Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

A surgical needs assessment for airway rapid responses: A retrospective observational study.

BACKGROUND: Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS: A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS: A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION: Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.

Beneficios de la evaluación integral en adultos mayores con dolores crónicos de columna en un centro periférico del conurbano bonaerense / Benefits of the comprehensive evaluation in older adults with chronic back pain, in a peripheral medical center of the Buenos Aires suburbs

Introducción. Desde hace varios años, el abordaje de los pacientes adultos mayores que consultan por dolor crónico en un centro periférico del Hospital Italiano del conurbano bonaerense se realiza de manera integral, mediante la evaluación conjunta de una kinesióloga y un médico de familia, lo que facilita la indicación terapéutica individualizada, con la aplicación de estrategias cognitivo-conductuales. Objetivo. Documentar los resultados clínicos luego de una evaluación integral de pacientes mayores de 60 años que consultaron por dolor crónico de columna refractarios a tratamientos monodisciplinarios. Métodos. Estudio observacional, analítico tipo antes-después, prospectivo. Recolectamos variables descriptivas de los participantes al momento de la evaluación integral (demográficas, antropométricas, contextuales y clínicas) y de desenlace: dolor, calidad de vida y actividad física a los tres y seis meses, consultas no programadas y a servicio de traumatología durante ese periodo. Estimamos necesaria una muestra de 30 pacientes, pero debido a la pandemia por SARS-CoV-2finalizamos precozmente el estudio con los pacientes reclutados hasta ese momento. Resultados. Incluimos nueve participantes (edad media 66,5 años, desviación estándar 4,9; 67 % sexo femenino). Todos completaron el seguimiento a seis meses. Observamos reducción del dolor y mejoría de la calidad de vida a los seis meses (cambio en la escala visual analógica [EVA] -3, intervalo de confianza [IC] 95 % -5,1 a -0,94; cambio en el puntaje del EQ-5D-3L 0,17, IC 95 % 0,08 a 0,26, respectivamente). Conclusión. En los pacientes adultos mayores de 60 años con dolor crónico de columna no oncológico evaluados de manera integral por un médico de familia y un kinesiólogo se observó una mejoría del dolor y la calidad de vida a los seis meses de seguimiento. Debido a que el diseño no incluyó un grupo control estas diferencias no pueden atribuirse de manera fehaciente a la intervención, aunque estos hallazgos son concordantes con los de ensayos previos. (AU)

Introduction. For several years, the approach of elderly patients who consult for chronic pain in a peripheral center ofthe Hospital Italiano de Buenos Aires has been carried out in a comprehensive way, through the joint evaluation of akinesiologist and a family doctor, which facilitates individualized therapeutic indication, with the application of cognitive-behavioral strategies.Objective. To document the clinical results after the comprehensive evaluation of patients over 60 years of age whoconsulted for chronic back pain refractory to monodisciplinary treatments. Methods. Observational, analytical, before-after, prospective study. We collected descriptive variables from the participantsat the time of the comprehensive evaluation (demographic, anthropometric, contextual and clinical) and outcome variables:pain, quality of life and physical activity at three and six months, unscheduled consultations and trauma service during thatperiod. We estimate that a sample of 30 patients is necessary, but due to the SARS-CoV-2 pandemic we ended the studyearly with the patients recruited up to that time. Results. We included nine participants (mean age 66.5 years, standard deviation 4.9; 67 % female). All completed the six-month follow-up. We observed reduction in pain and improvement in quality of life at six months (change in visual analogscale [VAS] -3, 95 % confidence interval [CI] -5.1 to -0.94; change in score of the EQ-5D-3L 0.17, 95 % CI 0.08 to 0.26,respectively). Conclusion. In adult patients over 60 years of age with chronic non-cancer back pain who were comprehensively evaluatedby a family doctor and a kinesiologist, an improvement in pain and quality of life was observed at six months of follow-up. Since the design did not include a control group, these differences cannot be reliably attributed to the intervention, althoughthese findings are consistent with those of previous trials. (AU)

Development of claims-based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care.

OBJECTIVE: To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays. DATA SOURCES: Medicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices. STUDY DESIGN: Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+ data. PRINCIPAL FINDINGS: Repeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions. CONCLUSIONS: This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.

Analysis of the first 5 years of an interdisciplinary Rheumatology-Dermatology clinic.

BACKGROUND: Multispeciality clinics, such as combined psoriasis-psoriatic arthritis clinics, have shown improved outcomes in various diseases. At Massachusetts General Hospital, we are entering our ninth year of having an interdisciplinary Rheumatology-Dermatology (R-D) clinic. AIM: To evaluate the contribution of an R-D clinic by comparing care of patients pre- and post-evaluation in the combined clinic. As proxies of care, rates and comprehensiveness of evaluations (capillaroscopic examination, skin and joint examination) were compared between the combined clinic and standard Rheumatology or Dermatology clinic. METHODS: This was a retrospective chart review of patients at the R-D clinic in Massachusetts General Hospital during the period November 2012 to December 2017. RESULTS: Prior to the patients visiting the R-D only 5% of capillaroscopic examinations were documented, only 5% of rheumatologists specifically described a rash even when present, and pruritus was documented in only 6% of rheumatology notes. By contrast, in the R-D clinic, capillaroscopic, skin and joint examinations were documented in 100% of visits, and 19% of patients were given a different or a refined diagnosis. Although all our patients had cutaneous manifestations of their disease (hair loss, rash, itch, Raynaud phenomenon, ulcerations, calcinosis) only 34% had seen a dermatologist prior to the combined clinic and only 5% of those had had their concerns addressed by the rheumatologist. This suggests that 95% had a more complete evaluation and management of all aspects of their disease by attendance at the R-D clinic. CONCLUSION: Despite this study being limited by its retrospective nature, we found that it is an efficient model to achieve more comprehensive and potentially lower medication costs. Collaboration between dermatologists and rheumatologists in a combined clinic led to more complete skin and joint examinations, consistent tracking of capillaroscopic examination, better description of rash and improved management. Having this clinic helped in reaching a diagnosis and overall better disease control and outcome.

Readmission and complications after robotic surgery: experience of 10,000 operations at a comprehensive cancer center.

Evaluation of safety is of paramount importance with adoption of novel surgical technology. Although robotic surgery has become widely used in oncologic surgery, analysis of safety is lacking in comparison to traditional techniques. Standardized assessment of robotic surgical outcomes and adverse events following oncologic surgery is necessary for quality improvement with innovative technology. Between 2003 and 2016, 10,013 unique robotic operations were performed in 9,858 patients. Our prospectively maintained database was retrospectively reviewed for hospital readmissions and Clavien-Dindo grade ≥ 2 complications within 30 days. Multivariable logistic regression was used to identify predictors of surgical complications and hospital readmissions. Cases were stratified by discipline: genitourinary (n = 8240), gynecologic (n = 857), thoracic (n = 457), gastrointestinal (n = 322), hepatobiliary (n = 60), ear/nose/throat (n = 44) and general (n = 33). Intraoperative complications occurred in 42 surgeries (0.4%). Postoperative complications occurred in 946 patients [9.4%, highest grade 2 (n = 574), 3 (n = 288), 4 (n = 72), 5 (n = 10)]. Most frequent complications were ileus (154, 16.3%), anemia (91, 9.6%), cardiac arrhythmia (62, 6.6%), deep vein thrombosis/pulmonary embolus (47, 5.0%), wound infection (45, 4.8%) and urinary leak (43, 4.5%). 405 patients (4.0%) required readmission. Most common causes for hospital readmission were ileus (44, 10.9%), urinary leak (23, 5.7%), urinary tract infection (23, 5.7%), intra-abdominal abscess/fluid collection (23, 5.7%), and small bowel obstruction (19, 4.7%). On multivariable analysis, longer operative time and older age predicted complications and readmissions (p ≤ 0.02). Robotic-assisted surgery appears a safe for oncologic surgery with acceptable hospital readmission and complication rates. Older age and longer operative time were associated with complications and readmission.

Avaliação da integralidade na atenção primária à saúde da criança na perspectiva dos cuidadores / Assessment of comprehensiveness in children's primary health care as seen by caregivers / Evaluación de la integralidad en la atención primaria de salud infantil según la perspectiva de los cuidadores

Objetivo: avaliar, sob a ótica do cuidador, o atributo da integralidade na atenção primária à saúde da criança no município de Porto Velho, Brasil. Método: estudo avaliativo, transversal realizado com 420 cuidadores de crianças atendidas em um hospital infantil em 2017. Utilizou-se o Primary Care Assessment Tool Brasil - versão criança e os dados foram analisados pelo software Statistic 13.0. A pesquisa foi aprovada pelo Comitê de Ética e Pesquisa. Resultados: na avaliação das dimensões do atributo integralidade, o escore médio dos serviços disponíveis (4,67) e dos serviços prestados (5,26) à criança mostrou baixa orientação para a atenção primária à saúde, principalmente no que tange às orientações recebidas pelos profissionais, sobre crescimento, segurança, benefícios sociais, problemas visuais e de comportamento da criança. Conclusão: o atributo integralidade na saúde da criança está presente, porém de forma fragmentada, necessitando que os serviços revejam as prioridades nos cuidados à criança junto ao familiar/cuidador.

Objective: to assess, from the caregiver's perspective, the comprehensiveness of children's primary health care in Porto Velho, Brazil. Method: in this evaluative, cross-sectional study of 420 caregivers at a children's hospital in 2017, the Primary Care Assessment Tool Brazil ­ children's version was used and data were analyzed using Statistic 13.0 software. The research was approved by a research ethics committee. Results: in evaluation of dimensions of comprehensiveness, children's services available scored an average of 4.67 and services provided, 5.26, showing poor orientation towards primary health care, particularly as regards the guidance received by health personnel on children's growth, safety, social benefits, eyesight and behavioral problems. Conclusion: comprehensive child health care is present, although fragmented, requiring that services review child care priorities with family members/caregivers.

Objetivo: evaluar, desde la perspectiva del cuidador, la integralidad de la atención primaria de salud infantil en Porto Velho, Brasil. Método: en este estudio evaluativo, transversal de 420 cuidadores en un hospital infantil en 2017, se utilizó la Herramienta de Evaluación de Atención Primaria Brasil - versión infantil y los datos se analizaron mediante el software Estadística 13.0. La investigación fue aprobada por un comité de ética en investigación. Resultados: en la evaluación de las dimensiones de integralidad, los servicios disponibles para la infancia obtuvieron un promedio de 4,67 y los servicios prestados, 5,26, mostrando una mala orientación hacia la atención primaria de salud, particularmente en lo que respecta a la orientación que recibe el personal de salud sobre el crecimiento, la seguridad, los beneficios sociales, la vista del niño y problemas de comportamiento. Conclusión: la atención integral de la salud infantil está presente, aunque fragmentada, lo que requiere que los servicios revisen las prioridades del cuidado infantil con los miembros de la familia / cuidadores.

STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

Distress and problem assessment among people living with cancer from Culturally and Linguistically Diverse backgrounds.

OBJECTIVE: To examine whether routine assessment of distress, recommended as part of comprehensive cancer care, is utilised equally with culturally and linguistically diverse (CALD) vs non-CALD people living with cancer. METHODS: A medical records review of all patients attending cancer-specific treatment units at a single tertiary hospital in Melbourne, Australia between 2015-2018. Recording of administration of the Distress Thermometer and Problem Checklist (DT and PC) was extracted for all patients. Details regarding how the DT and PC (used together) was administered were extracted for a random sub-sample of 294 CALD patients and 294 matched non-CALD patients. RESULTS: A total of 6977 patients were identified (12.0% CALD). Just over half of the CALD (54.7%) and non-CALD (58.2%) patients had a recorded DT and PC (P > 0.05). For the sub-sample analysis, CALD patients were less likely to complete the form themselves (14.8% vs 75.9% non-CALD) and were more likely to have a family member complete the form (55.1% vs 15.1% non-CALD). CALD patients reported a similar level of distress to non-CALD patients. Distress scores for CALD and non-CALD patients were higher when family members completed the form. Provision of discussion, written information, referral offers and rates of referral acceptance were similar between CALD and non-CALD patients. CONCLUSIONS: Assessment of distress and associated problems, and the process following assessment, were similar for CALD and non-CALD patients. However, differences in how the form was completed highlight the need for further improvements to ensure that CALD patients are actively involved in their care.

Effective care management by Next Generation accountable care organizations.

OBJECTIVES: The objectives of this study were to estimate the utilization and spending impact of a standardized complex care management program implemented at 5 Next Generation accountable care organizations (NGACOs) and to identify reproducible program features that influenced program effectiveness. STUDY DESIGN: In 2016 and 2017, high-risk Medicare beneficiaries aligned to 5 geographically diverse NGACOs were identified using predictive analytics for enrollment in a standardized complex care management program. We estimated the program's impact on all-cause inpatient admissions, emergency department visits, and total medical expenditures (TME) relative to a matched cohort of nonparticipants. In a subanalysis, we studied the modifying effects of intervention fidelity on program impact. METHODS: We created 1897 propensity score-matched case-control pairs based on preprogram similarities in disease profile, predictive risk score, medical cost, and utilization. Changes in outcomes 6 months post program were measured using difference-in-differences analyses. We used principal components analysis to identify program features associated with reduced inpatient admissions, classified cases according to intervention fidelity, and measured postprogram changes in TME for each subgroup. RESULTS: Program participation was associated with a 21% reduction in all-cause inpatient admissions (P = .03) and a 22% reduction in TME (P = .02) 6 months after program completion. Relative spending reductions were 2.1 times greater for high-fidelity interventions compared with overall program participation (P < .001). CONCLUSIONS: Centrally staffed complex care management programs can reduce costs and improve outcomes for high-risk Medicare beneficiaries. Integrating predictive risk stratification, evidence-based intervention design, and performance monitoring can ensure consistent outcomes.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Evaluation of comprehensive care for older adults in primary care services.

OBJECTIVE: To evaluate the performance of comprehensive care for older adults in primary care services in the Brazilian Unified Health System in the state of São Paulo, Brazil. METHODS: A total of 157 primary care services from five health regions in midwestern São Paulo responded, from October to December 2014, the pre-validated 2014 questionnaire for primary care services assessment and monitoring. We selected 155 questions, based on national policies and guidelines on this theme. The responses indicate the service performance in older adults' care, clustered into three areas of analysis: health care for active and healthy aging (45 indicators, d1), chronic noncommunicable diseases care (89 indicators, d2), and support network in aging care (21 indicators, d3). Performance was measured by the sum of positive (value 1) or negative (value 0) responses for each indicator. Services were clustered according to k-means of the performance scores of each domain. After weighting the domains (Z tests), we estimated the associations between the scores of each domain and independent management variables (typology, planning and evaluation of services), with simple and multiple linear regression. RESULTS: Chronic noncommunicable diseases care (d2) showed, for all clusters, better average performance (55.7) than domains d1 (35.4) and d3 (39.2). Service performance in the general area of planning and evaluation associates with the performance of older adults' care. CONCLUSIONS: The evaluated services had incipient implementation of comprehensive care for older adults. The evaluation framework can contribute to processes to improve the quality of primary health care.

Evaluation of comprehensive care for older adults in primary care services / Avaliação da atenção integral ao idoso em serviços de atenção primária

ABSTRACT OBJECTIVE To evaluate the performance of comprehensive care for older adults in primary care services in the Brazilian Unified Health System in the state of São Paulo, Brazil. METHODS A total of 157 primary care services from five health regions in midwestern São Paulo responded, from October to December 2014, the pre-validated 2014 questionnaire for primary care services assessment and monitoring. We selected 155 questions, based on national policies and guidelines on this theme. The responses indicate the service performance in older adults' care, clustered into three areas of analysis: health care for active and healthy aging (45 indicators, d1), chronic noncommunicable diseases care (89 indicators, d2), and support network in aging care (21 indicators, d3). Performance was measured by the sum of positive (value 1) or negative (value 0) responses for each indicator. Services were clustered according to k-means of the performance scores of each domain. After weighting the domains (Z tests), we estimated the associations between the scores of each domain and independent management variables (typology, planning and evaluation of services), with simple and multiple linear regression. RESULTS Chronic noncommunicable diseases care (d2) showed, for all clusters, better average performance (55.7) than domains d1 (35.4) and d3 (39.2). Service performance in the general area of planning and evaluation associates with the performance of older adults' care. CONCLUSIONS The evaluated services had incipient implementation of comprehensive care for older adults. The evaluation framework can contribute to processes to improve the quality of primary health care.

RESUMO OBJETIVO Avaliar o desempenho da atenção integral ao idoso em serviços de atenção primária do Sistema Único de Saúde no estado de São Paulo, Brasi lMÉTODOS Um total de 157 serviços de atenção primária de cinco regiões de saúde do centro-oeste paulista respondeu, de outubro a dezembro de 2014, o instrumento pré-validado Questionário de Avaliação e Monitoramento de Serviços de Atenção Básica 2014. Foram selecionadas 155 questões, com base nas políticas e diretrizes nacionais sobre essa temática. As respostas indicam o desempenho do serviço na atenção ao idoso, agrupadas em três domínios de análise: atenção à saúde para o envelhecimento ativo e saudável (45 indicadores, d1), atenção às doenças crônicas não transmissíveis (89 indicadores, d2) e rede de apoio na atenção ao envelhecimento (21 indicadores, d3). A medida de desempenho foi a soma de respostas positivas (valor 1) ou negativas (valor 0) para cada indicador. Os serviços foram agrupados segundo k-médias dos escores de desempenho de cada um dos domínios. Após a ponderação dos domínios (testes Z), foram estimadas as associações entre os escores de cada domínio e variáveis independentes de gestão (tipologia, planejamento e avaliação dos serviços), por meio de regressão linear simples e múltipla. RESULTADOS A atenção às doenças crônicas não transmissíveis (d2) mostrou, para todos os agrupamentos, melhor desempenho médio (55,7) do que os domínios d1 (35,4) e d3 (39,2). O desempenho do serviço na área geral de planejamento e avaliação esteve associado ao desempenho da atenção ao idoso. CONCLUSÕES Os serviços avaliados apresentaram implementação incipiente da atenção integral ao idoso. O quadro avaliativo pode contribuir para processos de melhoria da qualidade da atenção primária à saúde.

Maternal and fetal outcomes of cesarean delivery and factors associated with its unfavorable management outcomes; in Ayder Specialized Comprehensive Hospital, Mekelle, Tigray, Ethiopia, 2017.

OBJECTIVES: This study aimed to determine the unfavorable outcomes and to assess factors contribute to the unfavorable management outcomes after cesarean deliveries in Ayder Specialized Comprehensive Hospital, Mekelle, Tigray, Ethiopia, 2017. RESULTS: The unfavorable maternal management outcomes were Adhesion 28 (8.3%), excessive blood loss and blood transfusion 19 (5.6%), cesarean hysterectomy 10 (3%), relaparotomy 5 (1.5%), wound infection and wound dehiscence 23 (6.8%). Unfavorable fetal outcomes were were stillbirth 9 (2.6%), early neonatal death 8 (2.4%), low birth weight 58 (17.2%). women who did not book for Antenatal Care and having a history of previous cesarean delivery were found to be associated with unfavorable maternal outcomes and indications of cesarean delivery as obstructed labor was associated with unfavorable fetal outcomes.

Primary care doctor and nurse utilisation rates for billed consultations across the Comprehensive Care Primary Health Organisation.

AIM: To examine socio-demographic trends in doctor and nurse utilisation rates for invoiced consultations across Comprehensive Care Primary Health Organisation (PHO). METHOD: De-identified enrolled patient information and Service Utilisation Reporting data for invoiced consultations were extracted from all general practices for January 2013-December 2016. Utilisation rates were calculated using the number of enrolled patients as the denominator. RESULTS: Data for 3,657,873 invoiced consultations across 66 general practices were analysed, including 2,941,624 doctor and 716,249 nurse consultations. Average utilisation rates were 3.1 visits per patient year for doctors and 0.7 visits for nurses, with considerable variability between practices. Utilisation rates were higher for females (3.3 visits for doctors; 0.8 for nurses), older adults (5.0-6.9; 1.3-1.6 visits) and patients residing in the most socially deprived quintile (3.3; 1.6 visits). European patients had the highest doctor utilisation rates (3.2 visits), while Maori and Pacific patients had the highest nurse utilisation rates (1.1 and 1.3 visits, respectively). CONCLUSION: Females, older adults and people residing in socially deprived areas utilise primary care more frequently according to invoiced consultation data. Analysis of all other consultations, including immunisations, Accident Corporation Claims and non-billed services is needed to more accurately capture utilisation rates, particularly for nurses, to better inform national decision-making, workforce planning and funding assumptions.

Comprehensive preventive care assessments for adults with intellectual and developmental disabilities: Part 2: 2003 to 2014.

OBJECTIVE: To determine if there has been an increase in preventive care among adults with intellectual and developmental disabilities (IDD) as a result of the publication of the Canadian consensus guidelines on the care of adults with IDD in 2006 and 2011. DESIGN: Ecological study. SETTING: Ontario. PARTICIPANTS: The study group consisted of community-dwelling adults with IDD between the ages of 40 and 64 living in Ontario identified in 2009-2010 through administrative health and social services data. The comparison group consisted of a propensity-score-matched sample of the remaining Ontario population. MAIN OUTCOME MEASURES: A combined measure of a health examination or a Primary Care Quality Composite Score (PCQS) of 0.6 or greater, or both. Both measures were identified using administrative health data. RESULTS: Adults with IDD were 2.04% more likely to have had a health examination or a PCQS of 0.6 or greater before 2011-2012 and 1.70% less likely after 2011-2012. Adults without IDD were 1.03% more likely before 2011-2012 and 13.74% less likely after 2011-2012 to have had a health examination or a PCQS of 0.6 or greater. Male patients with IDD were 15.60% more likely and male patients without IDD were 7.39% less likely to have had a health examination or PCQS of 0.6 or greater compared with female patients. CONCLUSION: Despite the publication of the guidelines there has not been a corresponding increase in the uptake of the annual health examination or in the quality of preventive care among adults with IDD. More is required to reduce this documented inequity in care.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery.

BACKGROUND: Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS: Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS: Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION: Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.

New approaches to measuring the comprehensiveness of primary care physicians.

OBJECTIVE: To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. DATA SOURCES AND STUDY SETTING: A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices. STUDY DESIGN: We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. PRINCIPAL FINDINGS: Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. CONCLUSIONS: These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.

Impact of stratification on the effectiveness of a comprehensive patient-centered strategy for multimorbid patients.

OBJECTIVE: The objective of this work was to assess the effectiveness of a population-level patient-centered intervention for multimorbid patients based on risk stratification for case finding in 2014 compared with the baseline scenario in 2012. DATA SOURCE: Clinical and administrative databases. STUDY DESIGN: This was an observational cohort study with an intervention group and a historical control group. A propensity score by a genetic matching approach was used to minimize bias. Generalized linear models were used to analyze relationships among variables. DATA COLLECTION: We included all eligible patients at the beginning of the year and followed them until death or until the follow-up period concluded (end of the year). The control group (2012) totaled 3558 patients, and 4225 patients were in the intervention group (2014). PRINCIPAL FINDING: A patient-centered strategy based on risk stratification for case finding and the implementation of an integrated program based on new professional roles and an extensive infrastructure of information and communication technologies avoided 9 percent (OR: 0.91, CI: 0.86-0.96) of hospitalizations. However, this effect was not found in nonprioritized groups whose probability of hospitalization increased (OR: 1.19, CI = 1.09-1.30). CONCLUSIONS: In a before-and-after analysis using propensity score matching, a comprehensive, patient-centered, integrated care intervention was associated with a lower risk of hospital admission among prioritized patients, but not among patients who were not prioritized to receive the intervention.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.