Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study.

OBJECTIVE: To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN: A qualitative study. SETTING: Oyam district, Uganda. PARTICIPANTS: We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS: Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS: The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.

Pilot of urgent care center evaluation for acute coronary syndrome.

OBJECTIVES: Patients with chest pain and concern for potential coronary ischemia are frequently referred to the emergency department (ED), resulting in substantial resource utilization and cost. The objective of this study was to implement a protocol for urgent care center (UCC) evaluation of potential acute coronary syndrome (ACS) and describe its performance. STUDY DESIGN: This is a descriptive, retrospective review of consecutive cases included in a protocol for UCC evaluation of ACS. METHODS: Consecutive patient encounters from 4 urgent care facilities of our regional integrated health system were reviewed from a period spanning 4.5 months of the 2017 calendar year. The primary outcome was avoidance of an ED visit within 30 days of the index visit, and the primary safety outcome was serious adverse events (AEs) occurring in the UCC setting. RESULTS: There were 802 patients evaluated, with a median age of 55 years, and 58% were female. Seventy-three (9.1%) patients were referred to the ED or hospitalized for any reason at the index visit, 10 (1.2%) of whom were ultimately diagnosed with ACS. Within 30 days, 56 (7.7%) of the remaining 729 patients had ED visits or hospitalization for any reason, 2 (0.2%) of whom received a diagnosis of ACS. Overall, 673 (83.9%) patients were managed without any ED visit. No serious AEs were recorded. CONCLUSIONS: Our initial pilot data demonstrate the feasibility of an outpatient UCC evaluation for ACS without refuting the underlying premise of safety.

Spiritual Care in the Intensive Care Unit: A Narrative Review.

Spiritual care is an important component of high-quality health care, especially for critically ill patients and their families. Despite evidence of benefits from spiritual care, physicians and other health-care providers commonly fail to assess and address their patients' spiritual care needs in the intensive care unit (ICU). In addition, it is common that spiritual care resources that can improve both patient outcomes and family member experiences are underutilized. In this review, we provide an overview of spiritual care and its role in the ICU. We review evidence demonstrating the benefits of, and persistent unmet needs for, spiritual care services, as well as the current state of spiritual care delivery in the ICU setting. Furthermore, we outline tools and strategies intensivists and other critical care medicine health-care professionals can employ to support the spiritual well-being of patients and families, with a special focus on chaplaincy services.

Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation.

OBJECTIVES: Three are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED. METHODS: A retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution. RESULTS: Over the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED. CONCLUSIONS: This assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

Uptake of evidence-based statin therapy among atrial fibrillation patients in China: A report from the CAFR (Chinese Atrial Fibrillation Registry) Study.

BACKGROUND: Atrial fibrillation (AF) is associated with increased incidence of cardiovascular disease, and hence, statin therapy is indicated in majority of AF patients. METHODS AND RESULTS: We analyzed data from the Chinese Atrial Fibrillation Registry (CAFR) involving 11,496 AF patients from 2011 to 2014. Practice patterns of statin therapy and factors associated with statin underuse were analyzed. Based on the 2013 ACC/AHA cholesterol management guidelines, statins should be recommended for 67.4% (7720/11,461) of AF participants in CAFR, but only 43.4% (3352/7720) with appropriate indications were taking statins. Statin underuse in AF patients was independently associated with male sex, tertiary hospital treatment, outpatient attendance, and absence of 'high risk' cardiovascular risk factors (overweight, diabetes, coronary heart disease, stroke/transient ischemic attack/peripheral embolism and hypertension). CONCLUSIONS: A high proportion of Chinese AF patients had indications for statin therapy. Evidence-based statin prescribing was suboptimal in this population. Greater efforts should be made to improve a holistic approach to cardiovascular risk management in the Chinese AF population.

Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study.

BACKGROUND: Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women's preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia. METHODS: We conducted ten focus group discussions (n = 100) with women of reproductive age (15-45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored. RESULTS: Our findings show that women's lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them. CONCLUSION: Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.

Serum magnesium levels in pediatric inpatients: a study in laboratory overuse.

BACKGROUND AND OBJECTIVE: Hypomagnesemia, defined as a serum magnesium (Mg) level<1.5 mg/dL (0.62 mmol/L), is often asymptomatic. The goals of this study were to determine the incidence of clinically significant abnormal Mg levels in the inpatient setting and to identify diagnoses for which testing would be diagnostically helpful. METHODS: We obtained data from 2010 through 2011 on charges for serum Mg levels and Mg supplementation for all non-ICU inpatients from the 43 tertiary care children's hospitals in the Pediatric Health Information System database. A manual chart review was performed for all patients at our institution with charges for both Mg levels and Mg supplementation. RESULTS: A median of 13.5% (interquartile range: 7.7-22.1) of non-ICU inpatients from Pediatric Health Information System centers had charges for Mg levels, at a total charge of $41 million in the 2010-2011 period. At our institution, 19.1% of non-ICU inpatients had charges for Mg levels, at a charge of $67.32/patient-day. Of the 4608 patients with Mg laboratory charges at our institution, 171 (3.7%) had an intervention, defined as addition or modification of an Mg supplement dose in response to a serum Mg level. The 4 most common groups of diagnoses (oncologic, abdominal surgery requiring total parenteral nutrition, solid organ transplant, and short bowel syndrome) accounted for 143 (83.6%) of these interventions. CONCLUSIONS: Serum Mg levels were frequently ordered in non-ICU inpatients, but levels were seldom abnormal and rarely resulted in changes in clinical management. These findings raise concerns about resource overutilization and provide a target for more judicious laboratory ordering practices.

Follow-up consultations for cervical cancer patients in a Mexican cancer center. Comparison with NCCN guidelines.

PURPOSE: This study aimed to determine the patterns of follow-up visits for cervix cancer in a national cancer center in Mexico. MATERIALS AND METHODS: The National Cancer Institute of Mexico is cancer center with 119 beds that mostly cares for an underserved and socially disadvantaged population. The medical records of cases of cervical cancer that had at least one year of clinical follow-up after being in complete response at the end of primary treatment were analyzed. We recorded the numbers of total and yearly follow-up visits and these were compared with the number of follow-up visits recommended by the National Comprehensive Cancer Network 2013, version 2 for cervical cancer. RESULTS: Between March and June 2007, the medical records of 96 consecutive patients were reviewed. Twenty (21%) of these met inclusion criteria and were selected. In the first year the median number of visits was 11 (4-20). In the ensuing years, 2nd, 3rd, 4th and 5th, the number of analyzed patients remaining in follow-up decreased to 17, 14, 13 and 9 respectively. There were 462 follow-up visits to primary treating services (Gynecology Oncology, Radiation Oncology and Medical Oncology) as compared to 220 suggested by the NCCN guidelines (X2 test p<0.0001). There were 150 additional visits to other services. CONCLUSIONS: Our results suggest that in our institution there is an overuse of oncological services by cervical cancer patients once treatment is completed.

[High utilisers with affective and schizophrenic disorders in the psychiatric health care system: a comparison between Eastern and Western Germany]. / High Utiliser in der psychiatrischen Versorgung: ein Ost-West-Vergleich bei affektiven und schizophrenen Störungen.

OBJECTIVE: High utilisers of psychiatric services are defined as a group of patients showing a great amount of service use, especially inpatient care, consequently causing immense costs. There is a lack of studies investigating differences between East and West Germany. METHODS: Service use and psychopathology were examined in 350 high utilisers receiving inpatient treatment in one East German and three West German psychiatric hospitals. RESULTS: Whereas current length of stay was higher in participants from West Germany, readmissions were more frequent in the East German participants who also exhibited higher psychopathology. CONCLUSION: Presumably, the deficient situation of outpatient health care in East Germany is compensated by increased stationary admission, consequently leading to a structural promotion of high utilisation.

The burden of inappropriate emergency department pediatric visits: why Italy needs an urgent reform.

OBJECTIVE: To better understand the issue of inappropriate pediatric Emergency Department (ED) visits in Italy, including the impact of the last National Health System reform. STUDY DESIGN: A retrospective cohort study was conducted with five health care providers in the Veneto region (Italy) in a 2-year period (2010-2011). ED visits were considered "inappropriate" by evaluating both nursing triage and resource utilization, as addressed by the Italian Ministry of Health in 2007. Factors associated with inappropriate ED visits were identified. The cost of each visit was calculated. PRINCIPAL FINDINGS: In total, 134,358 ED visits with 455,650 performed procedures were recorded in the 2-year period; of these, 76,680 (57.1 percent) were considered inappropriate ED visits. Patients likely to make inappropriate ED visits were younger, female, visiting the ED during night or holiday, when the primary care provider (PCP) is not available. CONCLUSION: The National Health System reform aims to improve efficiency, effectiveness, and costs by opening PCP offices 24 hours a day and 7 days a week. This study highlights the need for a deep reorganization of the Italian Primary Care System not only providing a larger time availability but also treating the parents' lack of education on children's health.

Yemeni women's perceptions of own authority during childbirth: what does it have to do with achieving the Millennium Development Goals?

BACKGROUND: women's underutilisation of professional care during childbirth in many low-income countries is a serious concern in terms of achievement of maternal Millennium Development Goal 5. OBJECTIVE: to explore women's perceived own authority within the modern and traditional spheres of childbirth in a high maternal mortality setting on the Arab peninsula. Yemen is a signatory to the Millennium Development Goals and one of 10 countries chosen for the United Nations Millennium Project. In Yemen, home birth has remained the norm for several decades in spite of high maternal mortality and morbidity rates. DESIGN: a multistage (stratified-purposive-random) sampling process was used. Two hundred and twenty women with childbirth experience in urban/rural Yemen were selected at random for interview. Answers to the question 'Did you feel that you were the authority during childbirth?' were analysed using qualitative content analysis. SETTING: the governorates of Aden, Lahej, Hadramout, Taiz and Hodeidah. FINDINGS: three main themes emerged from the analysis: (i) 'Being at the centre', including two categories 'being able to follow through on own wants' and its opposite 'to be under the authority of others'; (ii) 'A sense of belonging' with the categories 'belonging and support among women in the community' and 'the denial of support, the experience of separation' and (iii) 'Husband's role in childbirth' including one category 'opportunity to show authority over the husband'. Authority was experienced primarily among women within the traditional childbirth sector although a general complaint among women delivered by trained medical staff was the loss of own authority. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: these findings show that women's authority during childbirth is decreasing in the context of Safe Motherhood and the expansion of modern delivery care. This is likely to be an important reason why women underutilise professional care. Acquisition of knowledge from the traditional childbirth sector regarding how women exercise authority to facilitate childbirth would constitute an asset to skilled delivery and Safe Motherhood. The findings from Yemen are likely to be relevant for other low-income countries with similar persistent high home delivery rates, low status of women, and high maternal mortality and morbidity rates.

Characteristics of paediatric frequent presenters to an Australian emergency medicine network.

AIM: The study aims to describe the characteristics of paediatric emergency department (ED) patients defined as frequent presenters (FP) presenting to an Australian ED health service and compare these with a cohort of non-frequent presenters (NFP). METHOD: A retrospective chart review utilising an electronic emergency medicine patient medical record database was performed on paediatric patients (18 years or younger) presenting to Monash Health EDs from March 2009 to March 2010. NFPs were defined as patients presenting five or less times and FPs as presenting eight or more times in the study period. Characteristics of both groups were described and compared. RESULTS: During the 12-month study period, there were 130 paediatric FP patients with 839 admissions and 34,262 paediatric NFP patients with 46,043 admissions. FPs to the ED were more likely to be female, utilise the ambulance service to arrive at the hospital and more likely to be admitted to hospital. In particular, FPs were more likely to require admission for a mental health-related problem. They were also more likely to have a discharge diagnosis related to oncology, neurology, respiratory, endocrinology and psychiatric complaints, compared with NFP who were more likely to present with a diagnosis related to injury or trauma. CONCLUSIONS: Paediatric FPs are a vulnerable population with complex multidisciplinary care needs. A holistic approach towards their needs is essential to understanding the reasons for their higher frequency of attendance. By considering all the elements of the child's well-being, the child and family need support to assist in integration with other non-ED service providers. By focusing on wellness and self-management, there is a potential to reduce the reliance on acute emergency care for ongoing chronic health problems.

[Heavy use of psychiatric hospitals and the use of outpatient services in Switzerland]. / Stationärer Heavy Use und die Inanspruchnahme institutioneller ambulanter Dienste in einem Schweizerischen Versorgungssystem.

OBJECTIVE: To identify user groups of inpatient psychiatry. METHODS: Retrospective cohort study over two years (n = 1295). Identification of patient subgroups based on the number of inpatient admissions and inpatient days by means of latent class analysis. RESULTS: Two patient groups were identified: 28 % heavy users and 72 % ordinary users. Heavy users were often diagnosed with schizophrenia and they also showed increased use of outpatient services. CONCLUSIONS: Integrated service models should be developed and tested for patients with schizophrenia and HU.

Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration.

BACKGROUND: Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented. OBJECTIVE: To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample. DESIGN: Observational PARTICIPANTS: Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009. MAIN MEASURES: We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities. KEY RESULTS: Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months. CONCLUSIONS: Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.

Overlaps and accumulation in the use of rehabilitation services.

The Finnish rehabilitation system is considered fragmented and multisectoral, and thus it may produce 'multiclients' receiving inefficient and overlapping services. This paper addresses the overlaps and accumulation in the delivery of rehabilitation services in Finnish rehabilitation subsystems. Data were drawn from several administrative registers on the use of rehabilitation services during the years 2004 and 2005 in one hospital district area in Midwest Finland. To analyze the differences in use of rehabilitation services between the patient groups, cross-tabulations, logistic and linear regressions were used. Altogether 15 189 persons in the study area used rehabilitation services during 2004 and 2005; 9% of rehabilitees used services provided by two or more subsystems. These multiclients used 25% of all rehabilitation services. Men of working ages and living in larger municipalities were more likely to be multiclients. The proportion of multiclients among all rehabilitees was smaller than expected. However, these multiclients used a larger proportion of rehabilitation services. In the case of multiclients, the problems most likely occur in the rehabilitation process, as the services provided by different subsystems most probably are not linked together. To improve the performance of the rehabilitation system, more attention should be paid to integrating the subsystems.

[Referrals to dermatology: proportion of banal disorders]. / Demanda derivada a Dermatología: peso de la patología banal.

BACKGROUND AND OBJECTIVE: Skin diseases account for a large number of consultations in primary care. The objective of this study was to determine the characteristics and cost of referrals from primary care to a dermatology clinic. MATERIAL AND METHODS: Descriptive cross-sectional study of referrals from a primary care health center to a dermatology clinic. The dermatology clinic was situated in the same health center and was attended by a dermatologist from Complejo Hospitalario Universitario in Albacete, Spain. The study was performed on 10 days selected at random between April 21, 2009, and June 26, 2009. The data gathered included age, sex, use of cryotherapy, and diagnostic group. Patients were divided into 4 diagnostic groups: A) benign degenerative disease or trivial disorders whose treatment may not merit involvement of the national health service, B) diseases resolved with a single dermatology consultation at the health center, C) diseases requiring evaluation in hospital-based dermatology outpatients, and D) diseases referred for surgical treatment. RESULTS: Data were gathered on 257 patients with a mean age was 41.18 years and there was a slight female predominance. The majority of patients were in diagnostic group B (53.7%), followed by groups A (19.1%), C (19.1%), and D (8.2%). The total estimated cost of these 257 visits was €29 750.32, of which €5672.24 was for trivial disorders. CONCLUSIONS: The current high prevalence of trivial disorders in the caseload of dermatology clinics by trivial disorders makes it necessary to control referrals from primary care more strictly.