Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria / Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care

Objetivo. Conocer la prevalencia de pacientes crónicos complejos en el ámbito de Atención Primaria utilizando los criterios de pluripatología y los Clinical Risk Groups y el grado de concordancia entre estos 2 sistemas de identificación de los pacientes que precisan gestión de caso. Material y método. Estudio observacional transversal de 240 pacientes, seleccionados por muestreo aleatorio de 16 cupos asistenciales de 2 centros de salud de Atención Primaria de un área sanitaria. Solicitado consentimiento informado para acceder a su historia clínica electrónica con fines de investigación. Se registró la edad, el sexo, el estado de salud según los Clinical Risk Groups, nivel de gravedad, los criterios de pluripatológico e índice de Charlson por su médico durante la práctica clínica. Se excluyeron 3 pacientes por datos incompletos. Resultados. La prevalencia de pacientes pluripatológicos, siguiendo los criterios del Ministerio de Sanidad entre los demandantes, fue del 4,1% (IC 95% 2,1-7,3). La frecuencia de pacientes con Clinical Risk Groups de alto riesgo denominados G3 en la estrategia de cronicidad de la Comunidad Valenciana fue del 7,5% (IC 95% 4,7-11,7), que sumó los pacientes estado de salud 6 con nivel de complejidad 5 y 6 y los estados de salud 7, 8 y 9. La concordancia entre ambas clasificaciones fue baja con un índice kappa 0,17 (IC 95% 0-0,5). Conclusiones. Las prevalencias no difirieron significativamente de lo esperado y la concordancia entre ambas estratificaciones fue muy débil, no seleccionando a los mismos pacientes de alta complejidad para gestión de casos (AU)

Objective. To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. Material and method. A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. Results. The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5). Conclusions. The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management (AU)

The role of the long-term acute care hospital.

Long-term acute care hospitals (LTACHs) have a niche role in the health care system. They specialize in caring for patients who are ventilator-dependent, are on inpatient dialysis, or have multi-organ or multi-system failure, postsurgical or organ transplant complications, complex wounds that need care, or traumatic or acquired brain injury. Many physicians are unfamiliar with the work done by the interdisciplinary teams that serve these facilities.This article describes LTACHs and their approach to care.

[Medium-term strategy for the specific management of pneumology hospitals and wards after the decentralization of the sanitary system]. / Strategie pe termen mediu privind managementul specific al spitalelor si sectiilor de pneumologie dupa descentralizarea sistemului de sanatate.

Identifying and promoting new management techniques for the descentralized pneumology hospitals or wards was one of the most ambitious objectives of the project "Quality in the pneumology medical services through continuous medical education and organizational flexibility", financed by the Human Resourses Development Sectorial Operational Programme 2007-2013 (ID 58451). The "Medium term Strategy on the specific management of the pneumology hospitals or wards after the descentralization of the sanitary system" presented in the article was written by the project's experts and discussed with pneumology managers and local authorities representatives. This Strategy application depends on the colaboration of the pneumology hospitals with professional associations, and local and central authorities.

Medicare program; prospective payment system for long-term care hospitals RY 2008: annual payment rate updates, and policy changes; and hospital direct and indirect graduate medical education policy changes. Final rule.

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The final payment amounts and factors used to determine the updated Federal rates that are described in this final rule were determined based on the LTCH PPS rate year July 1, 2007 through June 30, 2008. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and continue to be effective each October 1. The final outlier threshold for July 1, 2007, through June 30, 2008, is derived from the LTCH PPS rate year calculations. We are also finalizing policy changes which include revisions to the GME and IME policies. In addition, we are adding a technical amendment correcting the regulations text at Sec. 412.22.

Medicare program; prospective payment system for long-term care hospitals: annual payment rate updates, policy changes, and clarification. Final rule.

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined based on the LTCH PPS rate year July 1, 2005 through June 30, 2006. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2005 through June 30, 2006 is also derived from the LTCH PPS rate year calculations. We are adopting new labor market area definitions for the purpose of geographic classification and the wage index. We are also making policy changes and clarifications.

[Survey of hemodialysis inpatients in long-term care facilities].

OBJECTIVE: In Japan, the number of elderly patients on hemodialysis has markedly increased in recent years. We conducted a survey to confirm the current status of inpatient hemodialysis patients and dialysis facilities with the aim of providing better care. MATERIAL AND METHODS: The subjects were 57 dialysis patients admitted to the Jishu Hospital for three consecutive months or longer as of February 2004. The survey was conducted by obtaining informed-consent from the patients and their families. The patients were interviewed and a questionnaire was sent to their families. The survey items were as follows; 1) patient characteristics, 2) domestic status, 3) physical and mental condition and 4) awareness concerning the hospital. RESULTS: The survey showed that dementia is present in almost all elderly hemodialysis patients and they require some degree of assistance for the activities of daily living. In addition, 57.9% patients had already been admitted to or had visited two or more hospitals. The current status of inpatients had improved slightly. Although the period of hospitalization was longer than one year in 64.9% of respondents, it had decreased by around 13% in comparison with that in the previous survey at 1997. These results were considered to be caused by increases in inpatient dialysis facilities, aging-related deaths, and by patients switching to home care after discharge because of the higher economic burden. In the interview, some patients were satisfied with inpatient life, but about one half of the patients said they wanted home care. Key caregivers for patients are mainly middle-aged or older family members (> 50 years old), indicating that caregivers are aging. On the other hand, the present study showed that hospitalization provides advantages for family life, such as improvements in peace of mind, life rhythm, leisure time and physical condition. CONCLUSION: Since the aging of dialysis patients results in a decrease in physical activity and progression of dementia, long-term hospitalization has a high potential to induce bedridden patients. In addition to the requirement for more long-term facilities, efforts should be made to improve physical activities and inhibit the progression of dementia.

Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics.

The Ryan White CARE Act supports comprehensive care to persons with HIV infection. With an annual budget of over $1 billion, it is the largest federally funded programme for HIV care in the USA. We analysed data from the HIV Costs and Services Utilization Study, a nationally representative sample of HIV patients. Patient data were collected in 1996-97 and clinic data were collected in 1998-99. We examined whether CARE Act funded clinics differed from other HIV clinics in (1) the characteristics of their patients, and (2) their organization, staffing, and services. We found that patients at CARE Act clinics were younger, less educated, poorer, and more likely to be female, non-white, unemployed, uninsured, and have heterosexual contact as an HIV risk factor, compared to patients at other HIV clinics. CARE Act clinics tended to specialize in HIV care, had more infectious disease specialists, had fewer total patients, and provided more support services (e.g. mental health, nutrition, case management, child care). These results are consistent with findings of other studies that were limited by non-probability samples or restricted geographical areas.

Characteristics of Ryan White and non-Ryan White funded HIV medical care facilities across four metropolitan areas: results from the Antiretroviral Treatment and Access Studies site survey.

The Ryan White Comprehensive AIDS Resources Emergency Act 1990 (CARE Act) is one of the largest federal programmes funding medical and support services for individuals with HIV disease. Data that report services and gaps in service coverage from the organizational perspective are very limited. The Antiretroviral Treatment and Access Studies included a mail survey of 176 HIV medical care facilities in four US inner cities on clinic characteristics, services and practices, and patient characteristics. Characteristics of 143 (85%) responding Ryan White (RW) funded and non-RW funded facilities are described. RW funded facilities reported offering more services than non-funded facilities including evening/weekend hours (49% vs. 18%), transportation (71% vs. 22%), and on-site risk reduction counselling (88% vs. 55%). More RW funded facilities reported offering on-site adherence support services, such as support groups (44% vs. 12%), formal classes (20% vs. 2%), and pillboxes (83% vs. 43%), and served a larger proportion of uninsured patients (41% vs. 4%) than non-funded facilities. Our analysis showed that the RW funded HIV care facilities offered more clinic, non-clinic, and adherence support services than non-RW funded facilities, indicating that the disparities in services were still related to CARE Act funding, controlling for private-public facility type.

Medicare program; prospective payment system for long-term care hospitals: annual payment rate updates and policy changes. Final rule.

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined based on the LTCH PPS rate year. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2004 through June 30, 2005 is also derived from the LTCH PPS rate year calculations. In this final rule, we also are making clarifications to the existing policy regarding the designation of a satellite of a LTCH as an independent LTCH. In addition, we are expanding the existing interrupted stay policy and changing the procedure for counting days in the average length of stay calculation for Medicare patients for hospitals qualifying as LTCHs.

Comparisons of the cost-effectiveness among hospital chronic care, nursing home placement, home nursing care and family care for severe stroke patients.

AIM: This study compared the cost and effectiveness of long-term institutional care and home care for stroke patients with severe physical disabilities. BACKGROUND: Whether home care is more economical or effective than institutional care for patients with chronic illnesses remains controversial when the cost of family labour is considered. Thus, decisions concerning the appropriate type of care setting for patients with severe chronic illness remain difficult. METHODS: From November 1995 to March 1996, 313 hospitalized stroke patients with severe physical disabilities treated at one of five hospitals in the Taipei metropolitan area were followed from the day of hospital discharge until the third month after discharge. These 313 patients were divided into four groups as follows: (1) 106 who were admitted to a chronic care unit in a hospital, (2) 60 who were admitted to nursing homes, (3) 60 who received professional home nursing care and (4) 87 who returned home without receiving professional care. The change of physical functional status in the patient was examined as the difference between activities of daily living (ADL) scores measured at discharge and at the end of the third month after discharge. RESULTS: Information on family costs for caregiving, including pay for long-term services utilized, labour costs for caregiving and out-of-pocket expenditures for miscellaneous materials was obtained during a weekly telephone interview. The results indicated that caring for patients in their own homes was not only more expensive but was also less effective in improving ADL scores than caring for patients in nursing homes and in chronic care units of hospitals. CONCLUSIONS: The results suggest that caring for patients with severe physical disabilities in institutions is more appropriate than caring of them at home.

Long-term care hospitals under Medicare: facility-level characteristics.

Though accounting for only a small percentage of total Medicare spending, long-term care hospitals (LTCHs) (defined as having an average length of stay [LOS] of 25 days or more) have been growing, in number and in Medicare expenditures, at a rapid rate in recent years. Because they have not been widely studied, we conducted research to describe the characteristics of this increasingly important Medicare provider type. We found that most LTCHs specialize in the provision of respiratory care or rehabilitation. Information from this study can help inform the development of a Medicare prospective payment system for LTCHs.

Economic impact of feeding a phenylalanine-restricted diet to adults with previously untreated phenylketonuria.

The aim of the present study was to estimate the direct healthcare cost of managing adults with previously untreated phenylketonuria (PKU) for one year before any dietary restrictions and for the first year after a phenylalanine- (PHE-) restricted diet was introduced. The resource use and corresponding costs were estimated from medical records and interviews with health care professionals experienced in caring for adults with previously untreated PKU. The mean annual cost of caring for a client being fed an unrestricted diet was estimated to be 83 996 pound silver. In the first year after introducing a PHE-restricted diet, the mean annual cost was reduced by 20 647 pound silver to 63 348 pound silver as a result of a reduction in nursing time, hospitalizations, outpatient clinic visits and medications. However, the economic benefit of the diet depended on whether the clients were previously high or low users of nursing care. Nursing time was the key cost-driver, accounting for 79% of the cost of managing high users and 31% of the management cost for low users. In contrast, the acquisition cost of a PHE-restricted diet accounted for up to 6% of the cost for managing high users and 15% of the management cost for low users. Sensitivity analyses showed that introducing a PHE-restricted diet reduces the annual cost of care, provided that annual nursing time was reduced by more than 8% or more than 5% of clients respond to the diet. The clients showed fewer negative behaviours when being fed a PHE-restricted diet, which may account for the observed reduction in nursing time needed to care for these clients. In conclusion, feeding a PHE-restricted diet to adults with previously untreated PKU leads to economic benefits to the UK's National Health Service and society in general.