Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Economic Analysis of Mobile Integrated Health Care Delivered by Emergency Medical Services Paramedic Teams.

Importance: Mobile integrated health care (MIH) is a new model of community-based health care to provide on-site urgent or nonurgent care. Niagara emergency medical services (NEMS) started MIH in 2018 to serve the Niagara region of Ontario, Canada. However, its economic impact is unknown. Objective: To compare time on task and cost between MIH and ambulance delivered by NEMS from a public payer's perspective. Design, Setting, and Participants: This economic evaluation was an analysis of the NEMS databases regarding responses to emergency calls by the NEMS from 2016 to 2019. Emergency calls serviced by MIH in 2018 to 2019 were used as an intervention cohort. Propensity score matching was used to identify a 1:1 matched cohort of calls serviced by regular ambulance response for the same period and 2 years prior. Statistical analyses were performed from January to April 2020. Exposures: MIH compared with matched ambulance services. Main Outcomes and Measures: The main outcomes were the time on task (including time on scene and time at hospital) and costs. Costs were calculated in 2019 Canadian dollars using cost per minute and compared with the 3 ambulance cohorts. Results: In 2018 to 2019, there were 1740 calls serviced by MIH for which a matched ambulance cohort was identified for the same period and 2 years prior. The mean (SD) time on task was 72.7 (51.0) minutes for MIH, compared with 84.1 (52.0) minutes, 84.3 (54.1) minutes, and 79.4 (42.0) minutes for matched ambulance in 2018 to 2019, 2017 to 2018, and 2016 to 2017, respectively. Of calls serviced by MIH, 498 (28.6%) required ED transport (ie, after MIH team assessment, transport to ED was deemed to be necessary or demanded by the patient), compared with 1300 (74.7%) calls serviced by ambulance in 2018 to 2019, 1294 (74.4%) in 2017 to 2018, and 1359 (78.1%) in 2016 to 2017. The mean (SD) total cost per 1000 calls was $122 760 ($78 635) for MIH compared with $294 336 ($97 245), $299 797 ($104 456), and $297 269 ($81 144) for regular ambulance responses in the 3 matched cohorts, respectively. Conclusions and Relevance: Compared with regular ambulance response, MIH was associated with a substantial reduction in the proportion of patients transported to the ED, leading to a substantial saving in total costs. This finding suggests that the MIH model is a promising and viable solution to meeting urgent health care needs in the community, while substantially improving the use of scarce health care resources.

A cost analysis of a community-based support centre for cancer patients and their families in Ireland: the EVeCANs study.

Cancer patients and their families experience a range of physical, psychological and financial adverse effects. Community-based cancer centres offer a range of services and interventions, free of charge, to support those affected by cancer. While shown to be effective, there is a lack of information on the costs of these services. Our aim was to estimate the resource impact of a community-based cancer support centre. Over a 7-month period, there were 2032 contacts with 238 clients whose average age was 60 years. The most frequently used services were transport to treatment (20%), complementary therapies (48%), exercise classes (10%) and counselling (9%). This cost analysis estimated total annual cost to provide all services was €313,744. Average annual cost per person was €1138. Current uptake at the centre represents 8% of all cancer incidences in seven counties surrounding the centre. If uptake increases by 10%, scenario analyses predict an increase in total costs increase to €429,043 and a decrease in costs per patient to €915. As cancer incidences increase, the need for supportive care is growing. Community-based services have been established to meet these needs and fill this gap in national health services. Long-term sustainability of these centres is uncertain as they are entirely reliant on donations and volunteers. This analysis estimates the costs of one such community-based cancer support centre, for the first time in Ireland. Findings can be used to inform future planning of cancer supportive care services, including establishing links between tertiary and community-based centres, and cost effectiveness analyses, nationally and internationally.

Modelling cost benefit of community-oriented primary care in rural South Africa.

BACKGROUND: Globally, rural populations have poorer health and considerably lower levels of access to healthcare compared with urban populations. Although the drive to ensure universal coverage through community healthcare worker programmes has shown significant results elsewhere, their value has yet to be realised in South Africa. AIM: The aim of this study was to determine the potential impact, cost-effectiveness and benefit-to-cost ratio (BCR) of information and communications technology (ICT)-enabled community-oriented primary care (COPC) for rural and remote populations. SETTING: The Waterberg district of Limpopo province in South Africa is a rural mining area. The majority of 745 000 population are poor and in poor health. METHODS: The modelling considers condition-specific effectiveness, population age and characteristics, health-determined service demand, and costs of delivery and resources. RESULTS: Modelling showed 122 teams can deliver a full ICT-enabled COPC service package to 630 565 eligible people. Annually, at scale, it could yield 35 877 unadjusted life years saved and 994 deaths avoided at an average per capita service cost of R170.37, and R2668 per life year saved. There could be net annual savings of R120 million (R63.4m for Waterberg district) from reduced clinic (110.7m) and hospital outpatient (23 646) attendance and admissions. The service would inject R51.6m into community health worker (CHW) households and approximately R492m into district poverty reduction and economic growth. CONCLUSION: With a BCR of 3.4, ICT-enabled COPC is an affordable systemic investment in universal, pro-poor, integrated healthcare and makes community-based healthcare delivery particularly compelling in rural and remote areas.

The Impact of the Great Recession on Long-Term Services and Supports in the United States and England.

The Great Recession substantially affected most developed countries. How countries responded to the Great Recession varied greatly, especially in terms of public spending. We examine the impact of the Great Recession on long-term services and supports (LTSS) in the United States and England. Financing for LTSS in these two countries differs in important ways; by examining the two countries' financing and program structures, we learn how these factors influenced each country's response to this common external stimulus. We find that between 2006 and 2013, LTSS increased in the United States in terms of spending (17%) and number of people served; in contrast, over the same period, LTSS in England decreased in terms of spending (6%) and people served. We find that the use of earmarked LTSS funding in the United States, compared to non-earmarked funding in England, contributed to different trajectories for LTSS in the two countries. Other contributing factors included differences in service entitlements, variations in ability of state and local governments to tax, and larger macroeconomic strategies implemented to combat the recession. We analyze the implications of our findings, especially as related to the potential shift to Medicaid block grant LTSS funding in the United States.

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana.

BACKGROUND: The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide. METHODS: Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012-2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost. RESULTS: The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and $1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP. CONCLUSION: The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs.

Effects, costs and feasibility of the 'Stay Active at Home' Reablement training programme for home care professionals: study protocol of a cluster randomised controlled trial.

BACKGROUND: According to the principles of Reablement, home care services are meant to be goal-oriented, holistic and person-centred taking into account the capabilities and opportunities of older adults. However, home care services traditionally focus on doing things for older adults rather than with them. To implement Reablement in practice, the 'Stay Active at Home' programme was developed. It is assumed that the programme leads to a reduction in sedentary behaviour in older adults and consequently more cost-effective outcomes in terms of their health and wellbeing. However, this has yet to be proven. METHODS/ DESIGN: A two-group cluster randomised controlled trial with 12 months follow-up will be conducted. Ten nursing teams will be selected, pre-stratified on working area and randomised into an intervention group ('Stay Active at Home') or control group (no training). All nurses of the participating teams are eligible to participate in the study. Older adults and, if applicable, their domestic support workers (DSWs) will be allocated to the intervention or control group as well, based on the allocation of the nursing team. Older adults are eligible to participate, if they: 1) receive homecare services by the selected teams; and 2) are 65 years or older. Older adults will be excluded if they: 1) are terminally ill or bedbound; 2) have serious cognitive or psychological problems; or 3) are unable to communicate in Dutch. DSWs are eligible to participate if they provide services to clients who fulfil the eligibility criteria for older adults. The study consists of an effect evaluation (primary outcome: sedentary behaviour in older adults), an economic evaluation and a process evaluation. Data for the effect and economic evaluation will be collected at baseline and 6 and/or 12 months after baseline using performance-based and self-reported measures. In addition, data from client records will be extracted. A mixed-methods design will be applied for the process evaluation, collecting data of older adults and professionals throughout the study period. DISCUSSION: This study will result in evidence about the effectiveness, cost-effectiveness and feasibility of the 'Stay Active at Home' programme. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03293303 , registered on 20 September 2017.

Public Health System-Delivered Mental Health Preventive Care Links to Significant Reduction of Health Care Costs.

The objective was to estimate the association between health care expenditures and implementation of preventive mental health programs by local health departments (LHDs). Multilevel nationally representative data sets were linked to test the hypothesis that LHDs' provision of preventive mental health programs was associated with cost savings. A generalized linear model with log link and gamma distribution and state-fixed effects was used to estimate the association between LHDs' mental illness prevention services and total health care expenditures per person per year for adults aged 18 years and older. The main outcome measure was the annual total health care expenditure per person. The findings indicated that LHD provision of population-based prevention of mental illness was associated with an $824 reduction (95% confidence interval: -$1,562.94 to -$85.42, P < 0.05) in annual health care costs per person, after controlling for individual, LHD, community, and state characteristics. LHDs can play a critical role in establishing an integrated health care model. Their impact, however, has often been underestimated or neglected. Results showed that a small investment in LHDs may yield substantial cost savings at the societal level. The findings of this research are critical to inform policy decisions for the expansion of the Public Health 3.0 infrastructure.

Early Successes in an Open Access, Provincially Funded Hepatitis C Treatment Program in Prince Edward Island.

INTRODUCTION: The availability of curative hepatitis C therapies has created an opportunity to improve treatment delivery and access. Local providers, government, industry, and community groups in Prince Edward Island developed an innovative province-wide care model. Our goal was to describe the first year of program implementation. MATERIAL AND METHODS: Using a communitybased prospective observational study design, all chronic hepatitis C referrals received from April 2015 to April 2016 were recorded in a database. Primary analysis assessed the time from referral to assessment/treatment, as well as the number of referrals, assessments, and treatment initiations. Secondary objectives included: (1) treatment effectiveness using intention-to-treat analysis; and (2) patient treatment experience assessed using demographics, adverse events, and medication adherence. RESULTS: During the study period 242 referrals were received, 123 patients were seen for intake assessments, and 93 initiated direct-acting antiviral therapy based on medical need. This is compared to 4 treatment initiations in the previous 2 years. The median time from assessment to treatment initiation was 3 weeks. Eighty-two of 84 (97.6%, 95% CI 91.7 - 99.7%) patients for whom outcome data were available achieved sustained virologic response at 12 weeks post-treatment; 1 was lost to follow-up and 1 died from an unrelated event. In the voluntary registry, 39.7% of patients reported missed treatment doses. CONCLUSION: In conclusion, results from the first 12 months of this multi-phase hepatitis C elimination strategy demonstrate improved access to treatment, and high rates of safe engagement and cure for patients living with chronic hepatitis C genotype 1 infections.

Care for Child Development: an intervention in support of responsive caregiving and early child development.

BACKGROUND: An estimated 43% of children younger than 5 years of age are at elevated risk of failing to achieve their human potential. In response, the World Health Organization and UNICEF developed Care for Child Development (CCD), based on the science of child development, to improve sensitive and responsive caregiving and promote the psychosocial development of young children. METHODS: In 2015, the World Health Organization and UNICEF identified sites where CCD has been implemented and sustained. The sites were surveyed, and responses were followed up by phone interviews. Project reports provided information on additional sites, and a review of published studies was undertaken to document the effectiveness of CCD for improving child and family outcomes, as well as its feasibility for implementation in resource-constrained communities. RESULTS: The inventory found that CCD had been integrated into existing services in diverse sectors in 19 countries and 23 sites, including child survival, health, nutrition, infant day care, early education, family and child protection and services for children with disabilities. Published and unpublished evaluations have found that CCD interventions can improve child development, growth and health, as well as responsive caregiving. It has also been reported to reduce maternal depression, a known risk factor for poor pregnancy outcomes and poor child health, growth and development. Although CCD has expanded beyond initial implementation sites, only three countries reported having national policy support for integrating CCD into health or other services. CONCLUSIONS: Strong interest exists in many countries to move beyond child survival to protect and support optimal child development. The United Nations Sustainable Development Goals depend on children realizing their potential to build healthy and emotionally, cognitively and socially competent future generations. More studies are needed to guide the integration of the CCD approach under different conditions. Nevertheless, the time is right to provide for the scale-up of CCD as part of services for families and children.

Expanding The INSPIRED COPD Outreach Program™ to the emergency department: a feasibility assessment.

BACKGROUND: The Halifax-based INSPIRED COPD Outreach Program™ is a facility-to-community home-based novel clinical initiative that through improved care transitions, self-management, and engagement in advance care planning has demonstrated a significant (60%-80%) reduction in health care utilization with substantial cost aversion. By assessing the feasibility of expanding INSPIRED into the emergency department (ED) we anticipated extending reach and potential for positive impact of INSPIRED to those with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who avoid hospital admission. METHODS: Patients were eligible for the INSPIRED-ED study if >40 years of age, diagnosed with AECOPD and discharged from the ED, willing to be referred, community dwelling with at least one of: previous use of the ED services, admission to Intermediate Care Unit/Intensive Care Unit, or admission to hospital with AECOPD in the past year. We set feasibility objectives for referral rates, completion of action plans, advance care planning participation, and reduction in ED visit frequency. RESULTS: Referral rates were 0.5/week. Among eligible patients (n=174) 33 (19%) were referred of whom 15 (M=4, F=11) enrolled in INSPIRED-ED. Mean (SD) age was 68 (7) years, post-bronchdilator FEV1 44.2 (15.5) % predicted, and Medical Research Council (MRC) dyspnea score 3.8 (0.41). We met feasibility objectives for action plan and advance care planning completion. Frequency of subsequent ED visits fell by 54%. Mean (SD) Care Transition Measure (CTM-3) improved from 8.6 (2.0) to 11.3 (1.3), P=0.0004, and of 14 patients responding 12 (86%) found the program very helpful. An additional 34 patients were enrolled to our regular program from those referred but ineligible for INSPIRED-ED (n=27) or unwilling to participate (n=7). CONCLUSIONS: INSPIRED-ED outcomes were generally positive, however referral and enrollment rates were lower than anticipated. Despite the potential of early self-management education, the ED may not be the ideal recruitment setting for home-based programs. Our findings underline the importance of conducting preliminary work to ascertain best settings for implementing new self-management education initiatives.

Managing claudication in the community setting.

Advances made in medical management and treatment options in addressing lower extremity claudication and vascular disease have skyrocketed during the last decade. Given the recent advances in treatment options, there is often the perception within the medical community and general community that to get the most "cutting edge" treatment, one must go to an academic center or practitioner. The goal of this portion of the discussion is to explore the question of what differences in treatment options there are between a community practice and an academic practice within those members of the vascular surgery specialty. Are there really any differences in the types of treatments offered or availability of the different modalities, and what drives us as practitioners to one over the other?

Delivering Vitamin A Supplements to Children Aged 6 to 59 Months: Comparing Delivery Through Mass Campaign and Through Routine Health Services in Ethiopia.

BACKGROUND: The delivery of vitamin A supplements in Ethiopia has been shifting from Child Health Days (campaigns) to routine delivery via the community health services. OBJECTIVE: The objective of this study was to compare the cost and effectiveness of these 2 delivery methods. No previous studies have done this. METHODS: A mixed method approach was used. Quantitative data on costs were collected from interviews with key staff and coverage data from health facility records. Qualitative data on the 2 modalities were collected from key informants and community members from purposefully sampled communities using the 2 modalities. RESULTS: Communities appreciated the provision of vitamin A supplements to their under 5-year-old children. The small drop in coverage that occurred as a result of the change in modality can be attributed to normal changes that occur with any system change. Advantages of campaigns included greater ease of mobilization and better coverage of older children from more remote communities. Advantages of routine delivery included not omitting children who happened to miss the 1 day per round that supplementation occurred and not disrupting the availability of other health services for the 5 to 6 days each campaign requires. The cost of routine delivery is not easy to measure nor is the cost of disruption to normal services entailed by campaigns. CONCLUSION: Cost-effectiveness likely depends more on effectiveness than on cost. Overall, the routine approach can achieve good coverage and is sustainable in the long run, as long as the transition is well planned and implemented.

Contextual variations in costs for a community health strategy implemented in rural, peri-urban and nomadic sites in Kenya.

BACKGROUND: Many low and middle income countries have developed community health strategies involving lay health workers, to complement and strengthen public health services. This study explores variations in costing parameters pertinent to deployment of community health volunteers across different contexts outlining considerations for costing program scale-up. METHODS: The study used quasi experimental study design and employed both quantitative and qualitative methods to explore community health unit implementation activities and costs and compare costs across purposively selected sites that differed socially, economically and ecologically. Data were collected from November 2010 to December 2013 through key informant interviews and focus group discussions. We interviewed 16 key informants (eight District community health strategy focal persons, eight frontline field officers), and eight focus group discussions (four with community health volunteers and four with community health committee) and 560 sets of monthly cost data. Cost data were tabulated using Microsoft Excel. Qualitative data were transcribed and coded using a content analysis framework. RESULTS: Four critical elements: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits, drove cost variations across the three sites. Attrition rate was highest in peri-urban site where population is highly mobile and lowest in nomadic site. More households were covered by community health workers in the peri-urban area making per capita costs considerably less than in the nomadic settings where long distances had to be covered to reach sparsely distributed households. Livelihood opportunity costs for Community Health Volunteers were highest in nomadic setting, while peri-urban ones reported substantial employability benefits resulting from training. Social opportunity benefits were highest in rural site. CONCLUSIONS: Results show that costs of implementing community health strategy varied due to different area contextual factors in Kenya. This study identified four critical elements that drive cost variations: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits. Health programme managers and policy-makers need to pay attention to details of contextual factors in costing for effective implementation of community health strategies.

Integrated care organizations: Medicare financing for care at home.

OBJECTIVES: As the boomer population ages, there is a growing need for integrated care organizations (ICOs) that can integrate both medical care and long-term services and supports in the home. This paper presents a policy proposal to support the creation of ICOs, redesign care, and provide financing for home- and community-based services (HCBS), with the goal of enhancing financial protection for beneficiaries, coordinating care, and preventing costly hospital and nursing home use. METHODS: This study used the 2012 Medicare Current Beneficiary Survey (MCBS) Cost and Use File, inflated to 2016 figures, to describe the characteristics of Medicare beneficiaries and their healthcare utilization and spending. The costs of covering up to 20 hours of personal care services a week were estimated using MCBS population counts, participation assumptions based on the literature, and financing design parameters. RESULTS: A targeted HCBS benefit could be added to Medicare and financed with income-related cost sharing ranging from 5% to 50%, a premium paid by Medicare beneficiaries of approximately $42 a month, and payroll taxes estimated at around 0.4% of earnings on employers and employees. CONCLUSIONS: Adoption of an HCBS benefit in Medicare would improve financial protection for beneficiaries with physical and/or cognitive impairment and provide the financing for health organizations to better integrate medical and social services. ICOs and delivery models of care emphasizing care at home would improve accessibility of care and avoid costly institutionalization; additionally, it would also reduce beneficiary reliance on Medicaid.

Improving Benefits and Integrating Care for Older Medicare Beneficiaries with Physical or Cognitive Impairment.

Issue: Two-thirds of Medicare beneficiaries with physical and/or cognitive impairment (PCI) who live in the community have three or more chronic conditions and could benefit from integrated medical and social services. Over one-third of those with PCI have incomes under 200 percent of the federal poverty level but are not covered by Medicaid, exposing them to risk of financial burdens and nursing home placement. Goal: To analyze two policy options that expand financing for home- and community-based care for older adults with PCI. Methods: Potential costs are estimated using the Medicare Current Beneficiary Survey. Key findings and conclusions: Medicare Help at Home­a proposal to add supplemental home- and community-based services­could be financed by income-related cost-sharing, beneficiary monthly premiums of $42, and an incremental payroll tax on employers and employees of 0.4 percent. This could produce savings to Medicaid of $1.6 billion over 14 years. Using a different option­an extension of Medicaid Community First Choice­would cost $16,224 per person assisted, with costs offset by reduced nursing home placement.

Novel Three-Day, Community-Based, Nonpharmacological Group Intervention for Chronic Musculoskeletal Pain (COPERS): A Randomised Clinical Trial.

BACKGROUND: Chronic musculoskeletal pain is the leading cause of disability worldwide. The effectiveness of pharmacological treatments for chronic pain is often limited, and there is growing concern about the adverse effects of these treatments, including opioid dependence. Nonpharmacological approaches to chronic pain may be an attractive alternative or adjunctive treatment. We describe the effectiveness of a novel, theoretically based group pain management support intervention for chronic musculoskeletal pain. METHODS AND FINDINGS: We conducted a multi-centre, pragmatic, randomised, controlled effectiveness and cost-effectiveness (cost-utility) trial across 27 general practices and community musculoskeletal services in the UK. We recruited 703 adults with musculoskeletal pain of at least 3 mo duration between August 1, 2011, and July 31, 2012, and randomised participants 1.33:1 to intervention (403) or control (300). Intervention participants were offered a participative group intervention (COPERS) delivered over three alternate days with a follow-up session at 2 wk. The intervention introduced cognitive behavioural approaches and was designed to promote self-efficacy to manage chronic pain. Controls received usual care and a relaxation CD. The primary outcome was pain-related disability at 12 mo (Chronic Pain Grade [CPG] disability subscale); secondary outcomes included the CPG disability subscale at 6 mo and the following measured at 6 and 12 mo: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), pain acceptance (Chronic Pain Acceptance Questionnaire), social integration (Health Education Impact Questionnaire social integration and support subscale), pain-related self-efficacy (Pain Self-Efficacy Questionnaire), pain intensity (CPG pain intensity subscale), the census global health question (2011 census for England and Wales), health utility (EQ-5D-3L), and health care resource use. Analyses followed the intention-to-treat principle, accounted for clustering by course in the intervention arm, and used multiple imputation for missing or incomplete primary outcome data. The mean age of participants was 59.9 y, with 81% white, 67% female, 23% employed, 85% with pain for at least 3 y, and 23% on strong opioids. Symptoms of depression and anxiety were common (baseline mean HADS scores 7.4 [standard deviation 4.1] and 9.2 [4.6], respectively). Overall, 282 (70%) intervention participants met the predefined intervention adherence criterion. Primary outcome data were obtained from 88% of participants. There was no significant difference between groups in pain-related disability at 6 or 12 mo (12 mo: difference -1.0, intervention versus control, 95% CI -4.9 to 3.0), pain intensity, or the census global health question. Anxiety, depression, pain-related self-efficacy, pain acceptance, and social integration were better in the intervention group at 6 mo; at 12 mo, these differences remained statistically significant only for depression (-0.7, 95% CI -1.2 to -0.2) and social integration (0.8, 95% CI 0.4 to 1.2). Intervention participants received more analgesics than the controls across the 12 mo. The total cost of the course per person was £145 (US$214). The cost-utility analysis showed there to be a small benefit in terms of quality-adjusted life years (QALYs) (0.0325, 95% CI -0.0074 to 0.0724), and on the cost side the intervention was a little more expensive than usual care (i.e., £188 [US$277], 95% CI -£125 [-US$184] to £501 [US$738]), resulting in an incremental cost-effectiveness ratio of £5,786 (US$8,521) per QALY. Limitations include the fact that the intervention was relatively brief and did not include any physical activity components. CONCLUSIONS: While the COPERS intervention was brief, safe, and inexpensive, with a low attrition rate, it was not effective for reducing pain-related disability over 12 mo (primary outcome). For secondary outcomes, we found sustained benefits on depression and social integration at 6 and 12 mo, but there was no effect on anxiety, pain-related self-efficacy, pain acceptance, pain intensity, or the census global health question at 12 mo. There was some evidence that the intervention may be cost-effective based on a modest difference in QALYs between groups. TRIAL REGISTRATION: ISRCTN Registry 24426731.

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

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

[Relations with emergency medical care and primary care doctor, home health care].

Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

Any qualified provider: a qualitative case study of one community NHS Trust's response.

OBJECTIVE: To examine how those managing and providing community-based musculoskeletal (MSK) services have experienced recent policy allowing patients to choose any provider that meets certain quality standards from the National Health Service (NHS), private or voluntary sector. DESIGN: Intrinsic case study combining qualitative analysis of interviews and field notes. SETTING: An NHS Community Trust (the main providers of community health services in the NHS) in England, 2013-2014. PARTICIPANTS: NHS Community Trust employees involved in delivering MSK services, including clinical staff and managerial staff in senior and mid-range positions. FINDINGS: Managers (n=4) and clinicians (n=4) working within MSK services understood and experienced the Any Qualified Provider (AQP) policy as involving: (1) a perceived trade-off between quality and cost in its implementation; (2) deskilling of MSK clinicians and erosion of professional values; and (3) a shift away from interprofessional collaboration and dialogue. These ways of making sense of AQP policy were associated with dissatisfaction with market-based health reforms. CONCLUSIONS: AQP policy is poorly understood. Clinicians and managers perceive AQP as synonymous with competition and privatisation. From the perspective of clinicians providing MSK services, AQP, and related health policy reforms, tend, paradoxically, to drive down quality standards, supporting reconfiguration of services in which the complex, holistic nature of specialised MSK care may become marginalised by policy concerns about efficiency and cost. Our analysis indicates that the potential of AQP policy to increase quality of care is, at best, equivocal, and that any consideration of how AQP impacts on practice can only be understood by reference to a wider range of health policy reforms.