targeting strategies to implement specific health services innovations putting to the population to be served at the front of the strategy. This implies testing new modalities to strengthen primary health services, the empowerment of community participation, the training and allocation of health personnel that could respond adequately to population's demand, and the active involvement of competent state and local authorities in the assessment of the results of these innovations.

Technocratic recentralization in the French health care system: A critical evaluation.

The French health care system implemented several corporate management recipes such as diagnostic-related groups (DRGs), benchmarking, and activity-based management in a bid to restore fiscal discipline and to "reassert the center." The government also regrouped health policy decisions with the Regional Health Agencies and opted for a top-down line of command to ensure policy implementation. Though reforms emphasized evidenced-based policy and outputs measurement, outcomes were below expectations in many areas and led to a shift in values. Professional autonomy and patient engagement receded. This leads us to a critical evaluation of the French audit society.

[Determinants of time required by medical information technicians for quality control of hospital activity coding, in French medico-administrative system]. / Déterminants du temps nécessaire au contrôle qualité dans le cadre du programme de médicalisation des systèmes d'information (PMSI), dans le champ médecine, chirurgie et obstétrique (MCO) d'un centre hospitalier régional, par les techniciens d'information médicale.

BACKGROUND: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls. METHODS: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half. RESULTS: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10-4); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10-3). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding. CONCLUSION: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays.

Managers and clinicians: Perceptions of the impact of regionalization in two regions in Canada.

The aim of this paper is to examine the approach taken to regionalization in Ontario, Canada, and its impact on health system performance as perceived by managers and clinicians. This is a qualitative study, with thematic analysis, based on interviews with 23 managers and clinicians working in primary healthcare and emergency care in two regions of Ontario. Our findings demonstrate that both sets of actors see regional structures as contributing significantly to improving their respective health system although they also identify areas that require improvement. Managers and clinicians agreed on propositions to focus on health determinants, major considerations specific to the local context (population, geography) and support for a three-level system with well-defined functions. However, they also expressed differing propositions about the political power of hospitals.

Social capital in a regional inter-hospital network among trauma centers (trauma network): results of a qualitative study in Germany.

BACKGROUND: As inter-hospital alliances have become increasingly popular in the healthcare sector, it is important to understand the challenges and benefits that the interaction between representatives of different hospitals entail. A prominent example of inter-hospital alliances are certified 'trauma networks', which consist of 5-30 trauma departments in a given region. Trauma networks are designed to improve trauma care by providing a coordinated response to injury, and have developed across the USA and multiple European countries since the 1960s. Their members need to interact regularly, e.g. develop joint protocols for patient transfer, or discuss patient safety. Social capital is a concept focusing on the development and benefits of relations and interactions within a network. The aim of our study was to explore how social capital is generated and used in a regional German trauma network. METHODS: In this qualitative study, we performed semi-standardized face-to-face interviews with 23 senior trauma surgeons (2013-14). They were the official representatives of 23 out of 26 member hospitals of the Trauma Network Eastern Bavaria. The interviews covered the structure and functioning of the network, climate and reciprocity within the network, the development of social identity, and different resources and benefits derived from the network (e.g. facilitation of interactions, advocacy, work satisfaction). Transcripts were coded using thematic content analysis. RESULTS: According to the interviews, the studied trauma network became a group of surgeons with substantial bonding social capital. The surgeons perceived that the network's culture of interaction was flat, and they identified with the network due to a climate of mutual respect. They felt that the inclusive leadership helped establish a norm of reciprocity. Among the interviewed surgeons, the gain of technical information was seen as less important than the exchange of information on political aspects. The perceived resources derived from this social capital were smoother interactions, a higher medical credibility, and joint advocacy securing certain privileges. CONCLUSION: Apart from addressing quality of care, a trauma network may, by way of strengthening social capital among its members, serve as a valuable resource for the participating surgeons. Some member hospitals could exploit the social capital for strategic benefits.

Planning without action and action without planning? Examining a regional health system's efforts to improve patient flow, 1998-2013.

Most health care organizations engage in formal and informal planning, yet their improvement initiatives may remain disjointed and reactive. Research on organizational decision-making has found that the "discovery" approach (seek and assess multiple options before selecting one) outperforms "idea imposition" (identify 1 option, then gather information to [dis]confirm it), yet is observed relatively infrequently. Might this imply that discovery frequently collapses before fruition? This qualitative study sought to better understand the planning-action disjunction, as observed in 1 organization, by comparing its planning processes against the discovery approach. It focused on a Canadian regional health system's recurrent, unsuccessful attempts to improve patient flow. Through extensive document review supplemented by interviews with 62 managers, it identified all relevant regional plans/reports produced during a 15-year period and followed each recommendation forward in time to discover its fate. Each report presented a lengthy, unprioritized list of disparate recommendations, few of which progressed to full implementation. It appeared that decision-makers repeatedly embarked on a discovery approach, but rapidly allowed it to splinter into multiple idea-imposition approaches; numerous options were generated, but never evaluated against each other. Thus, the product of each planning process was not a coherent strategy but a list of disconnected actions.

[Challenges of implementing a geriatric trauma network : A regional structure]. / Herausforderung der Implementierung eines Alterstraumanetzwerks : Ein standortübergreifendes Verbundsystem.

BACKGROUND: At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers. METHODS: As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015. RESULTS: Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations. CONCLUSIONS: A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

Contextual factors and health service performance from the perspective of the provincial health administrators in Papua New Guinea.

INTRODUCTION: The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea. There are limitations in measuring performance of such projects through analysis of health information system data alone due to data quality issues and a multitude of unmeasured factors that affect performance. A mixed methods study was undertaken to understand the contextual factors that affect health service performance. METHODS: A performance assessment framework was developed including service delivery indicators derived from the National Health Information System. Prior to implementation, a baseline analysis of the indicators was undertaken. Subsequently, semi-structured interviews were conducted with health administrators, in which they were asked about factors they perceived to influence health facility performance. During the interviews, key informants were provided with health indicators for their province and asked to interpret the performance of facilities. Interviews were transcribed and inductive thematic analysis performed. RESULTS: Performance indicators varied greatly within and between districts. Key informants cited a number of reasons for this variation. Health facilities accessible by road in urban areas, with competent and/or higher level staff and health services operated by churches or private companies, were cited as contributors to high performance. For high performing districts, key informants also discussed use of health information, planning and targeted strategies to improve performance. Inadequate numbers of staff, poorly skilled staff, funding delays and challenging geography were major contributors noted for poor performance. CONCLUSION: Analysis of quantitative indicators needs to be performed at health facility level in order to understand district level performance. Interpretation of performance through key informant interviews provided useful insight into previously undocumented contextual factors affecting health delivery performance. The sequential explanatory mixed methods design could be applied to evaluations of other health service delivery programs in similar contexts.

One province, one healthcare system: A decade of healthcare transformation in Alberta.

Nearly a decade has passed since Alberta folded nine regional health authorities and three government agencies into one province-wide health system: Alberta Health Services (AHS). Deemed a reckless experiment by some at the time, there is now mounting evidence province-wide integration of services across the healthcare continuum is an enabler of improved quality, safety, and financial sustainability. The article highlights specific examples of how AHS is strengthening partnerships, standardizing best practices, and driving innovation, making Alberta a national and international leader in areas such as stroke care and potentially inappropriate use of antipsychotics in long-term care. It also shows how province-wide integration is being leveraged to build workplace culture, enhance patient safety, and find operational efficiencies that result in cost savings and cost avoidance.

Health policy programs realised in Poland in 2016-2017

Background: Health Policy Program (Program Polityki Zdrowotnej ­ PPZ) is a state policy tool for engaging local government units into the mechanism of granting provision of health services. Authors show areas in which self-governments most often took preventive health care actions and describe legislative changes in the Act on provision of health services. Objective: The aim of the article is to quantitative and qualitative statement of PPZ prepared in Poland in 2016 and 2017, as well as presenting changing legal situation in the scope of evaluation of these projects. Materials and methods: Authors use descriptive method, presenting changes of legal status. The article includes data available in the Bulletin of Public Information by The Agency for Health Technology Assessment. 590 programs were analyzed (239 from 2016 and 351 from 2017). Results: In 2016 ­ 67% of submitted programs were given a positive opinion and in 2017 ­ 71%. The most of positively evaluated PPZ submitted by local government units (53% in 2016; 47% in 2017) referred to prevention of infectious diseases by vaccines. On the basis of analyses conducted, significant differences were observed in the implementation of the PPZ in various regions of Poland. Conclusions: In the recent years a big improvement in the quality of planned self-government health programs is observed. It is suggested that due to the regulation defining the model of the health policy program and the model of the final report, this trend will continue.

Regional initiatives for malaria elimination: Building and maintaining partnerships.

Andrew Lover and colleagues discuss regional malaria initiatives, the strengths and challenges.

Advanced pancreatic adenocarcinoma outcomes with transition from devolved to centralised care in a regional Cancer Centre.

BACKGROUND: Previous observations suggest suboptimal 'real world' survival outcomes for advanced pancreatic adenocarcinoma. We hypothesized that centralisation of advanced pancreatic adenocarcinoma management would improve chemotherapy treatment and survival from the disease. METHODS: The data was prospectively collected on all cases of advanced pancreatic adenocarcinoma reviewed through Clatterbridge Cancer Centre according to two groups; 1 October 2009-31st Dec 2010 (devolved care) or 1 January 2013-31 March 2014 (centralised care). Analysis included treatment received, 30-day chemotherapy mortality rate and overall survival (OS). RESULTS: More patients received chemotherapy with central care (67.0% (n=115) vs 43.0% (n=121); P=2.2 × 10-4) with no difference in 30-day mortality (20.8% vs 25%; P=0.573) but reduced time to commencement of chemotherapy (18 vs 28 days, P=1.0 × 10-3). More patients received second-line chemotherapy with central care (23.4% vs 1.9%, P=1.4 × 10-4), while OS was significantly increased with central care (median: Five vs three months, HR 0.785, P=0.045). Exploratory analysis suggested that it was those with a poorer performance status, elderly or with metastatic disease who benefited the most from transition to central care. CONCLUSIONS: A centralised clinic model for advanced pancreatic cancer management resulted in prompt, safe and higher use of chemotherapy compared with devolved care. This was associated with a modest survival benefit. Prospective studies are required to validate the findings reported and the basis for improved survival with centralised care.

Management of patients with acute aortic syndrome through a regional rapid transport system.

OBJECTIVE: The objective of this study was to describe the outcomes of patients with acute aortic syndrome (AAS) during and after transfer to a regional aortic center by a rapid transport system. METHODS: Review of patients with AAS who were transferred by a rapid transport system to a regional aortic center was performed. Data regarding demographics, diagnosis, comorbidities, transportation, and hospital course were acquired. Severity of existing comorbidities was determined by the Society for Vascular Surgery Comorbidity Severity Score (SVSCSS). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score assessed physiologic instability on admission. Risk factors associated with system-related (transfer and hospital) mortality were identified by univariate and multivariate linear regression analysis. RESULTS: During a recent 18-month period (December 2013-July 2015), 183 patients were transferred by a rapid transport system; 148 (81%) patients were transported by ground and 35 (19%) by air. Median distance traveled was 24 miles (range, 3.6-316 miles); median transport time was 42 minutes (range, 10-144 minutes). Two patients died during transport, one with a type A dissection, the other of a ruptured abdominal aortic aneurysm. There were 118 (66%) patients who received operative intervention. Median time to operation was 6 hours. Type B dissections had the longest median time to operation, 45 hours, with system-related mortality of 1.9%; type A dissections had the shortest median time, 3 hours, and a system-related mortality of 16%. Overall, system-related mortality was 15%. On univariate analysis, factors associated with system-related mortality were age ≥65 years (P = .026), coronary artery disease (P = .030), prior myocardial infarction (P = .049), prior coronary revascularization (P = .002), SVSCSS of >8 (P < .001), abdominal pain (P = .002), systolic blood pressure <90 mm Hg at sending hospital (P = .001), diagnosis of aortic aneurysm (P = .013), systolic blood pressure <90 mm Hg in the intensive care unit (P < .001), and APACHE II score >10 (P = .004). Distance traveled and transport mode and duration were not associated with increased risk of system-related mortality. Only SVSCSS of >8 (odds ratio, 7.73; 95% confidence interval, 2.32-25.8; P = .001) was independently associated with an increase in system-related mortality on multivariate analysis. CONCLUSIONS: Implementation of a rapid transport system, regardless of mode or distance, can facilitate effective transfer of patients with AAS to a regional aortic center. An SVSCSS of >8 predicted an increased system-related mortality and may be a useful metric to assess the appropriateness of patient transfer.

Long-Term Mortality of Emergency Medical Services Patients.

STUDY OBJECTIVE: Emergency medical services (EMS) provides out-of-hospital care to patients with life-threatening conditions, but the long-term outcomes of EMS patients are unknown. We seek to determine the long-term mortality of EMS patients in Denmark. METHODS: We analyzed linked EMS, hospital, and vital status data from 3 of 5 geographic regions in Denmark. We included events from July 1, 2011, to December 31, 2012. We classified EMS events according to primary dispatch category (unconsciousness/cardiac arrest, accidents/trauma, chest pain, dyspnea, neurologic symptoms, and other EMS patients). The primary outcome was 1-year mortality adjusted for age, sex, and Charlson comorbidity index. RESULTS: Among 142,125 EMS events, primary dispatch categories were unconsciousness or cardiac arrest 5,563 (3.9%), accidents or trauma 40,784 (28.7%), chest pain 20,945 (14.7%), dyspnea 9,607 (6.8%), neurologic symptoms 17,804 (12.5%), and other EMS patients 47,422 (33.4%). One-year mortality rates were unconscious or cardiac arrest 54.7% (95% confidence interval [CI] 53.4% to 56.1%), accidents or trauma 7.8 (95% CI 7.5% to 8.1%), chest pain 8.5% (95% CI 8.1% to 9.0%), dyspnea 27.7% (95% CI 26.7% to 28.7%), neurologic symptoms 14.1% (95% CI 13.6% to 14.7%), and other EMS patients 11.1% (95% CI 10.8% to 11.4%). Compared with other EMS conditions, adjusted 1-year mortality was higher in unconsciousness or cardiac arrest (risk ratio [RR] 2.6; 95% CI 2.5 to 2.7), dyspnea (RR 1.5; 95% CI 1.4 to 1.5), and in neurologic symptoms (RR 1.1; 95% CI 1.0 to 1.1), but lower in chest pain (RR 0.6; 95% CI 0.6 to 0.7) and accidents or trauma (RR 0.8; 95% CI 0.8 to 0.8). CONCLUSION: EMS patients with unconsciousness or cardiac arrest, dyspnea, and neurologic symptoms are at highest risk of long-term mortality. Our results suggest a potential for outcome improvement in these patients.

[Primary and secondary data on dementia care as an example of regional health planning]. / Planung einer kleinräumigen Versorgung unter Nutzung von Primär- und Sekundärdaten am Beispiel von Demenzerkrankten.

BACKGROUND: Health service planning that takes into account as far as possible the regional needs and regional discrepancies is a controversial health issue in Germany. OBJECTIVES: In a pilot scheme, we tested a planning process for regional healthcare services, based on the example of dementia care. The aim of this article is to present the strengths and limitations of this planning process. MATERIALS AND METHODS: We developed an indicator set for dementia care based on routine regional data obtained from two German statutory health insurance companies. Additionally, primary data based on a questionnaire sent to all GPs in the area were evaluated. These data were expanded through the addition of official socio-demographic population data. Procedures and evaluation strategies, discussion of the results and the derivation of planning measures followed, in close agreement with a group of local experts. RESULTS: Few epidemiological data on regional variations in health care planning are publicly available. Secondary data from statutory health insurance companies can be assessed to support the estimation of regional health care needs, but interpretation is difficult. The use of surveys to collect primary data, and the assessment of results by the local health board may facilitate interpretation and may contribute towards more valid statements regarding regional health planning. CONCLUSIONS: Despite the limited availability of data and the considerable efforts involved in data analysis, the project demonstrates how needs-based health service planning can be carried out in a small region, taking into account the increasing demands of the local health care providers and the special local features.