Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study.

BACKGROUND: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults. OBJECTIVES: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY's cost-effectiveness. DESIGN: A quasi-experiment study. SETTING: The ED of a 1700-bed tertiary hospital. PARTICIPANTS: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas. INTERVENTION: EDIFY versus standard-care. MEASUREMENTS: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined. RESULTS: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY's cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY's average programmatic cost approximated SGD$469.30. CONCLUSIONS: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center.

Healthcare context and nursing workforce in a main city of Angola.

BACKGROUND: Angola is one of the largest African countries with continuing levels of insecurity, considerable weakness in terms of respect for human rights, destroyed infrastructure and low transparency and social accountability levels. The health system displays gaps and nursing represents the main contingent among human resources in health. AIM: This research aims to understand the healthcare context in Angola from the perspective of Brazilian nurses who were involved in helping their Angolan colleagues. This general view of health services is followed by a description of nursing workforce particularities at a tertiary health service in the province of Luanda. METHODS: Data were extracted from the database of the Global Network of World Health Organization Collaborating Centres for Nursing and Midwifery Development, constructed based on technical visits to Angola in 2009. Information related to health service characteristics was used, focusing on nursing human resource activities at two tertiary, one secondary and one primary health institutions located in the province of Luanda. The study data were analysed through descriptive statistics. FINDINGS: Among the problems the nursing workforce faces, the lack of human, material and financial resources stands out, as well as insufficient professional qualification, excessive work journeys, low remunerations, non-valuation of professionals, leading to unsatisfactory work environments and discouraged human resources. CONCLUSIONS: Nursing in Angola is conquering its professional space. Therefore, regulatory policies are fundamental, defining the rights and obligations of all categories involved, with a view to determining nurses' function in the health team, including respect for and acknowledgement of their role in the community.

A whole sample toxicity assessment to evaluate the sub-lethal toxicity of water and sediment elutriates from a lake exposed to diffuse pollution.

The impact of diffuse pollution in aquatic systems is of great concern due to the difficult to measure and regulate it. As part of an ecological risk assessment (ERA), this study aims to use a whole sample toxicity assessment to evaluate the toxicity of water and sediment from Lake Vela, a lake that has been exposed to diffuse pollution. In this way, standard (algae: Pseudokirchneriella subcapitata; cladoceran: Daphnia magna) and local species (algae: Aphanizomenon flos-aquae; cladoceran: Daphnia longispina) were exposed to surface water, and sediment elutriates were collected seasonally from two sites at Lake Vela: one near the east bank (ES), surrounded by agricultural lands; and the other near the west bank (WS), surrounded by a forest. The results confirmed the seasonal contamination of both environmental compartments by pesticides, including organochlorine pesticides, and the presence of high concentrations of nutrients. Although both sites were contaminated, higher levels of pesticides and nutrients were detected in ES, particularly in the sediments. Bioassays showed that water samples (100% concentration) collected in summer and autumn significantly affected the growth rate of P. subcapitata, which could be attributed to the presence of pesticides. Likewise, they revealed an apparent toxicity of elutriates for P. subcapitata and for both daphnids, in summer and autumn. In fact, although pesticides were not detected in elutriates, high levels of un-ionized ammonia were recorded, which is considered highly toxic to aquatic life. By comparing the several species, P. subcapitata was revealed to be the most sensitive one, followed by the daphnids, and then by A. flos-aquae. Results obtained in this study underlined the importance of whole samples toxicity assessment for characterizing the ecological effects of complex mixtures from diffuse inputs, in the ERA processes.

Nursing and the health system in Brazil.

The purpose of this article is to describe nursing in the Brazilian health system and to analyze the characteristics of nursing personnel in Brazil. This description includes types of health institutions, services rendered, and the distribution of nursing personnel by professional categories in 1956, 1982, and 1995. Discussion of the challenges facing Brazilian nurses is presented using data from the Brazilian Institute of Geography and Statistics (IBGE), Federal Nursing Board (COFEn), Regional Nursing Board (COREn), and the Brazilian Nursing Association (ABEn). An increase in the number of outpatient units and in diagnostic and therapeutic examinations has led to an increased the demand for nurses. Public health nurses participate in planning, management, sanitary education, health promotion, and supervision of nursing care provided by nursing technicians, assistants, and other helpers.

[Integrated planning in health: a possibility of participative action]. / Planeamiento integrado de salud: una possiblitad de la acción participativa.

This paper intends to report an experience with the process of integrated planning in a Basic Health Unit at Riberiao Preto-SP. we selected as our object of analysis the interactions and dialogues that were expressed in the scope of the local health system. Therefore, we sought to consider the individual dynamics of this reality and the social agents involved (teachers, students, directors, health workers and community workers), trying to understand the communicative action according to HABERMAS (1989). We believe that this is an open space in the perspective of widening the level of integrated participation in the administration of public health services.

Using computer systems to enhance case management.

This article describes how an on-line computer system can enhance case management by improving communication within internal departments and adding consistency and objectivity to the referral process. At PacifiCare, the computer system has supported case management's efforts to provide members with cost-effective medical care and has improved satisfaction with the health plan.