Home and community care for older people in urban China: Receipt of services and sources of payment.

This study investigates the characteristics of Chinese older people receiving home and community care and the factors associated with the sources of payment for care services. The data come from the Social Survey of Older People in Urban China, which collected information from a random sample of 3,247 older people aged 60 and over in 10 large cities in different regions of China in 2017. Anderson's behavioural model of care utilisation is used to guide the analyses. The study identifies four striking features of the Chinese social care system. First, although disabilities are a significant predictor of receiving home and community care, a large proportion of care recipients do not have disabilities. Second, perceived proximity of care is the most important predictor, which implies high elasticity of demand for care services with regard to perceived distance and the great geographical inequality of care resources in the cities. Third, the government policies support the use of the internet to facilitate care access, but the enabling effect of the internet among older people is limited. Finally, sources of payment for care differ significantly according to people's age, living arrangements, disability and level of education. We argue that the government should consider shifting the focus of financial support from service providers to care recipients in the future.

Estimating the health-care costs of wound care in Ireland.

OBJECTIVE: To estimate the cost of wound care to the Irish health-care system. METHODS: A bottom-up, prevalence-based analysis was undertaken using a decision analytic model to estimate costs. Health-care resource activity was identified from a recently published study from the UK and was valued using unit cost data for Ireland. RESULTS: The base case analysis estimated the total annual healthcare cost of wound care to be €629,064,198 (95% Confidence interval (CI): €452,673,358 to €844,087,124), accounting for 5% (95% CI: 3% to 6%) of total public health expenditure in Ireland in 2013. The average cost per patient was €3,941 (95% CI: €2,836 to €5,287). However, this study is subject to many limitations and plausible changes in the model's inputs showed that the total annual health-care cost of wound care could range from €281,438,970 to €844,316,912. CONCLUSION: Caring for wounds places a substantial burden on the Irish health-care system. In light of growing pressures to finance an already resource-constrained health-care system, these results provide useful information for those charged with future wound care service design and provision in Ireland and elsewhere.

The sustainability of a community nurses programme aimed at supporting active ageing in mountain areas.

BACKGROUND: Community Nurse Supporting Elderly iN a changing SOciety is a project funded by the European Union, which is aimed at developing an innovative care model based on community nurses to support active ageing in mountain areas. The planned sustainability of this innovative approach relies on social entrepreneurship, and this work highlights the necessary conditions for the existence of these entrepreneurial initiatives on the market, with community nurses' services purchased by the public health care system. METHODS: The authors propose a sustainability framework for this project based on three relevant dimensions (ie, health, organisation, and context), highlighting the necessary conditions for continued provision of health services beyond project conclusion. Then, considering the Piedmont Region and those aged 65 or older as target population, health outcomes are analysed, proposing a break-even analysis to calculate expected levels. RESULTS: According to our results, in order to care for 191 977 elderly people for 3 years, a successful pro-active approach is needed to prevent 1657 falls with hip fracture, reducing the prevalence of this adverse outcome by 36%. These are the expected health outcome levels for the existence of a social market, which can be achieved through the successful involvement of local public health organisations and stakeholders. CONCLUSIONS: Policy makers need clear information on the economic impact of extending this new intervention to the whole target population and on the required preconditions for its financial sustainability in terms of health outcomes. However, a participatory process involving all relevant local stakeholders and organisations is crucial to extend current achievements beyond project conclusion.

Urinary catheter-related visits to the emergency department and implications for community services.

Thousands of patients live with urinary catheters and the potential complications deriving from long-term use. Disjointed community services may result in patients attending the emergency department (ED) to manage catheter complications. AIM: to conduct a service review of catheterised patients attending the ED of a large London hospital; to describe incidence, reasons for attendance and cost to inform future planning for out-of-hospital care. METHOD: a catheter collaborative, consisting of multidisciplinary health professionals and patients, formulated survey questions. Patients were identified from the electronic patient record by searching for the code 'urological complaint'. One month of clinical records were retrospectively reviewed and analysed using descriptive statistics. RESULTS: 287 patients attended the department with urological complaints: 41 (14%) had urinary catheter problems, of these 24 (59%) patients were discharged and 17 (41%) were admitted for further treatment. Stays in ED varied from 1 hour 13 minutes to 17 hours (mean = 4.8 hours). A total of 9 patients (38%) were sent home during antisocial hours (9 pm to 7 am), 4 patients were discharged between midnight and 2 am. Patients admitted had mean stays of 4.11 days. Most admissions were short term for intravenous (IV) treatments; 3 patients were hospitalised for 20 days. A total of 14 patients (34%) were diagnosed with catheter-related infections: 11 (79%) had bladder infections and 3 (21%) had septicaemia. All 14 patients (100%) had urine-culture-confirmed infections, mainly from coliform, proteus and pseudomonas species. A total of 20 patients (49%) received antibiotic treatment. The majority of patients received an initial IV dose followed, where required, by oral treatment on discharge. CONCLUSIONS: many catheterised patients had complex needs with high rates of urinary infections and admissions for urosepsis. High attendance related less to old age but more to complexity of history, such as neurological conditions and disability. Only a proportion of these patients could be safely treated by district nurse teams. A significant proportion would require more responsive community services with several spells of short-term input (e.g. daily or more than once-daily visits) and access to diagnostics, microbiology, pharmaceutical input and IV treatments.

Cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people: Results of a cluster randomized trial.

OBJECTIVE: To evaluate the cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people in comparison with usual care. METHODS: We conducted cost-effectiveness and cost-utility analyses alongside a cluster randomized trial with one-year follow-up. Participants were aged ≥ 70 years and at increased risk of functional decline. Participants in the intervention group (n = 1209) received a comprehensive geriatric assessment and individually tailored multifactorial interventions coordinated by a community-care registered nurse with multiple follow-up visits. The control group (n = 1074) received usual care. Costs were assessed from a healthcare perspective. Outcome measures included disability (modified Katz-Activities of Daily Living (ADL) index score), and quality-adjusted life-years (QALYs). Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated using bootstrapped bivariate regression models while adjusting for confounders. RESULTS: There were no statistically significant differences in Katz-ADL index score and QALYs between the two groups. Total mean costs were significantly higher in the intervention group (EUR 6518 (SE 472) compared with usual care (EUR 5214 (SE 338); adjusted mean difference €1457 (95% CI: 572; 2537). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.14 at a willingness to pay (WTP) of EUR 50,000 per one point improvement on the Katz-ADL index score and 0.04 at a WTP of EUR 50,000 per QALY gained. CONCLUSION: The current intervention was not cost-effective compared to usual care to prevent or postpone new disabilities over a one-year period. Based on these findings, implementation of the evaluated multifactorial nurse-led care model is not to be recommended.

El gasto sanitario en las diferentes comunidades autónomas de España / Health expenditure in the different Autonomous Communities of Spain

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Trusted family help.

As a health visitor for 42 years, Carolyn Taylor is well qualified to say that the job provides the opportunity to improve people's lives. 'For someone who wants to make a difference to how children are brought up and protected, it's as rewarding a profession as it's always been,' says the Sunderland health visitor.

IV antibiotic therapy in the community: clinically effective and cost effective.

This article discusses how the introduction of new ways of working has resulted in a more cost-effective service for the delivery of intravenous (IV) antibiotic therapy in a community setting. When community IV therapy was originally initiated in the trust, the system involved two nurses to check calculations and oversee the administration of IV antibiotic therapy. However, as the demand for IV therapy escalated, and with some patients requiring multiple visits, pressures on community nursing teams created challenges relating to capacity and demand. This service improvement project involved two phases. Phase one examined patient safety and the administration of IV antibiotics by one nurse. Phase two reviewed the administration of IV antibiotic via a timed bolus route. Following the analysis, the implementation of these initiatives demonstrated maximisation of resources, a release of nurses' time to care and improvements to the patient experience.

Multicentre observational study of outcomes after drainage of acute perianal abscess.

INTRODUCTION: Management of perianal abscesses has remained largely unchanged for over 50 years. The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost. METHODS: Patients were recruited in 15 UK centres between December 2013 and October 2014. Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in ano and health utility scores (EQ-5D™). Pain was measured before, during and after dressing change on a visual analogue scale. RESULTS: Some 141 patients were recruited (median age 39 (range 18-86) years). The mean number of dressing changes in the first 3 weeks was 13 (range 0-21), equating to an annual cost to the National Health Service of €6 453 360 in England alone per annum. Some 43·8 per cent of wounds were healed by 8 weeks after surgery and 86 per cent of patients had returned to normal function. Some 7·6 per cent of abscesses had recurred and 26·7 per cent of patients developed a fistula in ano by 6 months following surgery. Patients reported a twofold to threefold increase in pain scores during and after dressing changes. CONCLUSION: Recurrent abscess is rare and fistula occurs in one-quarter of the patients. Packing is painful and costly.

Community Engagement: Leveraging Resources to Improve Health Outcomes.

Improving the health of communities requires creating partnerships and leveraging partner resources. Engagement with key stakeholders or partners who engage in collaborative community needs assessments has been linked to improved community health outcomes. Understanding how to engage community stakeholders, identify mutual goals, and establish a shared vision can maximize resources to improve the community's health. We applied our experience to an existing model for community engagement and leveraging of resources to improve the community's health and translate the model to a community case.

Vulnerabilidad socioeconómica en un vecindario como determinante de la utilización y frecuentación de servicios sanitarios / The socio-economic vulnerability in a neighborhood determines the use and frequentation of health services

Objetivo: Analizar en un entorno comunitario la relación entre vulnerabilidad socioeconómica y utilización y frecuentación de servicios sanitarios, usando una aproximación multidimensional del concepto de vulnerabilidad. Material y Métodos: Estudio transversal en adultos del barrio de Casablanca (Zaragoza). Se seleccionó una muestra representativa de 1032 personas mediante muestreo aleatorio estratificado. Mediante encuesta se obtuvo información sociodemográfica del estado de salud y utilización de servicios sanitarios. Se clasificó a los individuos como vulnerables en función del nivel educativo, ocupación e ingresos. Se describió el uso de servicios y perfil de los usuarios. Se estudiaron los determinantes socioeconómicos de utilización y frecuentación con análisis de regresión recogiendo la vulnerabilidad mediante sus tres componentes clave y un indicador agregado. Resultados: El 30% de los residentes en Casablanca habían tenido contacto con los servicios sanitarios durante las dos últimas semanas. El perfil de usuario fue: mujer, =60 años, con mala salud percibida y alguna enfermedad diagnosticada. Las personas vulnerables visitaron más al médico que las no vulnerables, con especial impacto en hombres. Existieron diferencias entre la utilización de indicadores de vulnerabilidad por separado y combinados, tanto para predecir la consulta médica como la frecuentación. Un bajo nivel de estudios y la inactividad económica reforzaron en varones la probabilidad de visita médica, mientras que la vulnerabilidad socioeconómica frenó la frecuentación. Conclusiones: Aunque las personas vulnerables visitaron más al médico que las no vulnerables, no trabajar o tener bajos ingresos se correlacionó con una menor frecuencia de visitas, principalmente en mujeres y edades medias de la vida (AU)

Objectives: To analyze the association between socioeconomic vulnerability and use and frequentation of health care attention in a neighbourhood, by using a multidimensional operative definition of socioeconomic vulnerability. Material and Methods: A transversal survey was implemented in Casablanca neighborhood (Zaragoza, Spain). 1032 people were selected by stratified random sampling. Information about demographic and socioeconomic characteristics, health perceived status and health care visits was obtained using a personal survey. Formal educational level, employment status and income level were integrated in unique classification criteria (socioeconomic vulnerability). Health care visits and user profile were described. Socioeconomic determinants of use and frequentation of health care services were studied by regression methods, controlled by three independent measures of socioeconomic vulnerability and by a single integrative indicator. Results: 30% Casablanca neighbors used health care resources during the two weeks previous to the interview. The user profile was: women, older than 60 years, with low self-rated health and diagnosed illnesses. Vulnerable people used medical resources with higher frequency than non-vulnerable people did, and a higher association was found in men. Statistically significant differences could be observed among the three socioeconomic independent measures, and the integrative unique vulnerability measure. For men, low formal educational level and unemployment predicted health care visit. However, socioeconomic vulnerability does not imply greater demand for health care. Conclusions: Although vulnerable people used with higher frequency the sanitary services than the non-vulnerable, unemployment and low income was correlated with a low frequency of visits, mainly in women and middle aged (AU)

Comparison of sole nurse and team-delivered community clozapine services for people with treatment-resistant schizophrenia.

AIM: To compare sole nurse and doctor-led multidisciplinary team delivery of community clozapine services for people with treatment-resistant schizophrenia. BACKGROUND: Around 20% of people with schizophrenia are treatment resistant and fail to respond to front line medications. Clozapine, a second-line treatment, has potentially serious side effects requiring regular monitoring. Different models of community clozapine services are emerging in the British National Health Service, but there is little evidence about which is best. DESIGN: Questionnaire survey of service users. METHODS: All patients on the lists of seven clozapine clinics (four sole nurse, three multidisciplinary team) in one trust were invited to participate, 2009-2010. Forward stepwise regression was used to investigate associations between patient well-being, functioning, self-efficacy and satisfaction, and clinic model attended, controlling for socio-demographic and health characteristics and processes of care. Use (and costs) of other health and social services accessed was compared between models. RESULTS: Sixty-six service users (35% participation rate) responded. Well-being and functioning were associated with patient characteristics and processes of care, not clinic model. Patients managed by sole nurses reported, over 3 months: more community psychiatric nurse visits and hospital psychiatrist appointments. Clinic list size affects costs per patient. CONCLUSIONS: Multidisciplinary team delivery may reduce use of other services. Although multidisciplinary team delivery is regarded as best practice, sole nurses can effectively provide clozapine services and may be warranted in areas of low population density.