Within and across country variations in treatment of patients with heart failure and diabetes.

OBJECTIVE: To compare within-country variation of health care utilization and spending of patients with chronic heart failure (CHF) and diabetes across countries. DATA SOURCES: Patient-level linked data sources compiled by the International Collaborative on Costs, Outcomes, and Needs in Care across nine countries: Australia, Canada, England, France, Germany, New Zealand, Spain, Switzerland, and the United States. DATA COLLECTION METHODS: Patients were identified in routine hospital data with a primary diagnosis of CHF and a secondary diagnosis of diabetes in 2015/2016. STUDY DESIGN: We calculated the care consumption of patients after a hospital admission over a year across the care pathway-ranging from primary care to home health nursing care. To compare the distribution of care consumption in each country, we use Gini coefficients, Lorenz curves, and female-male ratios for eight utilization and spending measures. PRINCIPAL FINDINGS: In all countries, rehabilitation and home nursing care were highly concentrated in the top decile of patients, while the number of drug prescriptions were more uniformly distributed. On average, the Gini coefficient for drug consumption is about 0.30 (95% confidence interval (CI): 0.27-0.36), while it is, 0.50 (0.45-0.56) for primary care visits, and more than 0.75 (0.81-0.92) for rehabilitation use and nurse visits at home (0.78; 0.62-0.9). Variations in spending were more pronounced than in utilization. Compared to men, women spend more days at initial hospital admission (+5%, 1.01-1.06), have a higher number of prescriptions (+7%, 1.05-1.09), and substantially more rehabilitation and home care (+20% to 35%, 0.79-1.6, 0.99-1.64), but have fewer visits to specialists (-10%; 0.84-0.97). CONCLUSIONS: Distribution of health care consumption in different settings varies within countries, but there are also some common treatment patterns across all countries. Clinicians and policy makers need to look into these differences in care utilization by sex and care setting to determine whether they are justified or indicate suboptimal care.

The Development and Operation of a Home Management System during the COVID-19 Pandemic: Experience of the Local Government Gyeonggi-do in Korea.

During the three the coronavirus disease 2019 (COVID-19) surges in South Korea, there was a shortage of hospital beds for COVID-19 patients, and as a result, there were cases of death while waiting for hospitalization. To minimize the risk of death and to allow those confirmed with COVID-19 to safely wait for hospitalization at home, the local government of Gyeonggi-do in South Korea developed a novel home management system (HMS). The HMS team, comprised of doctors and nurses, was organized to operate HMS. HMS provided a two-way channel for the taskforce and patients to monitor the severity of patient's condition and to provide healthcare counseling as needed. In addition, the HMS team cooperated with a triage/bed assignment team to expedite the response in case of an emergency, and managed a database of severity for real-time monitoring of patients. The HMS became operational for the first time in August 2020, initially managing only 181 patients; it currently manages a total of 3,707 patients. The HMS supplemented the government's COVID-19 confirmed case management framework by managing patients waiting at home for hospitalization due to lack of hospital and residential treatment center beds. HMS also could contribute a sense of psychological stability in patients and prevented the situation from worsening by efficient management of hospital beds and reduction of workloads on public healthcare centers. To stabilize and improve the management of COVID-19 confirmed cases, governments should organically develop self-treatment and HMS, and implement a decisive division of roles within the local governments.

A SBM-DEA based performance evaluation and optimization for social organizations participating in community and home-based elderly care services.

The community and home-based elderly care service system has been proved an effective pattern to mitigate the elderly care dilemma under the background of accelerating aging in China. In particular, the participation of social organizations in community and home-based elderly care service has powerfully fueled the multi-supply of elderly care. As the industry of the elderly care service is in the ascendant, the management lags behind, resulting in the waste of significant social resources. Therefore, performance evaluation is proposed to resolve this problem. However, a systematic framework for evaluating performance of community and home-based elderly care service centers (CECSCs) is absent. To overcome this limitation, the SBM-DEA model is introduced in this paper to evaluate the performance of CECSCs. 186 social organizations in Nanjing were employed as an empirical study to develop the systematic framework for performance evaluation. Through holistic analysis of previous studies and interviews with experts, a systematic framework with 33 indicators of six dimensions (i.e., financial management, hardware facilities, team building, service management, service object and organization construction) was developed. Then, Sensitivity Analysis is used to screen the direction of performance optimization and specific suggestions were put forward for government, industrial associations and CECSCs to implement. The empirical study shows the proposed framework using SBM-DEA and sensitivity analysis is viable for conducting performance evaluation and improvement of CECSCs, which is conducive to the sustainable development of CECSCs.

Association of Palliative Care Use and Setting With Health-care Utilization and Quality of Care at the End of Life Among Patients With Advanced Lung Cancer.

BACKGROUND: Palliative care is associated with improved survival and quality of life among patients with lung cancer; however, its influence on health-care utilization and quality of care is unclear. RESEARCH QUESTION: Is palliative care, and the setting in which it occurs, associated with health-care resource utilization and quality of care among patients with advanced lung cancer? STUDY DESIGN AND METHODS: This was a retrospective cohort study of 23,142 patients with stage IIIB/IV lung cancer in the Veterans Affairs HealthCare System between 2007 and 2013. Exposures included the receipt of specialist-delivered palliative care, and the setting of the initial palliative care encounter (inpatient or outpatient) received after cancer diagnosis. Primary outcomes included rates of ED visits, along with rates of hospitalization and odds of ICU admission within the last 30 days of life. Secondary outcomes included any health-care utilization (ED, hospital, or ICU) related to chemotherapy toxicity. We used propensity score methods to perform Poisson and logistic regression modeling. RESULTS: Among the 23,142 patients, 57% received palliative care, and 36% of initial palliative care encounters were outpatient. Compared with no palliative care, initial palliative care encounter in the outpatient setting was associated with reduced rates of ED visits (adjusted incidence rate ratio [aIRR], 0.86; 95% CI, 0.77-0.96) and hospitalizations in the last 30 days of life (aIRR, 0.64; 95% CI, 0.59-0.70). Initial palliative care encounters in both inpatient (adjusted OR [aOR], 0.63; 95% CI, 0.53-0.75) and outpatient (aOR, 0.42; 95% CI, 0.35-0.52) settings were associated with reduced odds of ICU admission in the last 30 days of life. Palliative care was also associated with reduced health-care utilization related to chemotherapy toxicity (aOR, 0.88; 95% CI, 0.82-0.95). INTERPRETATION: Palliative care (particularly in outpatient settings) is associated with reduced health-care utilization at the end of life and may improve the quality of care among patients with advanced lung cancer. These findings support the role of palliative care as an important component of comprehensive cancer care and highlight the potential benefits of outpatient palliative care services.

Characterizing the Financial Value of In-Home Palliative Care for Patients, Payers, and Hospitals.

BACKGROUND: The holistic and multidisciplinary approach of in-home palliative care (IHPC) is known to offer high-quality and cost-effective care for patients at the end of life. However, the financial benefits of upstream IHPC programs to hospitals, patients, and payers have not been fully characterized for patients with comorbid chronic conditions. AIM: To characterize the financial benefits that upstream IHPC offers to patients with multiple chronic conditions. METHODS: A structured retrospective patient record review was conducted on the number of emergency department (ED) visits, number of inpatient hospitalizations, hospital length of stay (LOS), and payments made to the hospital for all patients (N = 71) enrolled in an IHPC program between January 1, 2016, and June 30, 2016. Discharge history from each patient's medical record was also assessed. Comparisons were drawn between patients' LOS on IHPC and an equivalent time period prior to enrollment in IHPC. RESULTS: After patients enrolled in IHPC, average ED and inpatient utilization declined significantly by 41% (P = .01) and 71% (P < .001), respectively. The payers for health-care services realized a significant decline of US$2,201 (P < .001) in hospital payments per patient per month. Inpatient LOS was also significantly lower than expected once patients enrolled in the program (P = .01). CONCLUSIONS: As the need for chronic disease management continues to grow, managers of health systems, managed care organizations, and home health agencies should be cognizant of the financial value that IHPC has to offer.

Nutritional status and clinical evolution of the elderly in home enteral nutritional therapy: a retrospective cohort study. / Estado nutricional e evolução clínica de idosos em terapia nutricional enteral domiciliar: uma coorte retrospectiva.

OBJECTIVE: to evaluate the clinical and nutritional evolution of elderly patients receiving home enteral nutritional therapy. METHOD: retrospective cohort observational study. Data collection was performed through the analysis of clinical and nutritional records. The demographic, nutritional and clinical variables were analyzed. The sample consisted of elderly patients using home enteral nutritional therapy via the probe or the stomach. For the statistical analysis, the Statistical Package for the Social Sciences program was used, adopting the level of significance of 5%. RESULTS: the sample was 218 participants, with a mean age of 76 ± 10.12 years, of which 54.1% were female. The main morbidity was the stroke sequelae. Malnutrition was the nutritional diagnosis and the overall subjective assessment, the main instrument of nutritional evaluation. The route of administration of the most prevalent diet was the nasoenteric/nasogastric tube, however, after one year of follow-up, gastrostomy became the main route. It was observed the predominance of general condition maintenance and the most prevalent clinical outcome was death. CONCLUSION: the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status. Therefore, this therapy may contribute to a better clinical and nutritional evolution.

Mothers´ experiences in relation to a new Swedish postnatal home-based model of midwifery care-A cross-sectional study.

BACKGROUND: The goal of postnatal care is to provide the highest possible quality of care and medical safety with the least possible intervention in order to optimize health and wellbeing of the new family. The aim of the study was to describe mothers´ experiences in relation to a new postnatal home-based model of midwifery care. METHODS: The current study uses a cross-sectional mixed method design to assess a new postnatal home-based model of midwifery care in Sweden. Healthy women with an uncomplicated pregnancy and childbirth, and with a healthy baby answered an online questionnaire one week after birth. Data were collected during one year (2017-2018) and analyzed using descriptive and inferential statistics for quantitative data, and manifest content analysis for qualitative data. FINDINGS: In total, 180 mothers with one to six children were included. They were most likely to have been discharged between six and 12 h after childbirth (56%) and 90% reported that the time for their discharge was good. The postnatal check-ups included were telephone contact (100%), home visit(s) (94%) and hospital visit(s) (98%). Most mothers had a positive postnatal care experience from using the new postnatal model of midwifery care (mean VAS 8.74, Std. Deviation 1.438). For 75%, of the participants, home-based postnatal care would be preferred for their next childbirth. CONCLUSION: Home-based postnatal care is well accepted by mothers who were discharged early after childbirth. Mothers with a positive experience of the new postnatal model of midwifery care would prefer home-based postnatal care for their next childbirth. Midwifery care should include home-based postnatal care.

Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System.

BACKGROUND: The number of outpatient mastectomies, with and without reconstruction, has increased nationwide. In well-selected patient populations, same-day surgery for mastectomy is a safe option. A pilot project was initiated within the Kaiser Permanente Northern California healthcare system to facilitate surgical home recovery (SHR) for mastectomy patients, including patients undergoing implant-based reconstruction and bilateral mastectomies. METHODS: Surgical home recovery for mastectomy patients was implemented in October 2017. Specific measures in this initiative included management of patient expectations at initial consultation, education about postoperative home care, multimodality pain management, and timely post-discharge follow-up. All patients undergoing mastectomy were included, except those undergoing autologous tissue reconstructions. After a 6-month implementation period, rate of same day discharge over 6 months was compared before and after the SHR initiative. We also compared emergency department (ED) visits, reoperations, and readmissions within 7 days. RESULTS: Twenty-one medical centers participated in this initiative. Before implementing SHR, 164 of the 717 (23%) mastectomies were outpatient procedures, compared with 403 of the 663 (61%) after the implementation period. Although the rate of outpatient mastectomy increased significantly, there were no statistically significant differences in ED visits (5.2% vs. 5.1%, p = 0.98), reoperation (3.5% vs. 3.5%, p = 0.99), or readmission rates (1.4% vs. 2.7%, p = 0.08). CONCLUSIONS: By implementing standard expectations and sharing best practices, there was a significant increase in the rate of home recovery for mastectomy without compromising quality of patient care. The success of this pilot program supports SHR for mastectomy.

The Origin of Present-on-admission Pressure Ulcers/Injuries Among Patients Admitted from the Community: Results of a Retrospective Study.

Research about community-acquired pressure ulcer/injuries (CAPU/I) remains limited. PURPOSE: The aim of this descriptive, retrospective study was to quantify the number of patients with pressure ulcers/injuries (PU/Is) present on admission (POA), with particular attention to patient residence (home or skilled/long-term care facility [SNF]). METHODS: Data from the electronic medical records (EMR) and the incident reporting system of a 620-bed integrated health system in northern California from January 1, 2017, to December 31, 2017, were examined and used to create a registry that included patient demographics, length of stay (LOS), source of admission (home versus SNF), co-existing conditions, and documentation on end of life and death. A manual chart review was conducted to confirm the accuracy of data entered into the registry. All patients at least 18 years old and with a nurse-reported incident and EMR-documented PU/I that was listed as POA were included; pediatric, pregnant, or incarcerated patients were excluded. Extracted variables included demographic data, stage of PU/I on admission, and major diagnosis (or co-existing condition) by groups (spinal cord injuries [tetraplegia, paraplegia], neurological conditions, end-stage renal disease, cardiac and vascular disease, end of life [EOL], and death while in hospital during the year 2017). Descriptive analysis was used to examine the data. RESULTS: Of the 2340 records of patients with an PU/I POA, 477 were complete and analyzed. The majority (336, 70.4%) originated from home. Patients admitted from home were younger than those admitted from SNF (average age 62.9 and 71.5 years, respectively) and had a higher proportion of co-existing paraplegia/tetraplegia (24.4% vs 12.8%). More than 60% of all patients had a stage 3, stage 4, or unstageable PU/I. CONCLUSION: The majority of patients with a PU/I POA were admitted from home. Additional research and improved efforts to help high-risk individuals living at home prevent and manage PU/Is are needed.

Efficacy of Implementing Home Care Using Eye Movement Desensitization and Reprocessing in Reducing Stress of Patients with Gastrointestinal Cancer.

Background: Gastrointestinal cancer is the third most common types of cancer in the world which leads to a lot of stress among sufferers. Pharmacological and non-pharmacological approaches are used to treat stress induced by serious diseases. Eye movement desensitization and reprocessing (EMDR) technique is considered as one of non-pharmacological method for decreasing patient's stress. Objective: This study was conducted to determine the effect of home care using EMDR technique on the stress of patients with gastrointestinal cancer. Materials and Methods: The current semi-experimental study was performed on patients with gastrointestinal cancer residing in Ilam, Iran. The patients were randomly divided into two groups of intervention (n=30) and control (n=30). Home care was provided for intervention group in patients' homes which included 2 sessions (a total of 60 sessions for all patients). Each session lasted for 45 to 60 minutes according to EMDR protocol. The data were analyzed using SPSS (version 16). Results: The findings of this study showed that most of patients were male (36, 60%), had diploma degrees (44, 73.3%), had a monthly income less than 500 thousand (38, 63.3%), were married (39, 65 %). The mean age of the patients was 69.18 ± 11.58 years. No statistically significant difference was observed between two groups before the intervention in terms of patients' perceived stress (P>0.05). However, efficacy and perceived distress of the intervention group significantly was decreased following the intervention (P<0.05). Conclusions: According to the findings regarding the impact of home care using EMDR technique on reducing stress in patients with gastrointestinal cancer, the implementation of this intervention and provision of education for patients are recommended to expand the nursing duty to community health wards as well as to improve the health status of patients.

Nationwide analysis of medical utilization in people with severe mental illness receiving home care case management.

AIM: This nationwide study investigated the change in medical utilization of psychiatric home care case management (CM). METHODS: This nationwide study enrolled patients receiving CM (N = 10,274) from January 1, 1999 to December 31, 2010, from Taiwan's National Health Insurance Research Database. Through a 2-year mirror-image comparison weighted by the contributed person-time for each subject, we evaluated changes in medical utilization. Furthermore, a case-crossover analysis was used to verify the independent effect of CM in changing medical utilization by adjusting the time-variant variables between the pre-2-year (within 2 years before receiving CM) and post-2-year (within years after receiving CM) periods. The same methodology was applied for the subsequent 2-year comparison to assess the maintenance effect. RESULTS: Of the 10,274 patients receiving CM, 69.7% had schizophrenia. The results showed a chronological trend for the intervention of CM. The adjusted mirror-image analysis revealed a significant decrement of psychiatric and involuntary admissions after the intervention, and the utilization shifted toward psychiatric outpatient service. The case-crossover analysis with the adjustment of time-variant covariates confirmed the independent effect of CM on the changes of medical utilization. The comparable effect persisted after the next 2 years of intervention. However, CM showed no impact on lowering the admission rate for comorbid physical illnesses after the intervention. CONCLUSIONS: The CM model can effectively reduce psychiatric hospitalization and involuntary admission frequency but has no effect on comorbid physical illnesses. Care models aimed at ameliorating physical problems in such patients are needed.

Feasibility and Patient Experience of a Home-Based Rehabilitation Program Driven by a Tablet App and Mobility Monitoring for Patients After a Total Hip Arthroplasty.

BACKGROUND: Recent developments in technology are promising for providing home-based exercise programs. OBJECTIVE: The objective of this study was to evaluate the feasibility and patient experience of a home-based rehabilitation program after total hip arthroplasty (THA) delivered using videos on a tablet personal computer (PC) and a necklace-worn motion sensor to continuously monitor mobility-related activities. METHODS: We enrolled 30 independently living patients aged 18-75 years who had undergone THA as a treatment for primary or secondary osteoarthritis (OA) between December 2015 and February 2017. Patients followed a 12-week exercise program with video instructions on a tablet PC and daily physical activity registration through a motion sensor. Patients were asked to do strengthening and walking exercises at least 5 days a week. There was weekly phone contact with a physiotherapist. Adherence and technical problems were recorded during the intervention. User evaluation was done in week 4 (T1) and at the end of the program (T2). RESULTS: Overall, 26 patients completed the program. Average adherence for exercising 5 times a week was 92%. Reasons mentioned most often for nonadherence were vacation or a day or weekend off 25% (33/134) and work 15% (20/134). The total number of technical issues was 8. The average score on the user evaluation questionnaire (range 0-5) was 4.6 at T1 and 4.5 at T2. The highest score was for the subscale "coaching" and the lowest for the subscale "sensor." CONCLUSIONS: A home-based rehabilitation program driven by a tablet app and mobility monitoring seems feasible for THA patients. Adherence was good and patient experience was positive. The novel technology was well accepted. When the home-based rehabilitation program proves to be effective, it could be used as an alternative to formal physiotherapy. However, further research on its effectiveness is needed.

Participation in Physical Activity During Center and Home-Based Pulmonary Rehabilitation for People With COPD: A SECONDARY ANALYSIS OF A RANDOMIZED CONTROLLED TRIAL.

PURPOSE: To compare levels of physical activity during center and home-based pulmonary rehabilitation (PR) in people with chronic obstructive pulmonary disease. METHODS: Forty-five consecutive participants (23 male, n = 20, in the home-based group) with mean age of 68 ± 8 yr and forced expiratory volume in the first second of expiration (FEV1) 53 ± 18% predicted undertook physical activity monitoring using the SenseWear Armband during the final week of the interventions of center or home-based PR. Differences in time spent in total physical activity (≥1.5 METs), time spent in moderate to vigorous intensity physical activity (≥3 METs), and steps were compared. RESULTS: Home participants spent a median and interquartile range of 310 (199-328) min/d engaged in total physical activity (29% moderate to vigorous intensity physical activity) compared with 300 (204-370) min/d for the center group (28% moderate to vigorous intensity physical activity, P = .98). Daily step count did not differ between groups (home-based median 5232 [2067-7718] versus center-based median 4049 [1983-6040], P = .66). Of note, center-based participants took 38% more steps on days of program attendance compared with nonattendance days (mean difference: 761 steps/d; 95% CI, -56 to 1579, P = .06). CONCLUSION: For people with chronic obstructive pulmonary disease undertaking PR, no differences in physical activity levels between center and home-based programs were demonstrated. Understanding the impact of the indirect supervision and motivational interviewing technique utilized during home-based PR on levels of physical activity in people with chronic obstructive pulmonary disease may support clinical implementation of the model as an alternative option to traditional care.

[The DISC tool improves communication and results in pulmonary rehabilitation]. / L'outil DISC améliore la communication et les résultats de la réhabilitation respiratoire : une approche comportementale adaptée.

INTRODUCTION: Competence in personal relationships is essential for a caregiver, especially in pulmonary rehabilitation (PR). Considering the behavioral profile of patients might help to optimize their management and the results of PR. METHODS: We evaluated eight hundred and thirty-two consecutive patients with chronic respiratory disease who received eight weeks of home-based PR. Their exercise tolerance (six-minute stepper test, 6MST), mood (HAD), and quality of life (VSRQ, MRF28) were evaluated at the beginning and end of PR. For six hundred and ninety patients, a behavioral approach was implemented at the beginning of PR by using the DISC tool to identify four behavioral profiles: dominance, influence, steadiness, conscientiousness. The remaining 142 patients served as the control group. RESULTS: Subjectively, the therapeutic alliance was more easily established with the behavioral approach. Compared with the control group, patients with the "steadiness" profile were younger (60.7±12 years) and mostly female (52.8%), whereas patients with the "conscientiousness" profile were older (67.5±10.6 years) and mostly male (85.5%). The four behaviorally profiled groups showed no differences in exercise tolerance, mood, or quality of life scores at baseline. Globally, all patients improved their exercise tolerance, mood and quality of life. The percentage of responders to 6MST and VSRQ (>MCID) was 7.5% and 5.3% higher with the behavioral approach. For non-responders to 6MST and VSRQ (

Mobile integrated health to reduce post-discharge acute care visits: A pilot study.

BACKGROUND: Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. STUDY OBJECTIVE: To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. METHODS: This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. RESULTS: Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). CONCLUSION: In this pilot before/after study, MIH significantly reduces acute care hospitalizations.

Palliative care in patients with haematological neoplasms: An integrative systematic review.

BACKGROUND: Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies. AIM: To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments. DESIGN: Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240). DATA SOURCES: PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies. RESULTS: The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking. CONCLUSION: Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Deaths in France: Characteristics, place of death, hospitalisations and use of palliative care during the year before death.

AIM: Only limited data are available concerning the diseases managed and the hospital pathway before death. The aim of this study was to describe diseases, hospitalisations, and use of palliative care one year before death as well as place of death in France. METHODS: French health insurance general scheme beneficiaries who died in 2013 were identified in the National Health Insurance Information System (SNIIRAM) with a selection of information concerning their various hospital stays, including hospital palliative care (HPC) and nursing home care. Diseases were identified by algorithms from reimbursement data recorded in the SNIIRAM database. RESULTS: A total of 347 253 people were included (61% of all deaths in France). The mean age of death was 77 years (SD 15.1). Diseases managed before death were cardiovascular/neurovascular diseases (56%), cancers (42%), neurological and degenerative diseases (25%), diabetes (21%) and chronic respiratory diseases (20%). Deaths occurred in hospital in 60% of cases: 51% in acute wards, 6% in rehabilitation units, 3% in hospital at home (HaH), and 13% in nursing homes. During the year preceding death, 84% of people were hospitalised at least once and 29% received HPC. People receiving HPC more often died in hospital than people not receiving HPC (69% vs. 44%). CONCLUSION: Health administrative data from the SNIIRAM database can refine our knowledge of the care pathway prior to death and of the use of hospital palliative care and can be useful to evaluate the new governmental palliative care plan recently deployed in France.

There's no place like home: Integrating pulmonary rehabilitation into the home setting.

Traditional, outpatient pulmonary rehabilitation provided to stable COPD patients leads to significant improvements in dyspnea, exercise capacity and health related quality of life.  Also, when started during or shortly after a hospitalization for a COPD exacerbation, pulmonary rehabilitation improves these patient-centered outcomes and arguably reduces subsequent health care utilization and mortality.  Despite these benefits, the uptake of traditional pulmonary rehabilitation remains disappointingly poor.  Home-based pulmonary rehabilitation, a safe and effective alternative to traditional, center-based programs, can broaden access. While proven improvements in dyspnea, exercise capacity and health status justify implementation of home-based pulmonary rehabilitation, it would be helpful to know whether it can also decrease health care utilization and be cost-effective.