A professional and institutional organization based on the "Aller vers" dynamic / Un acteur professionnel et institutionnel fondé sur la dynamique du « Aller Vers ¼

The French Union for Oral Health (UFSBD) embodies a professional initiative in institutional form, based on the philosophy of "Aller vers" (going toward). Based on plural representation, it brings together a variety of dentists, who are representative of the diversity of practices, whether in urban or rural areas, as employees or independent practitioners, or in local practice or hospital contexts. Proximity to the public is the very essence of its action and gives it a good understanding of realities on the ground. Since its creation, the UFSBD has been engaged in an ever-evolving collective mission, adapting its efforts to the changing needs of society and citizens. Its bold approach goes beyond the traditional boundaries of dental practice, by reaching out to the most vulnerable people and those furthest from the health system. This translates into an inclusive, proactive, and local approach. This dynamic has played a decisive role in advocating, since the 1990s, the recognition of oral health as an essential component of general health. Despite the obstacles and the time required to change mentalities, the UFSBD persevered, particularly regarding the challenge that periodontal diseases represent for oral health. Challenges persist, particularly with regard to access to prevention for populations at risk, population aging, and the integration of oral health into overall care pathways. However, the main objective remains that oral health regains its place as an undeniable national priority. Indeed, the mouth is at the heart of general health and can play an essential transversal role in public health.

L'Union Française pour la Santé Bucco-dentaire (UFSBD) incarne une initiative professionnelle sous forme institutionnelle qui repose sur la philosophie du « Aller Vers ¼. Fondée sur une représentation plurielle, elle réunit une diversité de Chirurgiens-dentistes, qui sont représentatifs de la diversité des pratiques, que ce soit en milieu urbain ou rural, en tant que salariés ou praticiens libéraux, dans des contextes citadins ou hospitaliers. Cette proximité avec les populations est l'essence même de son action et lui donne une bonne vision des réalités de terrain. Depuis ses débuts, l'UFSBD s'est engagée dans une mission collective en constante évolution, adaptant ses efforts aux besoins changeants de la société et des citoyens. Son approche audacieuse dépasse les frontières traditionnelles des cabinets dentaires, en se lançant à la rencontre des populations les plus vulnérables et éloignées du système de santé. Cela se traduit par une approche inclusive, proactive et de proximité. Cette dynamique a joué un rôle déterminant en plaidant, depuis les années 90, pour la reconnaissance de la santé bucco-dentaire en tant que composante essentielle de la santé générale. Malgré les freins et le temps nécessaire des plaidoyers pour faire évoluer les mentalités, l'UFSBD a persévéré, en particulier dans le défi que représentent les maladies parodontales pour la santé bucco-dentaire. Des défis perdurent, notamment en ce qui concerne l'accès à la prévention pour les populations à risques, le vieillissement de la population et l'intégration de la santé bucco-dentaire dans les parcours de soins globaux. Cependant, l'objectif principal demeure que la santé bucco-dentaire retrouve sa place de priorité nationale incontestable. En effet, la bouche est au cœur de la santé générale et peut jouer un rôle transversal essentiel en santé publique.

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

BACKGROUND: Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS: This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS: 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS: A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

[Urban caregivers helping students]. / Les professionnels de santé libéraux au secours des étudiants.

In this period of pandemic, urban caregivers are directly concerned by the mental or social distress of students. In addition to university health services, psychologists through associations, social workers, doctors and nurses are listening to young people for individual situations, but sometimes also for group situations. So many access to health to propose to the suffering students as well as to their families.

Can increased vigilance for chronic kidney disease in hospitalised patients decrease late referral and improve dialysis-free survival?

BACKGROUND: Insufficient vigilance for renal insufficiency is associated with late referral, increased morbidity and mortality. The present study examines whether increased vigilance for chronic kidney disease (CKD) leads to quicker referral to and better follow-up by a nephrologist, and whether it is associated with an improved outcome. METHODS: Patients with an eGFR < 45 ml/min/1.73 m2 during hospitalisation at the Ghent University Hospital were enrolled during a period of 100 days. The patients were interviewed about their awareness of CKD. Both the patients and their general practitioner were subsequently informed about CKD. The primary endpoint was the number of patients referred for nephrological follow-up within three months. The secondary endpoint was need for dialysis and mortality from any cause one year after inclusion. RESULTS: Of the 72 included patients, 54 had proven CKD, with eGFR consistently < 45 ml/min/1.73 m2 during at least three months before inclusion. Merely 65% was aware of having CKD and only 41% was in regular nephrological follow-up. After intervention, the percentage of patients with CKD in follow-up increased from 41% to 71% (p = 0.002). The proportion reaching the secondary endpoint was significant lower in the patients who were referred quickly than in those who were not (p = 0.015). Similarly, the proportion was significant lower in the patients who received nephrological follow-up than in those who did not (p = 0.006). CONCLUSION: Vigilance for CKD is poor. Simple interventions to augment the vigilance for CKD, as presented in this study, lead to a quicker referral to and follow-up by a nephrologist, which may result in better outcome.

Medical stabilization of adolescents with nutritional insufficiency: a clinical care path.

PURPOSE: Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS: A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS: Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS: A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.

Improving Quality Assurance in a Radiation Oncology Using ARIA Visual Care Path.

PURPOSE: Errors and incidents may occur at any point within radiotherapy (RT). The aim of the present retrospective analysis is to evaluate the impact of a customized ARIA Visual Care Path (VCP) on quality assurance (QA) for the RT process. MATERIALS AND METHODS: The ARIA VCP was implemented in June 2019. The following tasks were customized and independently verified (by independent checks from radiation oncologists, medical physics, and radiation therapists): simulation, treatment planning, treatment start verification, and treatment completion. A retrospective analysis of 105 random and unselected patients was performed, and 945 tasks were reviewed. Patients' reports were categorized based on treatment years period: 2019-2020 (A); 2021 (B); and 2022-2023 (C). The QA metrics included data for timeliness of task completion and data for minor and major incidents. The major incidents were defined as incorrect prescriptions of RT dose, the use of different immobilization systems during RT compared to the simulation, the absence of surface-guided RT data for patients' positioning, incorrect dosimetric QA for treatment plans, and failure to complete RT as originally planned. A sample size of approximately 100 was able to obtain an upper limit of 95% confidence interval below 5-10% in the case of zero or one major incident. RESULTS: From June 2019 to December 2023, 5300 patients were treated in our RT department, an average of 1300 patients per year. For the purpose of this analysis, one hundred and five patients were chosen for the study and were subsequently evaluated. All RT staff achieved a 100% compliance rate in the ARIA VCP timely completion. A total of 36 patients were treated in Period A, 34 in Period B, and 35 in Period C. No major incidents were identified, demonstrating a major incident rate of 0.0% (95% CI 0.0-3.5%). A total of 26 out of 945 analyzed tasks (3.8%) were reported as minor incidents: absence of positioning photo in 32 cases, lack of patients' photo, and absence of plan documents in 4 cases. When comparing periods, incidents were statistically less frequent in Period C. CONCLUSIONS: Although the present analysis has some limitations, its outcomes demonstrated that software for the RT workflow, which is fully integrated with both the record-and-verify and treatment planning systems, can effectively manage the patient's care path. Implementing the ARIA VCP improved the efficiency of the RT care path workflow, reducing the risk of major and minor incidents.

Integrating Patient Preferences with Guideline-Based Care in Neurogenic Lower Urinary Tract Dysfunction After Spinal Cord Injury.

Individual and social factors are important for clinical decision-making in patients with neurogenic bladder secondary to spinal cord injury (SCI). These factors include the availability of caregivers, social infrastructure, and personal preferences, which all can drive bladder management decisions. These elements can be overlooked in clinical decision-making; therefore, there is a need to elicit and prioritize patient preferences and values into neurogenic bladder care to facilitate personalized bladder management choices. For the purposes of this article, we review the role of guideline-based care and shared decision-making in the SCI population with neurogenic lower urinary tract dysfunction.

Corrigendum: Integration of digital health applications into the German healthcare system: development of "The DiGA-Care Path".

[This corrects the article DOI: 10.3389/frhs.2024.1372522.].

Integration of digital health applications into the German healthcare system: development of "The DiGA-Care Path".

Introduction: Since 2019 people who have insured in the German statutory health insurance are entitled to use certified apps called the Digitale Gesundheitsanwendungen [Digital Health Applications (DiGAs)]. The prerequisite for this is that an app certified as DiGA and suitable for their diagnosis exists. The DiGA can then either be prescribed by a physician or psychotherapist or requested by the patient from the statutory health insurance fund. Given the novelty of this type of healthcare, the implementation of a DiGA should be closely monitored to identify potential weaknesses and achieve quality improvements. To enable an analysis of the supply of DiGAs step-by-step, we aimed to create the DiGA-Care Path. Methods: We conducted three steps to create the DiGA-Care Path. First, a knowledge base was created based on a structured literature research matched with knowledge gathered from the superordinate research project "QuaSiApps" funded by the German Federal Joint Committee. Second, we aimed to create an "ideal-typical" DiGA-Care Path using a flowchart. Third, based on the first path, a final path was developed using the graphical modeling language "Event-Driven Process Chain." Results: The DiGA-Care Path was developed to depict the supply of DiGAs in Germany. The final path is constituted by a "main path" as well as a corresponding "sub-path". While the "main path" focuses more on the supply environment in which a DiGA is used, the "sub-path" depicts the supply delivered by the DiGA itself. Besides the process itself, the paths include relevant actors to indicate responsibilities for individual process steps. Discussion: The DiGA-Care Path helps to analyze the current supply of DiGAs step-by-step. Thereby, each step can be investigated in detail to identify problems and to detect further steps where quality improvements can be enabled. Depending on the perspective, focused either on the supply environment, or the supply delivered by the DiGA itself, the "main path" or the "sub-path" can be used, respectively. Besides the potential of the DiGA-Care Path to improve the current supply of DiGAs, it can help as an orientation for international policymakers or further stakeholders either to develop their own integration of apps into healthcare systems or for international manufacturers to consider entering the German market.

New treatment opportunities for older patients with acute myeloid leukemia and the increasing importance of frailty assessment - An oncogeriatric perspective.

With the introduction of targeted chemotherapy drugs, a new age of treatment for acute myeloid leukemia (AML) has begun. The promotion of the azacitidine+venetoclax combination regimen to first line of treatment in patients deemed ineligible for intensive chemotherapy marks the first of many novel combination regimens becoming part of national treatment guidelines. We review recent phase II and III clinical trials and conclude that these novel regimens offer significant increases in response rates, remission rates, and overall survival. The incidence of adverse events, the accrued time toxicity, and the healthcare costs, however, are increasing as well. Compared with clinical trials, older patients in the real world frequently present with an inferior baseline health status, which is associated with an increased risk of experiencing side effects. The key to reaping the maximum benefit of the new agents and their combination regimens therefore lies in sufficient attention being given to a patients' preexisting comorbidities, potential frailty, and quality of life. A systematic collaboration between hemato-oncologists and geriatricians can be a potent first step towards addressing the increased treatment intensity patients with AML experience under the novel regimens. In this narrative review article we provide an overview of recent and ongoing clinical trials, highlight encountered adverse events, discuss frailty assessment options, and outline an oncogeriatic care path for older patients with AML.

Referral care paths for non-alcoholic fatty liver disease-Gearing up for an ever more prevalent and severe liver disease.

Non-alcoholic fatty liver disease (NAFLD) is an increasingly prevalent and potentially severe liver disease, emphasizing the need for implementation of widely supported care paths for patients at risk for advanced stages of NAFLD. In particular, the distinction of patients with a progressive and/or advanced, fibrotic NAFLD from those with simple steatosis requires improvement, as well as the awareness for NAFLD among health care professionals. Broad acceptance and implementation of interdisciplinary care paths in the near future will bring enhanced identification of those patients that benefit from surveillance, intensive lifestyle management, and empirical or investigational pharmacotherapy and enhance our epidemiological grasp of NAFLD in relation to lifestyle, genetic background, and cardiometabolic comorbidities related to NAFLD.

Specialized Medical Weight Management Intervention for High-Risk Obesity.

Background: Bundled payments are services rendered at pre-determined costs with the goal of providing high value care. Our institution's Episodes of Care team partnered with its tertiary care obesity center to design a novel medical weight management bundle for employers that would collectively deliver high value obesity services. Objective: As a first step, we sought to evaluate short-term medical weight loss outcomes over 6 months at the obesity center. Methods: We retrospectively analyzed weight loss outcomes on 157 patients with commercial insurance coverage over a period of 6 months. Results: Patients ranged in age from 18-72 years, and 77.7% were female. Patients ranged in weight from 160-443 pounds, with a mean body mass index (BMI) of 42.7 kg/m2 (Class 3a severe obesity; BMI range 28.4-74.5). The prevalence of any obesity-related medical condition was 54.1%; at least a quarter of the patients had either prediabetes or Type 2 diabetes mellitus, approximately a third had hypertension, and over 8% had hyperlipidemia. Mean weight loss from the initial program start date was 6.28% (+/-0.48% standard error of mean [SEM]; 95% confidence interval [CI] 5.34-7.23%). Completers (defined as having at least 6 visits with a medical provider) achieved a higher percentage of weight loss (7.06%) from the initial program start compared to non-completers (4.68%; at least 4-5 visits with a medical provider; P<0.0158). Approximately 50% of patients were able to achieve >7% weight loss, with over 55% of patients achieving at least 3% weight loss or higher irrespective of BMI classification. Conclusions: Specialized medical weight intervention is effective in treating high-risk obesity with complications. This has implications for enhanced long-term cost savings related to employer coverage of such programs for their employees with obesity.

Electronic charting of radiation therapy planning and treatment: Report of Task Group 262.

While most Radiation Oncology clinics have adopted electronic charting in one form or another, no consensus document exists that provides guidelines for safe and effective use of the Radiation Oncology electronic medical records (RO-EMR). Task Group 262 was formed to provide these guidelines as well as to provide recommendations to vendors for improving electronic charting functionality in future. Guidelines are provided in the following areas: Implementation and training for the RO-EMR, acceptance testing and quality assurance (QA) of the RO-EMR, use of the RO-EMR as an information repository, use of the RO-EMR as a workflow manager, electronic charting for brachytherapy and nonstandard treatments, and information technology (IT) considerations associated with the RO-EMR. The report was based on a literature search by the task group, an extensive survey of task group members on their respective RO-EMR practices, an AAPM membership survey on electronic charting, as well as group consensus.

Geospatial Science and Point-of-Care Testing: Creating Solutions for Population Access, Emergencies, Outbreaks, and Disasters.

Objectives: (a) To understand how to integrate geospatial concepts when implementing point-of-care testing (POCT); (b) to facilitate emergency, outbreak, and disaster preparedness and emergency management in healthcare small-world networks; (c) to enhance community resilience by using POCT in tandem with geographic information systems (GISs) and other geospatial tools; and (d) to advance crisis standards of care at points of need, adaptable and scalable for public health practice in limited-resource countries and other global settings. Content: Visual logistics help integrate and synthesize POCT and geospatial concepts. The resulting geospatial solutions presented here comprise: (1) small-world networks and regional topography; (2) space-time transformation, hubs, and asset mapping; (3) spatial and geospatial care paths™; (4) GIS-POCT; (5) isolation laboratories, diagnostics isolators, and mobile laboratories for highly infectious diseases; (6) alternate care facilities; (7) roaming POCT-airborne, ambulances, space, and wearables; (8) connected and wireless POCT outside hospitals; (9) unmanned aerial vehicles; (10) geospatial practice-demographic care unit resource scoring, geographic risk assessment, and national POCT policy and guidelines; (11) the hybrid laboratory; and (12) point-of-careology. Value: Small-world networks and their connectivity facilitate efficient and effective placement of POCT for optimal response, rescue, diagnosis, and treatment. Spatial care paths™ speed transport from primary encounters to referral centers bypassing topographic bottlenecks, process gaps, and time-consuming interruptions. Regional GISs position POCT close to where patients live to facilitate rapid triage, decrease therapeutic turnaround time, and conserve economic resources. Geospatial care paths™ encompass demographic and population access features. Timeliness creates value during acute illness, complex crises, and unexpected disasters. Isolation laboratories equipped with POCT help stop outbreaks and safely support critically ill patients with highly infectious diseases. POCT-enabled spatial grids can map sentinel cases and establish geographic limits of epidemics for ring vaccination. Impact: Geospatial solutions generate inherently optimal and logical placement of POCT conceptually, physically, and temporally as a means to improve crisis response and spatial resilience. If public health professionals, geospatial scientists, and POCT specialists join forces, new collaborative teamwork can create faster response and higher impact during disasters, complex crises, outbreaks, and epidemics, as well as more efficient primary, urgent, and emergency community care.

[Securing patients pathways treated by oral antitumoral: Guidelines for better organization of departments and management of incoming calls]. / Sécurisation des parcours des patients sous traitement anti-tumoraux oraux : recommandations pour une meilleure organisation des services et gestion des appels entrants.

The emergence of oral cancer treatment in oncology has shifted patient follow-up from the hospital to the home. This trend has resulted in an increase in phone and e-mail interactions initiated by patients, but also by pharmacists, by liberal nurses, by general practitioners, and an increase in calls to the emergency response services (SAMU) both for real or perceived emergencies. This increased volume of patient and pharmacist communication has caused significant disruption in the daily activity of affected oncology departments and in particular of the secretariats. The procedures for formulating and securing appropriate responses within a short time frame are generally not established, and as a result, there is a risk that decisions made could be inappropriate for the patient's situation, especially in the case of complications.. Tracking responses to phone calls is necessary and answers should be noted in the medical file, including side effects, in particular the serious AEs for a good quality of care. This guideline describes best practices for oncologists who manage "incoming" calls from patients or professionals involved in the care pathway.

Institutional care paths: Development, implementation, and evaluation.

PURPOSE: The Cleveland Clinic experience with care paths, including their creation and implementation, challenges overcome during development and testing, and outcomes of selected care path evaluations, is described. SUMMARY: Care paths are tools to assist healthcare professionals in practicing evidence-based medicine. The Cleveland Clinic health system has implemented or is developing approximately 100 care paths, including care paths designed to optimize management of sepsis and septic shock and to promote timely use of i.v. tissue plasminogen activator and correct dosing of antithrombotics and statins in patients with stroke. Key steps in successful care path initiatives include (1) identifying key stakeholders, (2) achieving stakeholder consensus on a standardized approach to disease or condition management, (3) cultivating provider awareness of care paths, (4) incorporating care path tools into the electronic health record and workflow processes, and (5) securing the resources to develop, implement, and maintain care paths. Electronic health records facilitate the use of and adherence to care paths. After care path implementation, revisions are typically needed due to unexpected issues not initially identified and to optimize care path features and support resources for clinical practice. Ongoing evaluation is required to determine whether an implemented care path is producing the intended patient and quality performance outcomes. CONCLUSION: Care paths provide a standardized approach to treatment or prevention of a disease or condition, reducing unnecessary variability and expense while promoting optimal, cost-effective patient care.

Anticipating the role of the intensive care unit in healthcare and life trajectories.

Many people think that the intensive care unit is reserved for patients with extreme and life-threatening disease, and as such, it remains hypothetical in the collective conscience, and not something that can be predicted or anticipated. Yet, intensive care can be required in a number of situations, and raises many questions depending on whether the illness is chronic, or of sudden onset. It is essential, in this context, to ask whether, and how potential patients are informed, and prepared for the eventuality of intensive care unit (ICU) care. In this view, anticipating ICU admission is a key, yet new issue, and it raises questions about the place of the ICU physician and ICU teams in the healthcare pathway, and in life trajectories overall.

Management of patients with implantable cardioverter-defibrillators and pacemakers who require radiation therapy.

BACKGROUND: Radiation therapy (RT) may pose acute and long-term risks for patients with cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs). However, the frequency of these problems has not been accurately defined. OBJECTIVE: The purpose of this study was to determine the prevalence of CIEDs among patients requiring RT and report the common CIED-related problems when patients are managed according to a standard clinical care path. METHODS: In a single tertiary-care center, we prospectively screened all patients requiring RT and identified patients with ICDs or PMs. We collected clinical data about their cancer, RT treatment plan, and CIED. Radiation dose to the device was estimated in all patients, and any device malfunction during RT was documented. RESULTS: Of the 34,706 consecutive patients receiving RT, 261 patients (0.8%, mean age 77.9 ± 9.4 years) had an implantable cardiac device: 54 (20.7%) ICDs and 207 (79.3%) PMs. The site of RT was head and neck (27.4%), chest (30.0%), and abdomen/pelvis (32.6%). Using our care path, 63.2% of patients required continuous cardiac monitoring, 14.6% required device reprogramming, 18.8% required magnet application during RT, and 3.4% required device repositioning to the contralateral side before RT. Four patients (1.5%) had inappropriate device function during RT: 3 experienced hemodynamically tolerated ventricular pacing at the maximum sensor rate, and 1 experienced a device power-on-reset. No patient died or suffered permanent device failure. CONCLUSION: Nearly 1% of patients receiving RT in this series has a PM or ICD. However, with a systematic policy of risk assessment and patient management, significant device-related complications are rare.

A multidisciplinary network for the care of abnormal fatigue and chronic fatigue syndrome in the provinces of East and West Flanders in Belgium.

The organization of care for patients with the chronic fatigue syndrome (CFS) in tertiary care referral centres from 2002 onwards, was negatively evaluated by the Belgian Health Care Knowledge Centre on the endpoint of socio-professional reintegration. Subsequently, the federal health authorities asked for the elaboration of a new and innovative model of stepped care, aiming at improved integration of diagnosis and treatment into primary care and between levels of health care for patients with CFS. The reference centre of the University Hospital Ghent took the initiative of recruiting partners in the Belgian provinces of East and West Flanders to guarantee the care for patients with medically unexplained symptoms, in particular abnormal fatigue and CFS. A new and innovative care model, in which general practitioners play a central role, emphasizes the importance of early recognition of the patient 'at risk', correct diagnosis and timely referral. Early detection and intervention is essential in order to avoid or minimize illness progression towards chronicity, to safeguard opportunities for significant health improvement as well as to enhance successful socio-professional reintegration. This approach covers both the large sample of patients developing somatic complaints without obvious disease in an early phase as well as the more limited group of patients with chronic illness, including CFS. Cognitive behavioural therapy and graded exposure/exercise therapy are the evidence based main components of therapy in the latter. A biopsychosocial model underlies the proposed path of care.

Principles of Point of Care Culture, the Spatial Care Path™, and Enabling Community and Global Resilience: Enabling Community and Global Resilience.

GOALS: This article a) defines point of care (POC) culture; b) presents seven underlying fundamental principles; c) describes the importance of needs assessment; d) introduces a new innovation, the spatial care path™; and e) illustrates how POC testing that properly fulfills needs and spatial care paths™ enable community and global resilience. OBSERVATIONS: Often, POC testing supplants the conventional clinical laboratory, which may be too distant, prohibitively expensive, or simply not available in limited-resource settings. New POC technologies "fit" future medical problem solving. Screening and testing directly in the home or primary care facilitate rapid diagnosis, monitoring, and treatment. In contrast to the past where attention has been placed on emergency departments, hospitals, and referral centers, the spatial care path™ starts with the patient and guides him or her through an efficient strategy of care in small-world networks (SWNs) defined by local geography and topology, long-standing customs, public health jurisdictions, and geographic information systems (GIS). CONCLUSIONS: POC testing needs in limited-resource settings are striking. Fulfillment is best guided by thorough understanding of POC culture. Quick feedback and fast decision-making by patients and physicians alike yield significant value that motivates changes in patient lifestyles and physician interactions. Culturally sensitive technology assimilation addresses leadership challenges in nations adapting to increasing populations of young and old, despite scarcity of resources. The spatial care path™ facilitates an essential balance of prevention and intervention in public health and shifts future focus to the patient, empowerment, and primary care within the context of POC culture.