A Community-Based Model to the COVID-19 Humanitarian Crisis.

A multidisciplinary group, mainly from Bergamo region - the epicenter of the COVID-19 pandemic crisis in Italy on march 2020- has developed concept of creating intermediate care facilities and proposes a three-tier model of community-based care, with the goal of reducing hospital admissions, contagion and mortality related to hospital overloading and optimizing human resources.

The impact of different types of informal caregiving on cognitive functioning of older caregivers: Evidence from a longitudinal, population-based study in Germany.

STUDY AIM: This study's aim was to investigate the influence of different caregiving types on cognitive functioning of caregivers aged 65 years and older longitudinally and to look at potential gender differences in this association. METHOD: Data from the German Ageing Survey, a longitudinal population-based study assessing community-dwelling people in Germany, was used. Our sample consisted of participants 65 years and older (waves 2008, 2011 and 2014; N = 6560). Informal caregiving was assessed in terms of three caregiving types (help around the house, looking after someone, performing nursing care services). An adaption of the widely used Digit Symbol Substitution Test was used to assess cognitive function. RESULTS: Fixed-effects regressions demonstrated a positive association of looking after someone with cognitive functioning (ß = 1.90, p < .01). There was no significant association of help around the house (ß = 0.96, p = .22) or performing nursing care services (ß = 2.12, p = .09) with cognitive function. Stratifying for gender, we found this effect of looking after someone on cognitive functioning only in women (ß = 2.82, p < .01), but not in men (ß = 1.00, p = .23). The other caregiving types showed no significant association with cognitive function, neither in men (helping around the house: ß = 0.20, p = .85; performing nursing care services: ß = 1.16, p = .52), nor in women (helping around the house: ß = 1.67, p = .13; performing nursing care services: ß = 2.88, p = .09). CONCLUSIONS: Results indicate that informal caregiving, in terms of looking after someone, can be beneficial for cognitive function, at least for female caregivers. Thus, we recommend to consider caregiving types when investigating informal caregiving and cognitive function. Furthermore, we recommend to focus support more on other outcomes, particularly for female caregivers.

Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study.

OBJECTIVE: To show how segmentation can enhance risk stratification tools for integrated care, by providing insight into different care usage patterns within the high-risk population. DESIGN: A retrospective cohort study. A risk score was calculated for each person using a logistic regression, which was then used to select the top 5% high-risk individuals. This population was segmented based on the usage of different care settings using a k-means cluster analysis. Data from 2008 to 2011 were used to create the risk score and segments, while 2012 data were used to understand the predictive abilities of the models. SETTING AND PARTICIPANTS: Data were collected from administrative data sets covering primary and secondary care for a random sample of 300 000 English patients. MAIN MEASURES: The high-risk population was segmented based on their usage of 4 different care settings: emergency acute care, elective acute care, outpatient care and GP care. RESULTS: While the risk strata predicted care usage at a high level, within the high-risk population, usage varied significantly. 4 different groups of high-risk patients could be identified. These 4 segments had distinct usage patterns across care settings, reflecting different levels and types of care needs. The 2008-2011 usage patterns of the 4 segments were consistent with the 2012 patterns. DISCUSSION: Cluster analyses revealed that the high-risk population is not homogeneous, as there exist 4 groups of patients with different needs across the care continuum. Since the patterns were predictive of future care use, they can be used to develop integrated care programmes tailored to these different groups. CONCLUSIONS: Usage-based segmentation augments risk stratification by identifying patient groups with different care needs, around which integrated care programmes can be designed.

Identification of the palliative phase in people with dementia: a variety of opinions between healthcare professionals.

BACKGROUND: People with dementia can benefit from a palliative care approach. Recommendations, such as those of the EAPC have been proposed to strengthen the provision of palliative care for this group of patients. Yet, it remains challenging for professionals to identify when a person with dementia is in need of palliative care. The objective of this study therefore was to explore when professionals in long-term care settings consider a person with dementia in need of palliative care. METHODS: Teams with in total 84 professionals working in 13 long-term care settings from 6 countries (France, Germany, Italy, Norway, Poland and the Netherlands) received a case-vignette concerning a person with dementia recently admitted to a nursing home. Teams were asked to discuss when they considered people with dementia eligible for palliative care. The constant comparative method was used to analyse their answers. RESULTS: Three different time points in the disease trajectory when people with dementia were considered to be eligible for palliative care were extracted: (1) early in the disease trajectory; (2) when signs and symptoms of advanced dementia are present; and (3) from the time point that curative treatment of co-morbidities is futile. Yet, none of these time points was uniformly considered by the professional teams across Europe. In some cases, professionals working in the same nursing home didn't even reach consensus when considering persons with dementia eligible for palliative care. CONCLUSION: The results of the study identified that professionals across Europe have different opinions regarding the time point when to consider a person with dementia in need of palliative care.

Patient care complexity as perceived by primary care physicians.

INTRODUCTION: Currently there are various definitions of patient care complexity with little consensus. The numbers of patients with complex care needs are increasing. To improve interventions for "complex patients" and appropriately reimburse healthcare providers it is important to determine the characteristics or contextual factors contributing to complexity. METHOD: Action research methods were used to enhance an explicit understanding of complexity. Several conferences were organized and primary care physicians, nurses, social science faculty, and patients shared their perspectives on patient care complexity. A subset of attendees created a complex patient screening tool, which was piloted by 12 primary care physicians with 267 patients to identify which factors contribute to complexity. RESULTS: Complex patients were found to differ significantly from noncomplex patients based on factors associated with complexity. Based on latent class analysis, 58% of complex patients were characterized by multiple diagnoses, mental health issues, and a lack of effective participation in their care plans, while 42% of patients were considered complex because of multiple diagnoses only. In contrast, 90% of the noncomplex patients had no discernable pattern of health issues, while 10% of noncomplex patients had mental health and insurance issues that were easily managed. These results identify several factors that distinguish patients with complex care needs from those without complex care needs. The results also illustrate the heterogeneity within classes of patients identified as having complex care needs or non-complex needs. DISCUSSION: By identifying factors contributing to complexity, this research has important implications for enhancing the management of patients with complex care needs.

The use of a comparability scoring system in reporting observational studies.

The traditional statistical analyses with adjustment for confounders in observational studies assume that there is perfect similarity in the already-provided medical management between the comparison groups. However, variations in medical management frequently exist because of differences in circumstances of health care. We propose that to minimize the selection bias of observational studies, the degree of similarity or dissimilarity of the comparison groups regarding the circumstances of health care should be considered. Circumstances of health care include the geographic setting, health care setting, type of health care providers, and likelihood in having confounding introduced by differences in the medical management between comparison groups. We propose a comparability scoring system of circumstances of care and provide examples of the application of this system, using recent literature to assess comparability among study groups. In our examples, the presupposed statistical associations disappeared once the analyses accounted for the differences in circumstances of care. Authors of submitted manuscripts using an observational study design may consider incorporating our scoring system or an equivalent in their methods and in reporting of the results. The comparability score should be factored during statistical analysis so that the appropriate analysis can correct for differences in circumstances of care. The use of a comparability scoring system can provide important insights for reviewers and readers that will improve the interpretation of this type of research study.

A medida do músculo adutor do polegar está associada com indicadores antropométricos de avaliação de massa magra e de massa gorda em pacientes hospitalizados / Adductor pollicis muscle measure is associated with anthropometric indicator of muscle mass and fat mass of hospitalized patients

Nutritional assessment is essential to diagnose and correct nutritional status, thus reducing hospital costs and mortality due to malnutrition. A new technique to evaluate the muscular compartment is the assessment of the adductor pollicis muscle thickness. It is a simpler alternative compared to the anthropometric parameters presently used. The objective of this research was to verify the association of the adductor policis muscle thickness with the anthropometric and subjective parameters of hospitalized patients, and subsequently, identify a cutoff point to be used as indicator of nutritional status. One hundred twelve patients hospitalized in the Medical and Surgical Clinic of a University Hospital in the countryside of the State of Sao Paulo were evaluated. The patients were submitted to nutritional assessment using the following parameters: subjective global assessment, classic anthropometry, and measurement of the adductor pollicis muscle thickness. The sample consisted mostly of patients with cardiovascular diseases (30.4%). The nutritional status of patients was characterized according to body mass index on prevalence of overweight and obesity (53.6%) and subjective global assessment of patients classified as nourished (72.3%). The mean thickness of the adductor pollicis muscle was 12.4±5.1mm. The adductor policis muscle thickness was weakly associated with anthropometric and subjective measures and failed to identify the cutoff point as an indicator of nutritional status, since the majority of the patients assessed presented overweight and obesity.

La evaluación nutricional es fundamental para diagnosticar y corregir el estado nutricional, reduciendo así los costos hospitalarios y la mortalidad, derivados de la desnutrición. Una nueva técnica para evaluar el compartimiento muscular consiste en evaluar la espesura del músculo aductor del pulgar (EMAP), que resulta una alternativa tan o más simple que los parámetros antropométricos utilizados actualmente. El objetivo de este estudio fue investigar la asociación de la espesura del músculo aductor del pulgar con parámetros antropométricos y subjetivos de pacientes hospitalizados, y la posterior identificación de un punto de corte a ser usado como indicador del estado nutricional. Se evaluaron 112 pacientes hospitalizados en la Clínica Médica y Clínica Quirúrgica de un Hospital Universitario del interior paulista. Los pacientes fueron sometidos a evaluación nutricional, utilizándose la medida de espesura del músculo aductor del pulgar, la evaluación subjetiva global y la antropometría clásica. La muestra estaba compuesta en su mayoría por pacientes con enfermedades cardiovasculares (30,4%). El estado nutricional de los pacientes se caracterizó, de acuerdo con el índice de masa corporal, por la prevalencia de sobrepeso y obesidad (53,6%) y, de acuerdo con la evaluación subjetiva global, por pacientes clasificados como bien nutridos (72,3%). El promedio de espesura del músculo aductor del pulgar para la muestra total fue de 12,4±5,1mm. El EMAP presentó asociación débil con los indicadores antropométricos y subjetivos, aunque no fue posible determinar un punto de corte del EMAP para su uso como indicador de estado nutricional, como consecuencia de la gran proporción de sobrepeso y obesidad en la población estudiada.

A avaliação nutricional é fundamental para se diagnosticar e corrigir o quadro nutricional, reduzindo-se assim os custos hospitalares e a mortalidade decorrentes da desnutrição. Uma nova técnica para avaliar o compartimento muscular é a avaliação da espessura do músculo adutor do polegar que surge como uma alternativa tão ou mais simples frente aos parâmetros antropométricos já utilizados. O objetivo do trabalho foi verificar a associação da espessura do músculo adutor do polegar com parâmetros antropométricos e subjetivos de pacientes hospitalizados e, posteriormente, identificar um ponto de corte a ser utilizado como indicador do estado nutricional. Foram avaliados 112 pacientes internados nas enfermarias de Clínica Médica e Clínica Cirúrgica de um Hospital Universitário do interior paulista. Os pacientes foram submetidos à avaliação nutricional, sendo utilizada a medida da espessura do músculo adutor do polegar, a avaliação subjetiva global e a antropometria clássica. A amostra foi constituída, na sua maioria, por pacientes com doenças cardiovasculares (30,4%). O estado nutricional dos pacientes caracterizou-se, segundo o índice de massa corporal, por prevalência de sobrepeso e obesidade (53,6%) e, segundo a avaliação subjetiva global, de pacientes classificados como bem nutridos (72,3%). A média da espessura do músculo adutor do polegar para o total da amostra foi de 12,4±5,1mm. A EMAP apresentou fraca associação com os indicadores antropométricos e subjetivos, não sendo possível determinar um ponto de corte do EMAP para a classificação do estado nutricional, tendo em vista a grande proporção de sobrepeso e obesidade na população estudada.

Preventive care strategies based on disease prevalence among Japanese urban elderly: focus on disease prevention in mildly frail elders with long-term care insurance.

AIM: To investigate the relationship between prevalent diseases and medical conditions in frail elderly in Japan who require lighter levels of care in order to improve preventive care strategies. METHODS: Data from Japanese long-term care insurance (LTCI) documentation was used to investigate the relationship between the prevalence of diseases and medical conditions among 553 frail elderly people (193 men and 360 women) over 65 years old in a central area of Osaka prefecture. Logistic regression analysis was used to determine the associations among related diseases and main medical conditions in the lightest levels of care required. RESULTS: With age, the prevalence of hypertension, heart disease, dementia, and fractures increased, whereas neoplasms, cerebrovascular disease, and diabetes mellitus decreased. Neoplasms and circulatory disease were significantly more common in men, and musculoskeletal disease and injury were more common in women among main medical conditions requiring light care. Diseases significantly associated with the lightest level of care were hyperlipidemia (odds ratio 3.0), osteoporosis without fracture (1.9), and gonarthrosis (1.7) in women. CONCLUSIONS: Efforts to control musculoskeletal diseases and lifestyle diseases are essential preventive care strategies, especially in the preliminary stages of care under LTCI. Previously proven measures such as the cancer screening, intensive blood pressure control, continuous nutritional management, and thorough diabetes treatment beginning in middle age can help to prevent fractures, cancer, cerebrovascular disease, and dementia, all of which severely erode quality of life.

Characterizing medical care by disease phase in metastatic colorectal cancer.

OBJECTIVE: To characterize patterns of medical care by disease phase in patients with newly diagnosed metastatic colorectal cancer (mCRC). METHODS: Patients with mCRC newly diagnosed between 2004 and 2008 were selected from a large US national commercially insured claims database and were observed from initial mCRC diagnosis to death, disenrollment, or end of study period (July 31, 2009), whichever occurred first. The observation period was divided into 3 distinct phases of disease: diagnostic, treatment, and death. Within each phase, patterns of medical care were examined by the mutually exclusive service categories of inpatient, emergency department (ED), outpatient office and facility, outpatient pharmacy, chemotherapy, and biologic therapy, as measured by estimation of aggregate and category costs per patient per month. RESULTS: A total of 6675 patients with newly diagnosed mCRC were analyzed. Mean age was 64.1 years; 55.5% were males. Mean costs per patient per month for diagnostic, treatment, and death phases were $16,895, $8891, and $27,554, respectively. Inpatient care was the primary driver of medical care for both the diagnostic (41.7% of costs) and death (71.4% of costs) phases. The largest category of medical care for the treatment phase was outpatient care (45.0% of costs). Chemotherapy and biologic therapy accounted for 15.6% and 17.6% of costs in the treatment phase, respectively. CONCLUSION: Substantial differences in patterns of medical care were found between mCRC disease phases. Inpatient care was the key driver of medical care in the diagnostic and death phases compared with outpatient care in the treatment phase.

Incidence and types of non-ideal care events in an emergency department.

AIM: To identify and characterise hazardous conditions in an Emergency Department (ED) using active surveillance. METHODS: This study was conducted in an urban, academic, tertiary care medical centre ED with over 45,000 annual adult visits. Trained research assistants interviewed care givers at the discharge of a systematically sampled group of patient visits across all shifts and days of the week. Care givers were asked to describe any part of the patient's care that they considered to be 'not ideal.' Reports were categorised by the segment of emergency care in which the event occurred and by a broad event category and specific event type. The occurrence of harm was also determined. RESULTS: Surveillance was conducted for 656 h with 487 visits sampled, representing 15% of total visits. A total of 1180 care giver interviews were completed (29 declines), generating 210 non-duplicative event reports for 153 visits. Thirty-two per cent of the visits had at least one non-ideal care event. Segments of care with the highest percentage of events were: Diagnostic Testing (29%), Disposition (21%), Evaluation (18%) and Treatment (14%). Process-related delays were the most frequently reported events within the categories of medication delivery (53%), laboratory testing (88%) and radiology testing (79%). Fourteen (7%) of the reported events were associated with patient harm. CONCLUSIONS: A significant number of non-ideal care events occurred during ED visits and involved failures in medication delivery, radiology testing and laboratory testing processes, and resulted in delays and patient harm.

Clinical events classification for using the EHR to provide better patient care.

The Healthcare Record has been used in a "Before and After" situation to improve patient care. The main paradigm of the modern Health Care is changing towards pervasive person-centric care including prevention and home care. Medical compunetics is a very important applicative field for improving the interoperability and the quality of the healthcare information system, especially in the current climate with the empowerment patients. The success depends on the choice of the Clinical Events Classification for structuring the span of clinical information. For the purposes of universalizing medical electronic data-bases, it is very important to organize the data regarding Clinical Events in such manner that it would be possible to use this information-structure in different fields of Clinical Practice: e.g., for the creation of the diagnostic and drug-assistance protocols, for the evaluation of the quality of drug prescribing, and for communication with patients as well. For this purpose all Clinical Events were divided to 5 classes. This Paper will describe a "Before and After" situation consequent upon the introduction of the Clinical Events Classification and the introduction of Protocols for drug-prescribing. Use of the Protocol brought about a 50% reduction in mortality.

Evaluation of risk factor management of patients treated on an internal nephrology ward: a pilot study.

BACKGROUND: The objectives of this pilot study were to evaluate treatment quality for the risk factors of hypertension, diabetes and hyperlipidemia as well as the overall treatment quality for patients on an internal nephrology ward. This evaluation included the collection of data concerning the quality of therapeutic drug monitoring, drug use and potential drug-drug interactions. Establishing such baseline information highlights areas that have a need for further therapeutic intervention and creates a foundation for improving patient care, a subject that could be addressed in future clinical pharmacy research projects. METHODS: Medical charts of patients treated on a single internal nephrology ward were retrospectively evaluated using a predefined data collection form. Assessment of further need for therapeutic intervention was performed. RESULTS: For 76.5% (n = 78) of the total study population (n = 102), there was either a possibility (39.2%, n = 40) or a need (37.3%, n = 38) for further intervention based on the overall assessment. For the risk factors of hypertension, diabetes and hyperlipidemia, the proportions of patients that require further intervention were 78.8% (n = 71), 90.6% (n = 58) and 87.9% (n = 58), respectively. Patients with diabetes or hyperlipidemia were less likely to have optimal risk factor control. The number of drugs prescribed and the number of potential drug-drug interactions were significantly higher after in-hospital treatment. CONCLUSION: Risk factor treatment needs optimisation. Risk factor management, systematic medication reviews, and screening for and management of potential drug-drug interactions deserve great attention. Clinical pharmacy services could help in the achievement of treatment goals.