Scaling-Up Stage 4 Pediatric Obesity Clinics: Identifying Barriers and Future Directions Using Implementation Science.

Nearly one-fifth of the pediatric population in the United States has obesity. Comprehensive behavioral interventions, with at least 26 contact hours, are the recommended treatment for pediatric obesity; however, there are various barriers to implementing treatment. This Perspective applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to address barriers to implementing multidisciplinary pediatric weight management clinics and identify potential solutions and areas for additional research. Lack of insurance coverage and reimbursement, high operating costs, and limited access to stage 4 care clinics with sufficient capacity were among the main barriers identified. Clinicians, researchers, and patient advocates are encouraged to facilitate conversations with insurance companies and hospital and clinic administrators, increase telehealth adoption, request training to improve competency and self-efficacy discussing and implementing obesity care, and advocate for more stage 4 clinics.

Developing a composite index of spatial accessibility across different health care sectors: A German example.

The evolving lack of ambulatory care providers especially in rural areas increasingly challenges the strict separation between ambulatory and inpatient care in Germany. Some consider allowing hospitals to treat ambulatory patients to tackle potential shortages of ambulatory care in underserved areas. In this paper, we develop an integrated index of spatial accessibility covering multiple dimensions of health care. This index may contribute to the empirical evidence concerning potential risks and benefits of integrating the currently separated health care sectors. Accessibility is measured separately for each type of care based on official data at the district level. Applying an Improved Gravity Model allows us to factor in potential cross-border utilization. We combine the accessibilities for each type of care into a univariate index by adapting the concept of regional multiple deprivation measurement to allow for a limited substitutability between health care sectors. The results suggest that better health care accessibility in urban areas persists when taking a holistic view. We believe that this new index may provide an empirical basis for an inter-sectoral capacity planning.

[The role of supply-side characteristics of services in AIDS mortality in Mexico]. / Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México.

OBJECTIVE: To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. MATERIALS AND METHODS: We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. RESULTS: Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. CONCLUSIONS: Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

[Current problems for outpatients undergoing cancer chemotherapy in Ehime Priority Hospitals of Cancer Care Network (Ehime Cancer Kyoten Hospitals)].

Ehime Priority Hospitals of Cancer Care Network(Ehime Cancer Kyoten Hospitals)regularly have meetings to discus the current problems in cancer care in Ehime Prefecture. We established three subcommittees:"Registration of Cancer Incident," "Critical Paths for the Management of Patients with Cancer,"and"Palliative Care for Patients with Advanced Cancer"to exchange our opinions. We recently set up a new subcommittee related to the physical and spiritual care of patients undergoing chemotherapy treatment,"A Subcommittee dealing with Cancer Chemotherapy and its Management"."This subcommittee has tried to identify current problems with chemotherapy for outpatients in each institution through questionnaire and analysis. As a result of this survey, it was found that Ehime Priority Hospitals have total of seventy-three beds for outpatients undergoing chemotherapy, and that they performed chemotherapy 19, 671 times in 2008. A total of eight oncology physicians and sixteen oncology nurses were engaged in performing chemotherapy in this system. The questions patients most frequently asked during chemotherapy concerned the management of therapy-related complications, dealing with problems at night and during holidays after chemotherapy, and financial problems related to the costs of treatment. In this study we found three issues that need to be managed in Ehime Priority Hospitals. First, for the nursing of outpatients undergoing chemotherapy, more staff engaged in different types of care is required. Second, a new system to deal with emergencies at night and during holidays after chemotherapy is necessary, because Ehime Priority Hospitals use the same system to deal with chemotherapy patients as for other patients. Third, cooperation between pharmacies and out-clinics is important for patient compliance during chemotherapy, especially for the administration of oral anti-tumor agents. Ehime Priority Hospitals of Cancer Care Network is trying to improve each institution while dealing with these problems.

[Modern supplying concepts--what has been achieved with medical supplying centers]. / Moderne Versorgungskonzepte--Was wurde erreicht bei Medizinischen Versorgungszentren.

In the first quarter of this year, the number of medical supplying centers rose from around 50 to 126, and in September 2005, 192 medical supplying centers existed in Germany. These medical supplying centers predominantly include working groups of physician communities. The number of medical supplying centers with working groups in hospitals will continue to increase. A medical establishment wave is however not expected. The investment and initial costs represent a high risk. Established physicians often feel a medical supplying center as competition. The hospital must consider the effects on the number of patients being referred as a carrier medical supplying center therefore compellingly. The medical supplying center extends the forms of the ambulatory care. They cannot guarantee complete covering supply. The establishment of medical supplying centers does not have recognizable effects on the problem of a lack of physicians in the new states of the Federal Republic.

International pediatric emergency care: establishment of a new specialty in a developing country.

BACKGROUND: Emergency medicine is being established as a unique and independent specialty throughout the world. Pediatric emergency medicine, however, is a relatively new subspecialty in the United States and a newer subspecialty in the rest of the world. In most of Europe and Asia, this specialty has yet to be developed. OBJECTIVE: To analyze the establishment of a new pediatric emergency care system in a developing country and identify areas of need and potential collaboration. SETTING: Pristina University Hospital, the main academic medical center in Kosovo, Federal Republic of Yugoslavia. METHODS: Data were collected using convenience sample surveys of all emergency visits in 2001, hospital admissions, health department statistics, and interviews with government officials and healthcare providers. RESULTS: Emergency care of children in Kosovo is provided by three parallel 24-hour clinic systems. During 2001, approximately 31,000 children sought emergency care (10,000 in the pediatric clinic, 5000 in an emergency facility, and 16,000 in the infectious disease clinic). There was no coordination or cooperation between these different facilities. No attempt was made to diagnose acute otitis media or urinary tract infection in young children. No records were kept. No physician in this study had pediatric emergency medicine and/or emergency medicine training. Prehospital providers had limited equipment and training. CONCLUSIONS: Hospital clinic systems in this environment provide high-volume and often a high level of acute care. Barriers to improved care include limited specialized training, lack of coordination between departments, and failure to establish a medical records system.