Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Family suite: an innovative method to provide inexpensive postpartum care.

The postpartum hospital stay has been decreasing in the United States in recent decades. Early discharge to achieve cost savings has been criticized by many inside and outside the health care community as sometimes being detrimental to the mother and infant. This article describes the efforts of the administration, nursing staff, and medical staff of a large public urban hospital to develop an alternative to the forced early discharge of mothers and infants.

[Health economical benefits of personalized hospital treatment of chronic bronchitis]. / Sundhedsøkonomiske fordele ved personlig hospitalsbehandling af kronisk bronkitis.

One hundred patients (aged 48 to 89) with chronic obstructive pulmonary disease were allocated to receive either "personalized hospital practice" (PHP), which includes training in aspects of their disease, or standard hospital practice. Changes in "consumption" of health services per patient from one year before until one year after the intervention admission were evaluated in 82 (PHP group 42, controls 40). The increase in consumption of health services after intervention was on average kr 15.298 per patient per year less in the PHP group than in the control group (p = 0.048). Consumption of general practitioner services was significantly increased in the control group compared with the PHP group (mean 95% confidence limits) kr 1346 (549-2143) versus -89 (-423-245) per patient per year, p = 0.001). PHP reduces the consumption of health services by patients with chronic obstructive pulmonary disease, probably by increasing patients knowledge of disease and their ability to manage themselves.

Experience of a self-care unit as part of a hospital-based rehabilitation service.

The nature, advantages and disadvantages, and cost of a hospital-based self-care unit as part of a rehabilitation service are described. The unit's operational policy is critically examined after analysing the records of 40 patients admitted consecutively over a 2-year period and conducting interviews with 27 patients between 4 and 48 weeks after discharge. It is concluded that, compared with a hospital ward, a self-care unit is inexpensive to run and helps to prevent patients from giving up their homes and being admitted to residential homes prematurely. In addition to an assessment and confidence-building role, the unit provides a more appropriate and acceptable environment for patients waiting housing alteration or rehousing than a hospital ward.

New York University Medical Center's Cooperative Care Unit: patient education and family participation during hospitalization--the first ten years.

The New York University Medical Center Cooperative Care (CC) program is a model of a delivery system of acute inpatient hospital care characterized by a live-in family member or friend acting as a "care partner". It has an emphasis on education in order to encourage full patient and family involvement in care during the acute hospitalization, thereby preparing both parties for management at home after discharge. The education-intensive experience of CC provides an alternative to traditional inpatient hospital care with the expected outcome of CC being to increase patient and family knowledge and satisfaction, adherence to the medical regimen, and appropriate self-management. The functioning ability of the patient-care partner team should be improved on discharge, which may result in decreased subsequent utilization of high cost healthcare resources such as rehospitalization. This paper describes the structure of the CC form of inpatient care, the types of patients appropriate for such care, and the experience of its first ten years of operation, with its implications as a replicable model for other institutions.

Effectiveness of a hospital-based cooperative care model on patients' functional status and utilization.

The primary objective of this study was to test the hypothesis that inpatient care which emphasized structured, patient education, self-care and social support from a care partner (the Cooperative Care Program) is a cost-effective alternative to the more expensive staff-intensive, traditional hospital care; and that such care can be substituted without resulting in poorer outcomes with regard to subsequent health status or use of services. The effects of this program on patient and physician acceptance, patient knowledge and treatment and health status, were evaluated by means of an experimental design with comparable groups of patients assigned to experimental (cooperative care) or control (usual hospitalization) group status. Follow-up analyses of both groups of patients for a 12-month time period concluded that there were comparable and equally positive post-hospitalization experiences, with greater than 90% of both groups of patients functioning well with respect to a series of measures of functional status. There was no evidence that Cooperative Care patients were re-hospitalized more often or needed more emergency, home care or other types of services. There was, on the other hand, evidence of the positive effect on patient understanding, adherence to treatment, satisfaction, and self-management.

Comparative costs of a cooperative care program versus inpatient hospital care for obstetric patients.

The cost of obstetric care delivered in a cooperative care unit was compared with the cost for similar patients treated in a traditional inpatient maternity unit. The study sample contained 1,683 consecutive patients representing 23 diagnosis categories. The analysis indicates that cooperative care patients had significantly lower total hospital costs. This cost savings persisted even when we controlled for case severity. The only exception was for the obstetric patient requiring intra-abdominal surgery. For fiscal year 1986, hospital cost savings for the 576 patients who used the cooperative care unit was +80,640 or approximately +105,000 in total patient charges. The majority of the savings came from a reduction in routine nursing services that are directly attributable to the cooperative care unit. We conclude that cooperative care can be an economically feasible alternative for most obstetric patients.

An economic study of cost savings on a care-by-parent ward.

Alternatives to inpatient care that improve quality of care and save money are desirable during periods of restraint on hospital budgets. One such alternative is the care-by-parent unit (CBPU) in which a parent's stay on the ward can reduce costs by resuming nursing tasks, limiting unnecessary procedures, and encouraging early discharge. This study measured costs per case treated in the CBPU compared with the costs for similar patients treated in the inpatient nursing unit (NU). Average costs per episode were lower in the CBPU--33 per cent for general pediatrics, 13.5 per cent for tonsils and adenoids and 29 per cent for other surgery. These savings are capable of considerable expansion because more than half of the admissions to NU meet the criteria for admission to CBPU. If CBPU facilities were expanded, however, the savings estimated above would not follow automatically. New CBPU facilities must substitute for NU, not add to total utilization.

Consumer impact of a Cold Self-Care Center in a prepaid ambulatory care setting.

A Cold Self-Care Center was developed to be an alternative to professional care and to encourage more active involvement of consumers in their own care. A sample of the self-selected user population (n = 74) was studied by comparison with a random sample of plan members (n = 104), and the program was evaluated for cost, consumer satisfaction, and impact on behavior, knowledge and attitudes. Users demonstrated higher levels of knowledge about cold care than non-users, indicated more dependency on professional resources, and differed in health-related attitudes and cold-care behavior. The Cold Self-Care Center appears to have had little impact on self-medication behavior. However, it did affect care-seeking behavior. Knowledge of criteria for seeking professional care was greater than in non-users; 20 per cent sought professional care, and 6 per cent anticipated seeking professional care for future colds. General satisfaction with the program was quite high. Speed and ease of use were cited most often as reasons for satisfaction. The Center also was demonstrated to have a favorable impact on clinic costs. A flexible system which is convenient to use and which retains access to professional care when appropriate both can relieve clinic overload and meet the needs of a large percentage of cold patients.