Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review of randomised controlled trials (RCTs) and controlled trials (non-RCTs, NRCTs) is to investigate the effectiveness and related costs of case management (CM) for patients with heart failure (HF) predominantly based in the community in reducing unplanned readmissions and length of stay (LOS). SETTING: CM initiated either while as an inpatient, or on discharge from acute care hospitals, or in the community and then continuing on in the community. PARTICIPANTS: Adults with a diagnosis of HF and resident in Organisation for Economic Co-operation and Development countries. INTERVENTION: CM based on nurse coordinated multicomponent care which is applicable to the primary care-based health systems. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes of interest were unplanned (re)admissions, LOS and any related cost data. Secondary outcomes were primary healthcare resources. RESULTS: 22 studies were included: 17 RCTs and 5 NRCTs. 17 studies described hospital-initiated CM (n=4794) and 5 described community-initiated CM of HF (n=3832). Hospital-initiated CM reduced readmissions (rate ratio 0.74 (95% CI 0.60 to 0.92), p=0.008) and LOS (mean difference -1.28 days (95% CI -2.04 to -0.52), p=0.001) in favour of CM compared with usual care. 9 trials described cost data of which 6 reported no difference between CM and usual care. There were 4 studies of community-initiated CM versus usual care (2 RCTs and 2 NRCTs) with only the 2 NRCTs showing a reduction in admissions. CONCLUSIONS: Hospital-initiated CM can be successful in reducing unplanned hospital readmissions for HF and length of hospital stay for people with HF. 9 trials described cost data; no clear difference emerged between CM and usual care. There was limited evidence for community-initiated CM which suggested it does not reduce admission.

Study protocol for an evaluation of the effectiveness of 'care bundles' as a means of improving hospital care and reducing hospital readmission for patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND: Chronic Obstructive Pulmonary Disease is one of the commonest respiratory diseases in the United Kingdom, accounting for 10% of unplanned hospital admissions each year. Nearly a third of these admitted patients are re-admitted to hospital within 28 days of discharge. Whilst there is a move within the NHS to ensure that people with long-term conditions receive more co-ordinated care, there is little research evidence to support an optimum approach to this in COPD. This study aims to evaluate the effectiveness of introducing standardised packages of care i.e. care bundles, for patients with acute exacerbations of COPD as a means of improving hospital care and reducing re-admissions. METHODS / DESIGN: This mixed-methods evaluation will use a controlled before-and-after design to examine the effect of, and costs associated with, implementing care bundles for patients admitted to hospital with an acute exacerbation of COPD, compared with usual care. It will quantitatively measure a range of patient and organisational outcomes for two groups of hospitals - those who deliver care using COPD care bundles, and those who deliver care without the use of COPD care bundles. These care bundles may be provided for patients with COPD following admission, prior to discharge or at both points in the care pathway. The primary outcome will be re-admission to hospital within 28 days of discharge, although the study will additionally investigate a number of secondary outcomes including length of stay, total bed days, in-hospital mortality, costs of care and patient / carer experience. A series of nested qualitative case studies will explore in detail the context and process of care as well as the impact of COPD bundles on staff, patients and carers. DISCUSSION: The results of the study will provide information about the effectiveness of care bundles as a way of managing in-hospital care for patients with an acute exacerbation of COPD. Given the number of unplanned hospital admissions for this patient group and their rate of subsequent re-admission, it is hoped that this evaluation will make a timely contribution to the evidence on care provision, to the benefit of patients, clinicians, managers and policy-makers. TRIAL REGISTRATION: International Standard Randomised Controlled Trials - ISRCTN13022442 - 11 February 2015.

End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year.

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection - case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was 3173 pound per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians.

OBJECTIVES: Ambulatory or primary care sensitive conditions (ACSCs) are those conditions for which hospital admission could be prevented by interventions in primary care. At present, different definitions of ACSCs are used for research and health policy analysis. This study aimed to explore the impact of different definitions of ACSCs and associated disease codes on analysis of health service activity. STUDY DESIGN: Retrospective cross-sectional study using Hospital Episode Statistics (HES). METHODS: All ACSCs identified by a literature search were documented. Conditions and codes were standardized using International Classification of Diseases (ICD) 10. A subset of ACSCs commonly used in England was compared with all 36 ACSCs identified by the search in a retrospective cross-sectional study using HES. RESULTS: In total, 36 potential ACSCs were identified, which contained numerous subcategories. The most frequently used subset of ACSCs in the NHS only contains 19 ACSCs. There were 4,659,054 emergency admissions in England in 2005/6, of which 1,900,409 were ACSCs using the full set of 36 conditions. The proportion of these admissions attributable to the NHS subset of 19 ASCS was 35%. The underlying ICD10 codes used to define ACSCs vary widely across subsets of ACSCs used in the NHS. This impacts on rates of admission, length of stay and costs attributable to ACSCs. CONCLUSIONS: Rates of hospital admission for ACSCs are increasingly used as a measure of the effectiveness of primary care. However, different conceptual interpretations of the term 'ACSC' and use of differing definitions and diagnostic codes impact on the proportion of admissions that are attributed as ACSCs. Some resolution of these inconsistencies is required for this measure to be more useful to decision makers.

Enrollees' perceptions of participating in the education of medical students at an academically affiliated HMO.

PURPOSE: Little is known about how enrollees in health maintenance organizations (HMOs) perceive the benefits and risks of participating in the education of medical students. This case study elicited the views of enrollees of one academically affiliated HMO about the education of medical students. METHOD: Data from focus groups were used to design two questionnaires that were mailed to 488 adult patients and 298 parents or guardians of pediatric patients. A sample of non-respondents was followed up by telephone. Descriptive analyses were performed on the responses to the questionnaires. RESULTS: Response rates were 46% (adult) and 43% (parent or guardian). More than 75% of the respondents thought the HMO should be involved in teaching, most because teaching contributes to the training of better doctors and increases the skills of teacher-clinicians. Of those who responded, 28% of adults were concerned about risks to confidentiality and 18% were concerned about increased costs for enrollees. Nearly 50% of adults would be uncomfortable with students participating in visits involving "internal" examinations or emotional problems. Of those who responded, 56% of adults and 33% of parents or guardians were uncomfortable about a student's conducting an unsupervised history and physical examination. A total of 52% of adults preferred that the preceptor and student discuss their case in their presence. Respondents who had seen students previously were more comfortable with student activities associated with their care. CONCLUSIONS: The respondents thought the HMO should be involved in teaching, but they had specific concerns about the effects of student participation. Educators in other settings may wish to explore these concerns among their patient populations and develop policies to maximize the "enrollee-friendliness" of medical education in HMOs. While the study provides a first look at how enrollees at one HMO viewed participation in medical students' education, further research is needed at HMOs elsewhere to determine the representativeness of the study's findings.

Patient participation in research in the managed care environment: key perceptions of members in an HMO.

This study's objective was to elicit the views of research among enrollees in an HMO. A questionnaire was mailed to 207 adult enrollees, 55% had been exposed to research and 45% had not. Ninety-four percent of respondents supported research within the HMO, and 87% thought using information from medical records for research was acceptable. Sixty-three percent thought participation in research increased patient understanding of health care. Significantly more prior research participants thought that participation in research improves care. More patients would participate if written information were provided (67%), if feedback of results was provided (72%), and if their clinician invited them (67%). Only a modest percentage (20%) of patients would participate in a randomized trial.

Payer-based case management: perspectives on managing brain-injured patient.

As the payer environment is carved into many segments, each with its own accountability relative to its financial liability, family members, providers, and even other case managers often find it difficult to comprehend the perspectives of the various parties represented. Indeed, one brain injury case I recently evaluated had four payer case managers: one from the patient's health plan, one from a disease management program for his premorbid diabetes, and two from Medicaid-sponsored programs for the disabled. For payer-based case managers, the ubiquitous case manager role confusion compounds product unfamiliarity.

Rationing: a transatlantic perspective.

Despite the differing mechanisms of health care delivery and financing in the United Kingdom and the United States many of the issues faced by the two countries are similar, most notably the increasing financial pressures. In both countries there have been recent changes in the allocation of resources and the mechanisms of decision making. Different criteria for determining resource allocation have been tried in the two health care systems. These developments change long traditions of rationing decisions at the individual patient level in the US, and of centralised government decision making in the UK.

Longitudinal assessment of physiological and psychophysical measures in cochlear implant users.

OBJECTIVE: The purpose of this study was to evaluate the effects of long-term electrical stimulation on human cochlear implant users. DESIGN: Repeated measures of electrically evoked auditory brain steam response (EABR) threshold, slope of the EABR growth function, and behavioral measures of threshold and dynamic range were made for a group of 22 Ineraid cochlear implant users and 19 Nucleus cochlear implant users over a 3- to 5-yr period. RESULTS: Data from both Ineraid and Nucleus cochlear implant users suggest that EABR threshold, slope of the EABR growth function, and behavioral measures of threshold and dynamic range remain reasonably stable for periods up to 5 yr postimplant. CONCLUSIONS: The results of this study show little evidence that prolonged electrical stimulation through daily use of a cochlear implant has deleterious effects on the auditory system.

Public accountability for health: new standards for health system performance.

This article reviews the failure of contemporary quality oversight organizations to respond to the changing health care environment and suggests an overhaul of quality measurement and assurance functions. The authors examine the factors that have limited public accountability for health care, emphasizing the limited agreement that exists on the purpose of American health care, standards for evaluating care, or the appropriate locus of responsibility for quality of care. A five-part quality oversight system is proposed including development of quality measures, promulgation of national standards, validation and accreditation, use of data for purchasing and provider selection, and use of data for quality improvement.

Reported use of communication strategies by SHHH members: client, talker, and situational variables.

Two hundred and twelve members of the Self Help for Hard of Hearing People (SHHH) organization completed a survey that evaluated their use of communication strategies. Reported use of strategies was correlated with attitudinal variables and social-interaction indices. On average, subjects agreed most strongly with questionnaire items stating they would ask a talker to repeat a misperceived utterance. They agreed less strongly with items stating they would ask the talker to restructure or elaborate an utterance. Subjects agreed strongly that they would use the communication strategies with familiar talkers, and less strongly that they would use them with unfamiliar talkers. Subjects who appeared less likely to say nothing after misperceiving an utterance were more likely to disagree that they were frustrated with their speechreading skills, and they appeared less likely to avoid social interactions. Subjects who indicated a greater likelihood of using anticipatory strategies, such as reviewing potential vocabulary before an appointment, were on average more likely to avoid social interactions. They also agreed more strongly that poor speechreaders appear less intelligent.