Telenephrology: An Emerging Platform for Delivering Renal Health Care.

Electronic-based health care delivery systems are gaining popularity among patients and clinicians because of convenience. Importantly, telemedicine, the delivery of health care and/or health information using electronic systems, can deliver primary and specialized health care to geographically isolated patients, who account for nearly 20% of the US population. In nephrology, where a growing discrepancy exists between the geographic location of nephrologists and patients with kidney disease, telenephrology can bridge distance and deliver renal care and education to the isolated. Large nationalized health care systems, for which incentives are aligned to innovate and implement new platforms to deliver cost-effective care, have been at the forefront of telenephrology. These systems include synchronous direct physician-patient care through clinical videoconferencing, and asynchronous modalities such as electronic consultation and video telehealth to educate internists about specialized clinical topics. Large health care organizations are adopting these platforms as standalone services; however, expansion into the private health care system has been limited by reimbursement, regulations, and other issues. Though telenephrology is patient centered, studies are needed to rigorously test its clinical efficacy and cost-effectiveness. Nonetheless, growing patient demand for patient-centric health care will continue to expand the telenephrology space.

Patient preferences tug hospital spending toward outpatient facilities.

Hospital systems have begun in earnest to shift more of their capital spending to outpatient facilities to provide more cost-effective and convenient settings for consumers.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

[Organisation of headache units from a multidisciplinary point of view]. / Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.

Headache units have come into being to respond to the need to address the treatment of patients with complex headaches in a multidisciplinary manner. Although headaches are one of the most prevalent medical pathologies, it is surprising how little is being done to foster the development of such units. Within the multidisciplinary organisation, the role of the neurologist with adequate training in this field is essential. He or she is the person responsible for receiving, directing, supervising and coordinating the treatment, together with other medical specialties. The basic core of the team should consist of a psychiatrist, psychologist and physiotherapist. Their joint coordinated action generates an objective improvement in the pain over and beyond that achieved with each isolated treatment.

TITLE: Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.Las unidades de cefaleas surgen ante la necesidad de abordar de forma multidisciplinar el tratamiento de pacientes con dolores de cabeza complejos. A pesar de que las cefaleas son una de las patologias medicas mas prevalentes, es llamativa la poca promocion que existe para su desarrollo. Dentro de la organizacion multidisciplinar, el papel del neurologo debidamente formado en este campo es crucial. Es la persona encargada de recibir, dirigir, supervisar y coordinar el tratamiento, junto con otras especialidades medicas. Se debe contar con la participacion del psiquiatra, del psicologo y del fisioterapeuta como nucleo basico. Su actuacion conjunta y coordinada genera de forma objetiva una mejoria del dolor frente a cada tratamiento de forma aislada.

Study of outpatient neurological care in the Region of Madrid: The impact of implementing free choice of hospital.

INTRODUCTION: A new model permitting free choice of hospital has been introduced in the Region of Madrid. This may result in changes in how outpatient neurological care is provided and managed. The purpose of this study is to analyse initial visits to a general neurology department in the Region of Madrid and record the health district corresponding to each patient's residence. METHODS: Observational and prospective study of a cohort of patients making initial outpatient visits to a neurology department between 16 September 2013 and 16 January 2014. RESULTS: The study included 1109 patients (63.8% women, mean age 55.2±20.5). The most frequent diagnostic groups were periodic headache, cognitive disorders, and neuromuscular diseases. Non-neurological diseases were diagnosed in 1.1% of the cases. The mean time of delay was 7.2±5.1 days. Residents within the hospital's health district made up 73.8% of the total, while 26.2% chose a hospital outside of the health district corresponding to their residences. In the latter group, 59.5% made the choice based on the level of care offered, while 39.7% changed hospitals due to shorter times to consultation. The patients who came from another health district were younger (50.7 vs 57.3, P<.0001) and had a lower rate of discharges on the first visit (16.4% vs 30.1%, P<.0001). CONCLUSION: The model of free choice of hospital delivers significant changes in healthcare management and organisation. Reasons given for choosing another hospital are more ample experience and shorter delays with respect to the home district hospital. Management of patients from outside the health district is associated with greater complexity.

The T1D Exchange clinic registry.

CONTEXT: The T1D Exchange includes a clinic-based registry, a patient-centric web site called Glu, and a biobank. OBJECTIVE: The aim of the study was to describe the T1D Exchange clinic registry and provide an overview of participant characteristics. DESIGN: Data obtained through participant completion of a questionnaire and chart extraction include diabetes history, management, and monitoring; general health; lifestyle; family history; socioeconomic factors; medications; acute and chronic diabetic complications; other medical conditions; and laboratory results. SETTING: Data were collected from 67 endocrinology centers throughout the United States. PATIENTS: We studied 25,833 adults and children with presumed autoimmune type 1 diabetes (T1D). RESULTS: Participants ranged in age from less than 1 to 93 yr, 50% were female, 82% were Caucasian, 50% used an insulin pump, 6% used continuous glucose monitoring, and 16% had a first-degree family member with T1D. Glycosylated hemoglobin at enrollment averaged 8.3% and was highest in 13 to 25 yr olds. The prevalence of renal disease was ≤4% until T1D was present for at least 10 yr, and retinopathy treatment was ≤2% until T1D was present for at least 20 yr. A severe hypoglycemic event (seizure or coma) in the prior 12 months was reported by 7% of participants and diabetic ketoacidosis in the prior 12 months by 8%. CONCLUSIONS: The T1D Exchange clinic registry provides a database of important information on individuals with T1D in the United States. The rich dataset of the registry provides an opportunity to address numerous issues of relevance to clinicians and patients, including assessments of associations between patient characteristics and diabetes management factors with outcomes.

The effects of safety net hospital closures and conversions on patient travel distance to hospital services.

OBJECTIVE: To examine the effects of safety net hospital (SNH) closure and for-profit conversion on uninsured, Medicaid, and racial/ethnic minorities. DATA SOURCES/EXTRACTION METHODS: Hospital discharge data for selected states merged with other sources. STUDY DESIGN: We examined travel distance for patients treated in urban hospitals for five diagnosis categories: ambulatory care sensitive conditions, referral sensitive conditions, marker conditions, births, and mental health and substance abuse. We assess how travel was affected for patients after SNH events. Our multivariate models controlled for patient, hospital, health system, and neighborhood characteristics. PRINCIPAL FINDINGS: Our results suggested that certain groups of uninsured and Medicaid patients experienced greater disruption in patterns of care, especially Hispanic uninsured and Medicaid women hospitalized for births. In addition, relative to privately insured individuals in SNH event communities, greater travel for mental health and substance abuse care was present for the uninsured. CONCLUSIONS: Closure or for-profit conversions of SNHs appear to have detrimental access effects on particular subgroups of disadvantaged populations, although our results are somewhat inconclusive due to potential power issues. Policy makers may need to pay special attention to these patient subgroups and also to easing transportation barriers when dealing with disruptions resulting from reductions in SNH resources.

A census of movement disorders at a Thai university hospital.

There is little information available on the number of patients with movement disorders seen by physicians in Thailand. The authors reviewed the medical records of all movement disorders patients seen at the Chulalongkorn Comprehensive Movement Disorders Center (CUMDS) in Bangkok, Thailand over a 4.5-year period to determine the number of patients with movement disorders and disease characteristics. A total of 1993 patients were assessed at CUMDS. Most of these patients had a diagnosis of parkinsonism (72%), including Parkinson's disease (PD) (60.9%), followed by tremor (9.6%), and dystonia (8.4%). The diagnostic accuracy of PD according to United Kingdom Parkinson's Disease Society Brain Bank clinical diagnostic criteria was 90.3%. The average referral period waiting for the consultation was more than 2 years. In spite of the limited availability of medical resources in Thailand, patients with movement disorders tend to seek specialist care and most often it is indicated. This finding documents the need for awareness of PD and other movement disorders by health professionals in Thailand, including the need for specialized training in movement disorders for physicians, including neurologists.

Hospital care and capacity in the tri-state region of Indiana, Kentucky, and Ohio: analysis and insights.

Hospitals are a significant part of the burgeoning healthcare sector in the United States (U.S.) economy. Despite the availability of what some describe as the world's best healthcare, the U.S. suffers from wide discrepancies in healthcare provision across hospitals and regions of the country. Specifically, capacity, utilization, quality, and even financial performance of hospitals vary widely. Based on secondary data from 533 hospitals in the adjoining states of Indiana, Kentucky, and Ohio, this study develops several comparative metrics that enable benchmarking, which, in turn, leads to several inferences and implications for hospital administrators. The paper concludes with implications for hospital administrators and suggestions for future research.

Facilities for investigating occupational asthma in UK non-specialist respiratory departments.

BACKGROUND: The facilities which should be available to physicians offering specialist occupational asthma services have recently been agreed upon by a UK panel of experts. AIMS: This study aimed to investigate whether these facilities are available in UK non-specialist secondary care respiratory departments and to document tertiary care referral patterns. METHODS: A random sample of 100 UK respiratory units was selected, and the lead consultant invited to participate. Face-to-face interviews were conducted to document information on departmental facilities available for investigating cases of occupational asthma and utilization of tertiary referral centres. RESULTS: In total, 66% of consultants interviewed had seen a case of occupational asthma in the previous month, and 76% reported having ever referred a patient with suspected occupational asthma to a specialist centre for further investigation (referral distance range 1-111 miles). All the departments were able to perform the investigations previously deemed an absolute necessity in all patients. The availability of in-house facilities that were deemed as must be available varied between 3-100%. CONCLUSIONS: The results of this study demonstrate that while the majority of basic facilities are widely available, many respiratory departments do not have direct access to investigations routinely required to investigate occupational asthma. Access to specialist occupational respiratory centres varies within the UK, and in some parts of the country involves long travelling distances for patients.

Number of freestanding EDs up, helping ease overcrowding, serving rural areas.

Freestanding EDs must look and act exactly like the ED in the main facility to meet Medicare requirements. Facilities must be open 24 hours a day with trained nursing and matching physician credentials. Specialty on-call panel must include the same physicians as the one used by main ED. Moving patients into your main hospital is a direct admit, not an Emergency Medical Treatment and Labor Act-covered transfer.

Plan de servicios individualizados (PSI): experiencia en L'hospitalet de Llobregat. Barcelona

El 2 de Diciembre de 2002 comenzó a funcionar el Plan de Servicios Individualizados (PSI) que depende de Benito Menni CASM. El programa lo llevan a cabo dos trabajadoras sociales, una educadora y una enfermera que atienden aproximadamente a unas cuarenta personas de toda la ciudad de L'Hospitalet de Llobregat. Este nuevo servicio está ubicado en un despacho dentro del Centro de Salud Mental de Adultos de L'Hospitalet. Aún y así, el programa es móvil y el uso del despacho es para guardar registros, elaborar documentación, reunirse el equipo.El PSI es un nuevo dispositivo asistencial de carácter comunitario y específico para la atención de personas que cumplen criterios de Trastornos Mentales Severos, con grave repercusión social e inadecuada utilización de servicios, que por sus características, necesitan una mayor adaptación de los servicios sanitarios y/o sociales a sus necesidades concretas. Los usuarios acceden al programa de forma voluntaria, a través de una orientación terapéutica realizada tanto desde las unidades de hospitalización (Agudos/ subagudos del CASM Benito Menni y Unidad de psiquiatria de la Ciudad Sanitaria de Bellvitge), como desde el CSMA de L'Hospitalet y Unidad de Salud Mental de Collblanc.El PSI con una intervención flexible, individualizada y participativa, intenta favorecer la implicación del usuario en su propia recuperación, y la vinculación del mismo a los recursos comunitarios que mejor puedan cubrir sus necesidades, mejorando así su calidad de vida. A través del acompañamiento a servicios y coordinación de los mismos, junto con una tarea psicoeducativa continuada en el entorno del usuario, se pretende potenciar su máxima autonomía. Se atenderá a estos usuarios hasta que, de forma autónoma, puedan continuar el seguimiento en los servicios ambulatorios u otros dispositivos comunitarios que le correspondan (AU)

International pediatric emergency care: establishment of a new specialty in a developing country.

BACKGROUND: Emergency medicine is being established as a unique and independent specialty throughout the world. Pediatric emergency medicine, however, is a relatively new subspecialty in the United States and a newer subspecialty in the rest of the world. In most of Europe and Asia, this specialty has yet to be developed. OBJECTIVE: To analyze the establishment of a new pediatric emergency care system in a developing country and identify areas of need and potential collaboration. SETTING: Pristina University Hospital, the main academic medical center in Kosovo, Federal Republic of Yugoslavia. METHODS: Data were collected using convenience sample surveys of all emergency visits in 2001, hospital admissions, health department statistics, and interviews with government officials and healthcare providers. RESULTS: Emergency care of children in Kosovo is provided by three parallel 24-hour clinic systems. During 2001, approximately 31,000 children sought emergency care (10,000 in the pediatric clinic, 5000 in an emergency facility, and 16,000 in the infectious disease clinic). There was no coordination or cooperation between these different facilities. No attempt was made to diagnose acute otitis media or urinary tract infection in young children. No records were kept. No physician in this study had pediatric emergency medicine and/or emergency medicine training. Prehospital providers had limited equipment and training. CONCLUSIONS: Hospital clinic systems in this environment provide high-volume and often a high level of acute care. Barriers to improved care include limited specialized training, lack of coordination between departments, and failure to establish a medical records system.