[The personnel maintenance of primary health care physicians in condition of challenges from menaces to population health].

In condition of challenges from menaces to health due to COVID-19 the role of primary health care physicians increases that requires development of management decisions at the regional level. The purpose of the study. On the basis of analysis of medical demographic indicators and data concerning provision of primary health care personnel in the Russian Federation, proposals were made related to reforming of primary health care system in conditions of implementation of general medical practice with purpose to counteract menaces to population health. The analytical and statistical methods were applied. The official statistics data from the Minzdrav of the Russian Federation and Rosstat, results of original researches with content analysis and interpretation were used. The COVID-19 pandemic negatively impacted population health. The indicator of newly detected morbidity in the Russian Federation in 2020 decreased as compared to 2019 from 78024.3 to 75989.7‰oo (by 2.6%). This is the result of decreasing of dispensary and preventive activities among population. In next COVID-19 year (2021), as compared to 2020, indicator of primary morbidity increased to 85531.6‰oo that 12.6% higher than in 2020. The increase occurred in all classes of diseases that caused necessity of rehabilitation of these patients. The COVID-19 morbidity increased up to 2.4 times i.e. from 3391.1 in 2020 to 8085.7‰oo in 2021. The provision of physicians in the Russian Federation was 37.7‰o in 2021. Across the Federal Okrugs differences in indicators made up to 1.3 times and in subjects of the Russian Federation - up to 2.7 times. In conditions of COVID-19 significance of menaces to population health worsened. The situation requires both enhancement of primary health care and implementation of physicians of new formation - general practitioners responsible for patient health. The general practice (GP) widely developed in Russia in the 1990s during last ten years loses its significance in most subjects of the Russian Federation. In 2021, provision of general practitioners in the Russian Federation made up to 0.67‰o. In the Federal Okrugs, difference between indicators made up to 5.6 times. In the subjects of the Russian Federation the difference is enormous - 141.5 times. The article presents and scientifically substantiates prospective functional organizational models of general practice. The established situation with COVID-19 infection requires development of management decisions and measures at the regional level concerning improvement of organization of primary health care and implementation of general practice in conditions of counteracting risks of menaces to population health and health preservation.

Reforming for trust and professionalism in municipal healthcare services: implications for human resource management.

BACKGROUND: Many countries face an increasing demand for home-based healthcare services, and consequently experience a mismatch between expectations and available financial and human resources. It is therefore important to utilize human resources more efficiently, while at the same time offer jobs that attract the professionals they need. This article reports a study of the development and piloting of a new organizational model for home-based healthcare services in a Norwegian municipality, which addresses the need to provide efficient services and enhance trust and professionalism within healthcare services by improving work autonomy and involvement of employees. METHODS: The research project this article draws its empirical material from was commissioned by the municipality piloting the new organizational model and executed in collaboration with the municipality based on an evaluative trailing research (ETR) design. The data consists of interviews with key personnel and knowledge exchange between researchers and the involved actors in the pilot project. 20 semi-structured interviews involving a total of 34 informants were conducted. The analysis emphasises how different employee groups and management perceived and experienced various aspects of the work situation, as they were introduced to working and managing within the new organizational model. The aim is to shed light on how these employees and managers feel about it, interpret it, and respond to it. RESULTS: Overall, the results indicate that the model holds potential for realizing the benefits it aims for. However, there were also challenges that need resolving for the model to fulfil this potential. Central elements include clarification of roles and responsibilities for employees and managers, competence specification and development, and development of structures for inter-professional cross-team collaboration and information provision. CONCLUSIONS: Trust reform initiatives may be a strategy for fostering high-involvement work systems. To achieve this, sufficient attention must be paid to ensuring structures for information exchange and knowledge development in the early phases of implementation, or preferably prior to implementation. The theoretical model applied in this study could potentially be a useful managerial tool in preparing for and implementing trust reforms in healthcare services.

Preparedness and activities of the anti-SARS-CoV-2 convalescent plasma bank in the Veneto region (Italy): An organizational model for future emergencies.

BACKGROUND: Convalescent plasma (CP) has been used in the past in various pandemics, in particular in H1N1, SARS and MERS infections. In Spring 2020, when ongoing the SARS-CoV-2 pandemics, the Veneto Region (V-R) has proposed setting-up an anti-SARS-CoV-2 CP (CCP) Bank, with the aim of preparing a supply of CCP immediately available in case of subsequest epidemic waves. MATERIALS AND METHODS: Key-points to be developed for a quick set-up of the V-R CCP Bank have been recruitment of donors recovered from COVID-19 infection, laboratory analysis for the biological qualification of the CCP units, including titre of neutralizing antibodies and reduction of pathogens, according to National Blood Centre (CNS) Directives, adaptation of the V-R Information Technology systems and cost analysis. Some activities, including diagnostic and viral inactivation processes, have been centralized in 2 or 3 sites. Laboratory analysis upon preliminary admission of the donor included all tests required by the Italian laws and the CNS directives. RESULTS: From April to August 2020, 3,298 people have contacted the V-R Blood Transfusion Services: of these, 1,632 have been evaluated and examined as first time donors and those found to be suitable have carried out 955 donations, from which 2,626 therapeutic fractions have been obtained, at a cost around 215,00 Euro. Since October 2020, the number of COVID-19 inpatients has had a surge with a heavy hospital overload. Moreover, the high request of CCP therapy by clinicians has been just as unexpected, showing a wide therapeutic use. CONCLUSIONS: The organizational model here presented, which has allowed the rapid collection of a large amount of CCP, could be useful when facing new pandemic outbreaks, especially in low and middle income countries, with generally acceptable costs.

Current developments in delivering customized care: a scoping review.

BACKGROUND: In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care. METHODS: Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included "care customization", "personalized service and health care", individualized care" and "targeting population" in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers. RESULTS: We identified 70 articles published between 2008 and 2019. Most of the articles (n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles (n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles (n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation. CONCLUSIONS: There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care.

ANALYSIS OF THE EFFECTIVENESS OF THE FUNCTIONAL ORGANIZATIONAL MODEL FOR KNOWN PROPHYLAXIS OF CHRONIC NONINFECTIOUS DISEASES BASED ON THE ASSESSMENT OF THE QUALITY OF LIFE OF PATIENTS AT THE MEDICAL INSTITUTION.

OBJECTIVE: The aim: Study of the indicators of quality of life of patients served by a multidisciplinary health care institution with the functionally-organizational model of coded prevention of chronic noninfectious diseases is implemented. PATIENTS AND METHODS: Materials and methods: To evaluate the effectiveness of the model's use we used the assessment of the dynamics of QL indices, which was assessed according to the EUROHISQOL 8-item index methodology among 376 patients aged over 18 years. RESULTS: Results: Most of the respondents (61.4%) were dissatisfied to varying degrees with their state of health and, on average, evaluated their QL (56.1%). ЗThe overall assessment of the quality of life of the surveyed population was on a 20-point scale of 13.5 (3.19) points in 2017 before the introduction of the program of managed prevention of СNCDs and 14.6 (3.48) points after its three-year operation, with an increase integrated indicator on average by 1.1 (95% CI 0.59 - 1.60) points (p <0.001). Among the areas of QOL assessment, the assessments in the physical sphere and the environment increased at most (p<0.05). It is determined that the overall level of QOL of patients with NCDs is 40% due to medical and social factors that can be positively influenced by medical care using a model of managed prevention. CONCLUSION: Conclusions: The analysis of changes in the quality of life of patients of multidisciplinary institutions who have risk factors for СNCDs or suffer from chronic non-communicable diseases, showed that the introduction of a functional-organizational model of managed prevention at the health care institution level can improve integrated assessment of QOL and positively affect the overall complex of medical and social factors, including managed risk factors. This indicates the effectiveness of this model of managed prevention at the level of a multidisciplinary health care institution.

Organizational model for the management of patients with chronic allergic conditions.

INTRODUCTION: Allergic conditions present a serious problem for the Polish population. The most common form of allergy is allergic rhinitis. Due to its chronic nature and a complex pathophysiological mechanism the allergic rhinitis could be associated with others comorbidities. That is why it is a poses a considerable bio-psychosocial problem both for the affected individual patient and for the healthcare system. AIM: To identify organizational factors and analyse their effect on patients with chronic allergic conditions. MATERIAL AND METHODS: The study group comprised 9,370 respondents (including 1,967 patients with allergic rhinitis (AR), 372 patients with self-reported bronchial asthma (BA1), and 351 patients with physician-diagnosed bronchial asthma (BA2)) aged from 20 to 44 years, some of whom were additionally examined (skin pick tests) in an outpatient setting. The findings obtained in the outpatient subgroup (n = 4,783) were analysed in more detail. The study was based on translated and validated ECRHS and ISAAC questionnaires. RESULTS: Over a half of the evaluated patients with AR visited a specialist due to their symptoms. Some respondents neither visited their doctor regularly nor had regular check-ups, which undoubtedly affected their quality of life. CONCLUSIONS: The authors propose an organizational model incorporating the position of a healthcare educator (HE) as a coordinator in the process of managing chronic allergic conditions in adult patients within the Polish healthcare system. Adult patient education by the HE would include introducing the principles of secondary and tertiary prevention in order to improve the quality of life in patients with chronic allergic conditions.

A concept analysis of 'Meaning in work' and its implications for nursing.

AIM: To report an analysis of the concept of 'meaning in work'. BACKGROUND: Associated with initiatives to improve the quality of working life and the emerging movement of positive organizations, 'meaning in work' has been studied as a positive individual-level state. 'Meaning in work' has potential benefits that will improve the nursing workforce if this concept is embraced in nursing. However, the concept is not clearly defined because it has been approached from diverse theoretical perspectives and used interchangeably with analogous terms. DESIGN: A concept analysis. DATA SOURCES: Three key terms (using 'work', 'meaning' or 'meaningful', 'meaning of work', 'logotherapy') were searched in the CINAHL, PsycINFO, Business Source Complete and ABI/INFORM Global online databases from January 1940-March 2015. Among 346 articles retrieved, 28 studies were included for this concept analysis. METHODS: The procedure of concept analysis developed by Walker and Avant (2011) was used. RESULTS: Four critical attributes are identified: (1) experienced positive emotion at work; (2) meaning from work itself; (3) meaningful purpose and goals of work; and (4) work as a part of life that contributes towards meaningful existence. The identified antecedent of 'meaning in work' was a cognitive shift and the identified consequences were positive personal experience and positive impact on peers and organizations. CONCLUSION: This article provides a clear definition of 'meaning in work'. The resulting coherent definition will facilitate the use of 'meaning in work' in nursing research.

Toward a new paradigm of care: a surgical leaders' Delphi consensus on the organizational factors of the new pancreas units (E-AHPBA PUECOF study).

Pancreas units represent new organizational models of care that are now at the center of the European debate. The PUECOF study, endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), aims to reach an expert consensus by enquiring surgical leaders about the Pancreas Units' most relevant organizational factors, with 30 surgical leaders from 14 countries participating in the Delphi survey. Results underline that surgeons believe in the need to organize multidisciplinary meetings, nurture team leadership, and create metrics. Clinical professionals and patients are considered the most relevant stakeholders, while the debate is open when considering different subjects like industry leaders and patient associations. Non-technical skills such as ethics, teamwork, professionalism, and leadership are highly considered, with mentoring, clinical cases, and training as the most appreciated facilitating factors. Surgeons show trust in functional leaders, key performance indicators, and the facilitating role played by nurse navigators and case managers. Pancreas units have a high potential to improve patients' outcomes. While the pancreas unit model of care will not change the technical content of pancreatic surgery, it may bring surgeons several benefits, including more cases, professional development, easier coordination, less stress, and opportunities to create fruitful connections with research institutions and industry leaders.

Lessons Learned from the COVID-19 Vaccination Campaigns in Veneto Region: Population Vaccination Centers as Support for the Traditional Outpatient Model.

The extraordinary vaccination campaigns of the COVID-19 pandemic era put organizational and operational systems to the test in numerous territorial contexts. In the Veneto region, the activation of population vaccination centers (CVPs) guaranteed the provision of vaccines to mountain areas. These centers, drive-in and building-based, improved the efficiency of dose administration in relation to similar conditions where healthcare workers (HCWs) were routinely involved in clinics. Overall, a comparison of the two models investigated, with the same numbers of HCWs involved and the same opening hours for the vaccination sites, has shown that the CVPs are able to guarantee three times as many vaccines administered, compared with the traditional outpatient model. This study aims to provide a detailed analysis of the adopted organizational model, highlighting the best practices and improvements required to guarantee a timely and effective public health response, and evaluating the opportunities to deploy these innovative methods actively in a standard context.

To grade or not to grade safety requirements for transvenous lead extraction: Experience with 2216 procedures.

BACKGROUND: Transvenous lead extraction (TLE) procedures are now increasingly safe, but there is still a risk of major complications (MC). AIMS: We aimed to assess the impact of TLE organization on the safety of procedures. METHODS: We analyzed 2216 TLE procedures performed in two centers in the years 2006-2021 and compared three organizational procedural models: (1) TLE in an electrophysiology laboratory (EP-LAB) with intravenous analgesia/sedation; (2) TLE with grading of safety requirements (high-risk patients in the cardiac surgery operating theatre, others in EP-LAB); (3) TLE in the hybrid room in all patients under general anesthesia with transesophageal echocardiographic (TEE) monitoring. The safety of procedures and mortality after TLE in three-year follow-up were assessed. RESULTS: The rate of MC in the EP-LAB group was 1.55%, and the rate of procedure-related deaths (PRD) was 0.33%. While using the graded approach to safety requirements, the percentage of MC was 2.61% and PRD 0.29%. When performing TLE procedures in the hybrid room, the MC percentage was 1.33% and PRD 0.00%. Long-term survival after TLE was comparable in all study groups. CONCLUSIONS: A key factor in preventing TLE-related deaths is procedure organization that enables emergency cardiac surgery. TLE performed in a hybrid room with a collaborating cardiac surgeon and vital signs monitoring appears to be the safest possible option for the patient. A graded safety approach is associated with the risk of unexpected MC and PRD. Any newly established TLE center can achieve satisfactory results if the optimal organizational model of the procedure is used.

The Impact of the Introduction of the Breast Unit Model in a Northwestern Italian Region.

Breast cancer is the most common tumor in middle-aged and older women. In 2003, the European Parliament recommended to Member States that all women with breast cancer should be treated by a multidisciplinary team and that a network of certified breast centers be organized (the centers have been called Breast Units (BUs)). With the present study, we aim to explore the impact of the introduction of the BU organizational model in the Liguria region, Italy, through different outcome indicators. An explorative retrospective analysis was conducted through the period from 2013 to 2019 to assess the impact of the introduction of the BU model in our region. We identified two periods: before (2014-2015) and after (2017-2018) the introduction of this organizational model to assess its value impact through the definition of six measurable outcome indicators. Length of hospitalization, repeated specialist outpatient diagnostic procedures and the rate of subjects who started radiotherapy treatment within 60 days improved after the introduction of BUs. The passive health migration rate only improved significantly for one local health unit (LHU), while reintervention and diagnosis-surgery time did not show any enhancement after the introduction of the BU model. The BU model seems to provide an increase in several aspects of the healthcare offered to breast cancer patients in Liguria, specifically in those areas where a shared guideline could assist healthcare workers. Future research, such as pilot studies, are needed to assess the impact of the introduction of the BU model in our reality.

Improving the Effectiveness of Healthcare: Diagnosis-Centered Care Vs. Person-Centered Health Promotion, a Long Forgotten New Model.

Performance of healthcare can be measured as its ability to restore and preserve health with acceptable costs for the society. Under the current prevalence of chronic disease, medical care (the major content of healthcare) underperforms in all key indicators: clinical effectiveness, benefit/risk ratio of interventions, cost/benefit ratio, and general population health. In Russia key performance indicators (KPI) of healthcare do not allow effective decision-making; a similar situation is seen worldwide: most KPIs are either focused on the process (not results) of medical care, or depend on efforts out of control of healthcare decision-makers. The key root factors limiting clinical effectiveness and cost-effectiveness of healthcare are reactive diagnosis-centered organizational model of care and the underlying biomedical paradigm, generally inadequate in chronic diseases. They make healthcare intervene too late, use less effective prevention and treatment instruments, and be in a state of resource scarcity. In Russia there is also a lack of interdisciplinary and interagency cooperation essential for health preservation and promotion. Performance of healthcare system in overcoming the chronic disease epidemic can be improved through supplementing the current 'reactive' organizational model with preventive person-centered model based on the biopsychosocial paradigm. Enabling patients for early lifestyle-based interventions, the core P4 medicine approach, should prevail in managing chronic disease. Communication and information technologies should allow fast scaling up of the best person-centered practices.

A Newly Developed Egyptian Tool for Evaluating Rationing of Nursing Care: Relation to Organization Attributes and Patient Outcomes.

BACKGROUND AND PURPOSE: This work developed an Egyptian tool for evaluating rationing of nursing care in critical units and investigated its association with nursing organization attributes and six nurse-sensitive patient outcomes. METHODS: Rationing of the nursing care questionnaire and concurrent record review were conducted to collect data. RESULTS: Developed Egyptian tool of rationing of nursing care contained 36 items in six components. Adverse patient outcomes were detected as medication administration errors (27.9%), pulmonary infection (24.5%), pressure ulcer (20.3%), bloodstream infections (12.6%), urinary tract infections (10.3%), and patient falls (4.7%). The mild level of rationing of nursing care was positively associated with negative patient outcomes and negatively correlated with fair nursing organization attributes. CONCLUSION: The valid and reliable Egyptian tool for evaluating the rationing of nursing care was developed.

Success Factors and Barriers in Combining Personalized Medicine and Patient Centered Care in Breast Cancer. Results from a Systematic Review and Proposal of Conceptual Framework.

Breast Cancer (BC) is the leading cause of death due to cancer in women. Ensuring equitable, quality-assured and effective care has increased the complexity of BC management. This systematic review reports on the state-of-the art of available literature investigating the enactment of personalized treatment and patient-centered care models in BC clinical practice, building a framework for the delivery of personalized BC care within a Patient-Centered model. Databases were searched for articles (from the inception to December 2020) reporting on Patient-Centered or Personalized Medicine BC management models, assessing success factors or limits. Out of 1885 records, 25 studies were included in our analysis. The main success factors include clearly defined roles and responsibilities within a multi-professional collaboration, appropriate training programs and adequate communication strategies and adopting a universal genomic language to improve patients' involvement in the decision-making process. Among detected barriers, delays in the use of genetic testing were linked to the lack of public reimbursement schemes and of clear indications in timing and appropriateness. Overall, both care approaches are complementary and necessary to effectively improve BC patient management. Our framework attempts to bridge the gap in assigning a central role played by shared decision-making, still scarcely investigated in literature.

Retrospective Analysis of a Modified Organizational Model to Guarantee CT Workflow during the COVID-19 Outbreak in the Tertiary Hospital of Padova, Italy.

At the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) outbreak in Italy, the cluster of Vò Euganeo was managed by the University Hospital of Padova. The Department of Diagnostic Imaging (DDI) conceived an organizational approach based on three different pathways for low-risk, high-risk, and confirmed Coronavirus Disease 19 (COVID-19) patients to accomplish three main targets: guarantee a safe pathway for non-COVID-19 patients, ensure health personnel safety, and maintain an efficient workload. Thus, an additional pathway was created with the aid of a trailer-mounted Computed Tomography (CT) scanner devoted to positive patients. We evaluated the performance of our approach from February 21 through April 12 in terms of workload (e.g., number of CT examinations) and safety (COVID-19-positive healthcare workers). There was an average of 72.2 and 17.8 COVID-19 patients per day in wards and the Intensive Care Unit (ICU), respectively. A total of 176 high-risk and positive patients were examined. High Resolution Computed Tomography (HRCT) was one of the most common exams, and 24 pulmonary embolism scans were performed. No in-hospital transmission occurred in the DDI neither among patients nor among health personnel. The weekly number of in-patient CT examinations decreased by 27.4%, and the surgical procedures decreased by 29.5%. Patient screening and dedicated diagnostic pathways allowed the maintenance of high standards of care while working in safety.

Analysis of Patient Satisfaction with Emergency Medical Services.

BACKGROUND: This study analyses the degree of patient satisfaction regarding the Emergency Medical Services (EMS) by taking into account the waiting time which is considered to be associated with the success of the EMS organizational model. METHODOLOGY: Between 1 Jan 2016 and 31 March 2016 a cross-sectional research study among visitors of the EMS clinics in the EMS of the Primary Health Services of Gorenjska was performed. The EUROPEP survey was used for rating the degree of patient satisfaction. Statistical methods were utilized to determine the differences among the studied variables, namely the t test, one way ANOVA, as well as post-hoc multiple comparisons, were used. RESULTS: Nearly all questions associated with the patient survey scored higher than 4.0, indicating patients were generally very satisfied with EMS treatment. Patients were least satisfied with the length of time spent waiting for an examination. The results showed that the waiting time is a statistically significant factor concerning all four dimensions of patient satisfaction: medical staff, clinical facilities, clinical equipment and organization of services (p < 0.05). CONCLUSIONS: Research results have confirmed that the effectiveness of the EMS organizational model impacts on the degree of patient satisfaction. The research also revealed a deficiency in the current EMS organizational services at the prehospital level, given that triage frequently failed to be carried out upon a patient's arrival at the EMS clinics.

[Innovative health care models in Germany - success factors, barriers and transferability]. / Innovative Versorgungsmodelle in Deutschland ­ Erfolgsfaktoren, Barrieren und Übertragbarkeit.

INTRODUCTION: Safeguarding country-wide health care in Germany requires innovative ideas: a shortage of skilled staff among medical professionals and in long-term care on the one hand contrasts with an increasing number of multi-morbid elderly patients on the other hand. In the "Innovative Health Care Models" project sponsored by the Robert Bosch Foundation a nationwide status review and systematization of innovative approaches to health care was conducted, along with an analysis of the factors that promote or hinder the implementation of a health care model, and a study of the conditions that must be satisfied if successful concepts are to be transferred to other regions. METHODS: After identifying innovative and successfully implemented health care models, data on success factors and barriers for implementation as well as data on conditions of their transferability to other regions were collected during structured telephone interviews and entered into a specifically developed database. Content analysis was used to qualitatively evaluate the interviews. RESULTS: Interviews with 65 representatives of successfully implemented models with differing organizational structures and priorities were conducted and evaluated. Success factors and barriers were most obvious in the fields of leadership, readiness to participate, relational aspects, personality traits, cooperation and communication, resources and organizational and structural factors. DISCUSSION: Various regionally linked health care concepts already exist throughout Germany. The barriers, success factors and conditions influencing the transferability of a model to other regions are largely independent of the type of organization. The success of a model is determined by adequate personal and financial resources, sound organizational structures and external support from political and funding bodies.

A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy.

Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.

Prehospital factors determining regional variation in thrombolytic therapy in acute ischemic stroke.

BACKGROUND: Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands. AIM: To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model. METHODS: A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4·5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis. RESULTS: A total of 172 and 299 arriving within 4·5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3·11; 95% confidence interval, 1·59-6·06). Also, more misdiagnoses of stroke occurred in the central model (P = 0·05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4·5 h in the central vs. decentral model were 2·15 (95% confidence interval, 1·39-3·32) and 1·44 (95% confidence interval, 1·04-2·00), respectively. CONCLUSIONS: These results suggest that the larger proportion of patients arriving within 4·5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates.

Community-based distributive medical education: advantaging society.

This paper presents a narrative summary of an increasingly important trend in medical education by addressing the merits of community-based distributive medical education (CBDME). This is a relatively new and compelling model for teaching and training physicians in a manner that may better meet societal needs and expectations. Issues and trends regarding the growing shortage and imbalanced distribution of physicians in the USA are addressed, including the role of international medical graduates. A historical overview of costs and funding sources for medical education is presented, as well as initiatives to increase the training and placement of physicians cost-effectively through new and expanded medical schools, two- and four-year regional or branch campuses and CBDME. Our research confirms that although medical schools have responded to Association of American Medical Colleges calls for higher student enrollment and societal concerns about the distribution and placement of physicians, significant opportunities for improvement remain. Finally, the authors recommend further research be conducted to guide policy on incentives for physicians to locate in underserved communities, and determine the cost-effectiveness of the CBDME model in both the near and long terms.