Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality.

STUDY OBJECTIVE: Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DESIGN: Time Series of prospectively recorded and historical data. SETTING: Academic tertiary care medical center and health system. PATIENTS: 449 patients undergoing elective primary hip surgery. INTERVENTIONS: For the intervention group we redesigned care with a comprehensive 14-16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MEASUREMENTS: The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. MAIN RESULTS: Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). CONCLUSIONS: A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

Are patients receiving health promotion advice in the chiropractic teaching clinic setting?: an impact assessment of a brief intervention to increase advising rates and goal setting.

PURPOSE: The aim of this study was to analyze patient-reported health issues and levels of engagement, discussion of needed lifestyle changes, and goal setting with the patient's intern or staff doctor before and after a brief intervention to increase health-promoting activities in the clinic. METHODS: Patient surveys were developed and administered to outpatients before and after a brief intervention aimed at increasing staff and intern engagement with patients on health promotion measures. Patients self-reported areas of need and levels of engagement by their doctor or intern. Data were analyzed as pre- and postintervention independent, cross-sectional samples. Frequencies and chi-square assessments were performed. RESULTS: One hundred twenty-eight preintervention surveys and 162 postintervention surveys were collected. Back pain was the most common reason for being seen in the clinic (60% of patients) and most patients were white. More than 10% were smokers in both samples. Many patients reported poor diet, unhealthy weight, sleep issues, stress, or lack of regular physical activity, but 65% of the preintervention group and 72% of the postintervention group said a needed lifestyle change was discussed. Goals were set for 74% of the preintervention group and 84% of the postintervention group (p = .04). Information on lifestyle change was received by 52% of preintervention patients and 62% of postintervention patients and most were satisfied with this information. Goal setting was more common when a lifestyle change was discussed. Written information that was related to physical activity, for example, increased 350% (p < .0001). CONCLUSION: There are many opportunities for discussing needed lifestyle changes with patients. Patients self-report health behavioral issues related to physical activity, unhealthy weight, diet, stress, and sleep. More can be done in this area by this clinic, but initial assessments of impact from a brief intervention seem to have increased some levels of engagement by interns.

Health promotion practices in two chiropractic teaching clinics: does a review of patient files reflect advice on health promotion?

PURPOSE: To retrospectively review patient files in two teaching clinics in the United States and to assess the documented attempts to deliver health promotion messages when a chart indicated a need for health promotion or a red-flag condition that could be helped with positive behavioral changes. METHODS: Approximately 100 patient files were randomly selected from each of two separate chiropractic teaching clinics, for patients seen after January 2007. Files were assessed for pertinent family history of diseases, personal medical history, and red-flag conditions of patients that would warrant intervention with health promotion. RESULTS: Health promotion advice on at least one occasion was noted in 108 (53.7%) patient charts. Only 7 of 98 overweight or obese patients and none of those with family history of obesity were advised on weight management. Among 23 hypertensive patients, only 5 were advised and 17 of the 97 patients with risk of cardiovascular disease were advised. CONCLUSION: Chiropractic teaching clinics should assess what they are doing to help Americans reach their health goals. There is an opportunity to shape future practitioners so they include primary prevention as a part of what they do if the profession cares to move in that direction. Future research should look at mechanisms of delivery for health promotion, including better tracking of patients who need it and how staff doctors are trained to deliver oversight to interns in the area of primary prevention.

Salud en zonas urbanas de America Latina y del Caribe / Health in urban areas of Latin America and the Caribbean

Dentro del contexto global del desarrollo urbano, los problemas de salud tienen características que estan estrechamente asociadas con los numerosos efectos adversos para la salud de los habitantes de los centros urbanos. En este artículo se sugieren enfoques para los programas y proyectos que podrían establecer los países con la cooperación financiera y técnica de la OPS y de otras instituciones como los organismos de financiación internacionales y bilaterales