HIV-positive men's experiences with integrated family planning and HIV services in western Kenya: integration fosters male involvement

A growing body of evidence indicates that integrating family planning (FP) services into HIV care is effective at improving contraceptive uptake among HIV-positive women in resource-poor settings, yet little research has examined HIV-positive men's experiences with such integration. We conducted in-depth interviews with 21 HIV-positive men seeking care at HIV clinics in Nyanza, Kenya. All clinics were intervention sites for a FP/HIV service integration cluster-randomized trial. Grounded theory was used to code and analyze the data. Our findings highlight men's motivations for FP, reasons why men prefer obtaining their FP services, which include education, counseling, and commodities, at HIV care clinics, and specific ways in which integrated FP/HIV services fostered male inclusion in FP decision-making. In conclusion, men appear invested in FP and their inclusion in FP decision-making may bolster both female and male agency. Men's positive attitudes towards FP being provided at HIV care clinics supports the programmatic push towards integrated delivery models for FP and HIV services.

Health care utilisation in subjects with osteoarthritis, chronic back pain and osteoporosis aged 65 years and more: mediating effects of limitations in activities of daily living, pain intensity and mental diseases

Musculoskeletal diseases (MDs) have major consequences for the individual, and also for society and may thus lead to increased use of health care. It was the aim of this study to explore health care utilisation in patients with self-reported osteoarthritis, chronic back pain or osteoporosis compared with people of the same age without those diseases, based on data of the Austrian health interview survey including 3,097 subjects aged ≥ 65 years. Patients with MDs in our study visited a general practitioner (GP) and were hospitalised significantly more often compared with persons without the respective diseases. Problems in the activities of daily living (ADLs), pain intensity and anxiety/depression influenced GP consultations. Complex factors explain the higher health care utilisation in subjects with MDs in our study. Our results indicate that integrated strategies are needed to manage those patients, which should focus on management of ADL problems, pain and mental health.

Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system

OBJECTIVE

To evaluate the prevalence of and characterize resistant hypertension in a large representative population with successful hypertension management and reliable health information.

PATIENT AND METHODS

We performed a cross-sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system between January 1, 2006, and December 31, 2007. From individuals older than 17 years with hypertension, resistant hypertension was identified and prevalence was determined. Multivariable logistic regression was used to calculate odds ratios (ORs), with adjustments for demographic characteristics, clinical variables, and medication use.

RESULTS

Of 470,386 hypertensive individuals, 60,327 (12.8%) were identified as having resistant disease, representing 15.3% of those taking medications. Overall, 37,061 patients (7.9%) had uncontrolled hypertension while taking 3 or more medicines. The ORs (95% CIs) for resistant hypertension were greater for black race (1.68 [1.62-1.75]), older age (1.11 [1.10-1.11] for every 5-year increase), male sex (1.06 [1.03-1.10]), and obesity (1.46 [1.42-1.51]). Medication adherence rates were higher in those with resistant hypertension (93% vs 89.8%; P<.001). Chronic kidney disease (OR, 1.84; 95% CI, 1.78-1.90), diabetes mellitus (OR, 1.58; 95% CI, 1.53-1.63), and cardiovascular disease (OR, 1.34; 95% CI, 1.30-1.39) were also associated with higher risk of resistant hypertension.

CONCLUSION

In a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable with that of previous studies using more fragmented data sources. Past observations have been limited due to nonrepresentative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort, which was established using an electronic medical record-based approach, has the potential to provide a better understanding of resistant hypertension and outcomes.

A quick diagnosis unit as an alternative to conventional hospitalization in a tertiary public hospital: a descriptive study

INTRODUCTION

 Reports indicate that a significant number of patients admitted to internal medicine units could be studied on an outpatient basis.

OBJECTIVES

 This article assesses a quick diagnosis unit (QDU) as an alternative to acute hospitalization for the diagnostic study of patients with potentially serious diseases and suspected malignancy. 

PATIENTS AND METHODS

 Between March 2008 and June 2012, 1226 patients were attended by the QDU. Patients were referred from the emergency department, primary health care centers, and outpatient clinics according to well‑defined criteria. Clinical information was prospectively registered in a database. 

RESULTS

 There were 634 men (51.7%), with a mean age of 60.5 ±17.5 years. The mean time to the first visit was 3.5 ±5.3 days. Most patients (65.7%) required only 2 visits. The mean interval to diagnosis was 12.2 ±14.7 days. A total of 324 patients (26.4%) had cancer. The diagnosis was  solid tumor in 81.5% of the cases, lymphoma in 19.8%, and various hematologic malignancies in 4.3%. The second most common diagnosis was anemia not associated with cancer (8.6% of the cases). Admission to the QDU allowed to avoid conventional hospitalization for diagnostic studies in 71.5% of the patients, representing a mean freeing‑up rate of 7 internal medicine beds per day. In a satisfaction survey, 97% of the patients were completely or very satisfied and 96% preferred the QDU to conventional hospitalization. 

CONCLUSIONS

 A QDU may be a feasible alternative to conventional hospitalization for the diagnosis of otherwise healthy patients with suspected severe disease. Appropriately managed and supported, QDUs can lighten the burden of emergency departments and reduce the need for hospitals beds.

Assessment and management of adult cancer pain: a systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care

CONTEXT

Cancer pain is a common, burdensome problem, which is not well managed despite evidence-based guidelines.

OBJECTIVES

To develop insights for managing barriers and optimizing facilitators to adult cancer pain assessment and management within a comprehensive framework of patient care.

METHODS

We undertook a systematic review and synthesis of qualitative studies. Medline, PsycINFO, Embase, AMED, CINAHL, and Sociological Abstracts were searched from May 20 to 26, 2011. To be included, the articles had to be published in a peer-reviewed journal since 2000; written in English; and report original qualitative studies on the perspectives of patients, their significant others, or health care providers. Article quality was rated using the checklist of Kitto et al. Thematic synthesis followed a three-stage approach using Evidence for Policy and Practice Information and Co-ordinating Centre-Reviewer 4 software: 1) free line-by-line coding of "Results," 2) organization into "descriptive" themes, and 3) development of "analytical" themes informative to our objective. At Stage 3, a conceptual framework was selected from the peer-reviewed literature according to prima facie "fit" for descriptive themes.

RESULTS

Of 659 articles screened, 70 met the criteria, reporting 65 studies with 48 patient, 19 caregiver, and 21 health care provider samples. Authors rarely reported reflexivity or negative cases. Mead and Bower's model of patient-centered care accommodated 85% of the descriptive themes; 12% more related to the caregiver and service/system factors. Three themes could not be accommodated.

CONCLUSION

Findings highlight the need to integrate patient/family education within improved communication, individualize care, use more nonpharmacological strategies, empower patients/families to self-manage pain, and reorganize multidisciplinary roles around patient-centered care and outcomes. These conclusions require validation via consensus and intervention trials.

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants

BACKGROUND

The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

METHODS

Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

RESULTS

One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

CONCLUSIONS

Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

System integration and clinical utilization of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program-Trained Extended Role Practitioners in Ontario: a two-year, system-level evaluation

BACKGROUND

The Advanced Clinician Practitioner in Arthritis Care (ACPAC) program was developed in 2005 to prepare experienced physical and occupational therapists to function as extended role practitioners (ERPs) within models of arthritis care across Ontario, Canada.

PURPOSE

To examine the system-level integration and clinical utilization of the ACPAC program-trained ERP.

METHOD

A longitudinal survey was administered to all ACPAC graduates over a two-year period (n=30).

RESULTS

The majority of ERPs were physical therapists working in urban settings. Family physicians or physician specialists referred the majority of patients. The longest median wait time to access ERPs' services was 22 days. Half of the ERPs triaged patients, and most of those who did triage (75%) worked under medical directives. Approximately half (51.6%) of the patients seen had a diagnosis of osteoarthritis, followed by rheumatoid arthritis (14.7%).

CONCLUSION

Understanding the system-level impact of this unique human resource can help to shape healthcare planning and delivery of care.

Treatment of co-occurring psychotic and substance use disorders

People with psychotic disorders and other serious mental illnesses, such as schizophrenia, bipolar disorder, and severe major depression, have high rates of co-occurring substance use disorder, which can wreak havoc in their lives. In this article the authors describe strategies for assessing substance use problems in people with serious mental illnesses, and then address the treatment of these co-occurring disorders. The authors review principles of treatment of co-occurring disorders, including integration of mental health and substance abuse services, adopting a low-stress and harm-reduction approach, enhancing motivation, using cognitive-behavioral therapy strategies to teach more effective interpersonal and coping skills, supporting functional recovery, and engaging the social network. The authors include a section on how social workers may play a key role in assessment, treatment, or referral for co-occurring disorders in a variety of settings. Throughout the article the authors emphasize that belief in the possibility of recovery from co-occurring disorders and instilling hope in clients, their family members, and other treatment providers, are vital to the effective treatment of co-occurring disorders.

Prevalence of childhood and adolescent overweight and obesity from 2003 to 2010 in an integrated health care delivery system

An observational study of the Kaiser Permanente Northern California (KPNC) BMI coding distributions was conducted to ascertain the trends in overweight and obesity prevalence among KPNC members aged 2-19 between the periods of 2003-2005 and 2009-2010. A decrease in the prevalence of overweight (-11.1% change) and obesity (-3.6% change) and an increase in the prevalence of healthy weight (+2.7% change) were demonstrated. Children aged 2-5 had the greatest improvement in obesity prevalence (-11.5% change). Adolescents aged 12-19 were the only age group to not show a decrease in obesity prevalence. Of the racial and ethnic groups, Hispanics/Latinos had the highest prevalence of obesity across all age groups. The KPNC prevalence of overweight and obesity compares favorably to external benchmarks, although differences in methodologies limit our ability to draw conclusions. Physician counseling as well as weight management programs and sociodemographic factors may have contributed to the overall improvements in BMI in the KPNC population. Physician training, practice tools, automated BMI reminders and performance feedback improved the frequency and quality of physician counseling. BMI screening and counseling at urgent visits, in addition to well-child care visits, increased the reach and dose of physician counseling.

Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system

BACKGROUND

Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions.

DESIGN, SETTING, PATIENTS

Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED.

METHODS

Evaluation of 178,315 ED non-ICU admissions to 13 US community hospitals. We tabulated the outcome of unplanned ICU transfer by patient characteristics and hospital volume. We present factors associated with unplanned ICU transfer after adjusting for patient and hospital differences in a hierarchical logistic regression.

RESULTS

There were 4,252 (2.4%) non-ICU admissions transferred to the ICU within 24 hours. Admitting diagnoses most associated with unplanned transfer, listed by descending prevalence were: pneumonia (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2-1.9), myocardial infarction (MI) (OR 1.5; 95% CI 1.2-2.0), chronic obstructive pulmonary disease (COPD) (OR 1.4; 95% CI 1.1-1.9), sepsis (OR 2.5; 95% CI 1.9-3.3), and catastrophic conditions (OR 2.3; 95% CI 1.7-3.0). Other significant predictors included: male sex, Comorbidity Points Score >145, Laboratory Acute Physiology Score ≥7, arriving on the ward between 11 PM and 7 AM. Decreased risk was found with admission to monitored transitional care units (OR 0.83; 95% CI 0.77-0.90) and to higher volume hospitals (OR 0.94 per 1,000 additional annual ED inpatient admissions; 95% CI 0.91-0.98).

CONCLUSIONS

ED patients admitted with respiratory conditions, MI, or sepsis are at modestly increased risk for unplanned ICU transfer and may benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute decompensation. More research is needed to determine how intermediate care units, hospital volume, time of day, and sex affect unplanned ICU transfer. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.

Improving sexual health for HIV patients by providing a combination of integrated public health and hospital care services; a one-group pre- and post test intervention comparison

BACKGROUND

Hospital HIV care and public sexual health care (a Sexual Health Care Centre) services were integrated to provide sexual health counselling and sexually transmitted infections (STIs) testing and treatment (sexual health care) to larger numbers of HIV patients. Services, need and usage were assessed using a patient perspective, which is a key factor for the success of service integration.

METHODS

The study design was a one-group pre-test and post-test comparison of 447 HIV-infected heterosexual individuals and men who have sex with men (MSM) attending a hospital-based HIV centre serving the southern region of the Netherlands. The intervention offered comprehensive sexual health care using an integrated care approach. The main outcomes were intervention uptake, patients' pre-test care needs (n=254), and quality rating.

RESULTS

Pre intervention, 43% of the patients wanted to discuss sexual health (51% MSM; 30% heterosexuals). Of these patients, 12% to 35% reported regular coverage, and up to 25% never discussed sexual health topics at their HIV care visits. Of the patients, 24% used our intervention. Usage was higher among patients who previously expressed a need to discuss sexual health. Most patients who used the integrated services were new users of public health services. STIs were detected in 13% of MSM and in none of the heterosexuals. The quality of care was rated good.

CONCLUSIONS

The HIV patients in our study generally considered sexual health important, but the regular counselling and testing at the HIV care visit was insufficient. The integration of public health and hospital services benefited both care sectors and their patients by addressing sexual health questions, detecting STIs, and conducting partner notification. Successful sexual health care uptake requires increased awareness among patients about their care options as well as a cultural shift among care providers.

Managing the physics of the economics of integrated health care

The physics metaphor, as applied to the economics (and financial performance) of the integrated health system, seems appropriate when considered together with the nine principles of management framework provided. The nature of the integrated design enhances leaders' management potential as they consider organizational operations and strategy in the markets ahead. One question begged by this argument for the integrated design is the durability, efficiency and ultimate long-term survivability of the more "traditional" community health care delivery models, which, by design, are fragmented, internally competitive and less capital efficient. They also cannot exploit the leverage of teams, optimal access management or the pursuit of revenues made available in many forms. For those who wish to move from the traditional to the more integrated community health system designs (especially those who have not yet started the journey), the path requires: * Sufficient balance sheet capacity to fund the integration process-especially as the model requires physician practice acquisitions and electronic health record implementations * A well-prepared board13, 14 * A functional, durable and sustainable physician services enterprise design * A redesigned organizational and governance structure * Favorable internal financial incentives alignment design * Effective accountable physician leadership * Awareness that the system is not solely a funding strategy for acquired physicians, rather a fully -.. committed clinical and business model, one in which patient-centered integrated care is the core service (and not acute care hospital-based services) A willingness to create and exploit the implied and inherent potential of an integrated design and unified brand Last, it's important to remember that an integrated health system is a tool that creates a "new potential" (a physics metaphor reference, one last time). The design doesn't operate itself. Application of the management principles presented here are necessary as a complete recipe. Leaders of health systems moving toward integration are cautioned to apply the recipe in full. This article ends with two questions. First, if not an integrated model of health care, what's the alternative? Since it seems clear that many of the existing community-based models are excessively fragmented and inefficient, especially in a reforming U.S. health care marketplace, is there a new model that is superior to the integrated models and, if so, what is it and what are its functional principles? The second question: Is there more than one functional form of integration? This article argues for the most integrated form. Others would argue that clinical integration is sufficient,'s and full integration isn't required. The stability, durability and adaptability of the fully integrated models have, arguably, been tested. The lesser integrated models remain to be proven in an unstable health care marketplace seeking higher levels of economic efficiency.

Systems of care: the story behind the numbers

This article presents a brief description of a longitudinal study of system-level change, offers observations about what has been learned about the evolution of systems of care from the unique and qualified perspectives of the group of site visitors who gathered the data for the study, and identifies a set of issues that needs to be addressed to advance the system of care model in community based care of children and youth with behavioral health needs and their families. The article describes the system of care assessment portion of the national evaluation of the Federal Children's Mental Health Initiative and presents a brief summary of accumulated findings from the assessments conducted in communities funded in six successive waves of awards to provide context for the site visitors' observations and the authors' recommendations. The authors draw upon the expert observations of the site visitors, who represent many different disciplines and backgrounds, which suggest that, as a set of guiding principles, the system of care philosophy and approach seem to have become accepted standards of program practice and system operation in the funded sites, although implementation is uneven across principles and sites. The article concludes with the authors' identification of high-level system issues that must be addressed more effectively if systems of care are to come to scale.

Medicinal plants used with Thai Traditional Medicine in modern healthcare services: a case study in Kabchoeng Hospital, Surin Province, Thailand

ETHNOPHARMACOLOGICAL RELEVANCE

Thai Traditional Medicine (TTM) is available in many modern hospitals in Thailand. However, there have been difficulties in integrating TTM, particularly the practices of the use of herbal medicines, into modern healthcare services. Kabchoeng Hospital is one hospital that has been able to overcome these difficulties. Thus, this study aimed to document the successful utilization of herbal medicine at Kabchoeng Hospital. The documentation focused on both the knowledge of medicinal plants and the success factors that facilitated the utilization of herbal medicine in the context of a modern hospital in Thailand.

MATERIALS AND METHODS

Kabchoeng Hospital was intentionally selected for this case study. Participatory observation was used for the data collection. There were six groups of key informants: three applied Thai Traditional Medicine practitioners (ATTMPs), a pharmacist, two physicians, two folk healers, the head of an herbal cultivation and collection group, and 190 patients. The plant specimens were collected and identified based on the botanical literature and a comparison with authentic specimens; these identifications were assisted by microscopic and thin layer chromatography (TLC) techniques.

RESULTS

Eighty-nine medicinal plants were used for the herbal preparations. The ATTMPs used these plants to prepare 29 standard herbal preparations and occasional extemporaneous preparations. Moreover, in this hospital, seven herbal preparations were purchased from herbal medicine manufacturers. In total, 36 preparations were used for 10 groups of symptoms, such as the treatment of respiratory system disorders, musculo-skeletal system disorders, and digestive system disorders. Four success factors that facilitated the utilization of herbal medicine at Kabchoeng Hospital were determined. These factors included a proper understanding of the uses of herbal medicines, the successful integration of the modern and TTM healthcare teams, the support of an herbal cultivation and collection group, and the acceptance of the local people.

CONCLUSIONS

The practices that support the use of herbal medicine at Kabchoeng Hospital illustrated the successful application of TTM and also represented a model for the integration of TTM, and particularly the use of herbal medicine, into modern hospitals. This integration will be beneficial for sustainable healthcare systems in Thailand and in other countries where modern medicine is the mainstream medical system.

How are the costs of care for medical falls distributed? The costs of medical falls by component of cost, timing, and injury severity

PURPOSE OF THE STUDY

To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity.

DESIGN AND METHODS

We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other."

RESULTS

The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers.

IMPLICATIONS

Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates.

Effectiveness of a multidisciplinary care program on recovery and return to work of patients after gynaecological surgery; design of a randomized controlled trial

BACKGROUND

Return to work after gynaecological surgery takes much longer than expected, irrespective of the level of invasiveness. In order to empower patients in recovery and return to work, a multidisciplinary care program consisting of an e-health intervention and integrated care management including participatory workplace intervention was developed.

METHODS/DESIGN

We designed a randomized controlled trial to assess the effect of the multidisciplinary care program on full sustainable return to work in patients after gynaecological surgery, compared to usual clinical care. Two hundred twelve women (18-65 years old) undergoing hysterectomy and/or laparoscopic adnexal surgery on benign indication in one of the 7 participating (university) hospitals in the Netherlands are expected to take part in this study at baseline. The primary outcome measure is sick leave duration until full sustainable return to work and is measured by a monthly calendar of sickness absence during 26 weeks after surgery. Secondary outcome measures are the effect of the care program on general recovery, quality of life, pain intensity and complications, and are assessed using questionnaires at baseline, 2, 6, 12 and 26 weeks after surgery.

DISCUSSION

The discrepancy between expected physical recovery and actual return to work after gynaecological surgery contributes to the relevance of this study. There is strong evidence that long periods of sick leave can result in work disability, poorer general health and increased risk of mental health problems. We expect that this multidisciplinary care program will improve peri-operative care, contribute to a faster return to work of patients after gynaecological surgery and, as a consequence, will reduce societal costs considerably.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2087.

COCPIT: a tool for integrated care pathway variance analysis

Electronic Health Record (EHR) data has the potential to track patients' journeys through healthcare systems. Many of those journeys are supposed to follow Integrated Care Pathways (ICPs) built on evidence based guidelines. An ICP for a particular condition sets out "what should happen", whereas the EHR records "what did happen". Variance analysis is the process by which the difference between expected and actual care is identified. By performing variance analysis over multiple patients, patterns of deviation from idealised care are revealed. The use of ICP variance analysis, however, is not as widespread as it could be in healthcare quality improvement processes - we argue that this is due to the difficulty of combining the required specialist knowledge and skills from different disciplines. COCPIT (Collaborative Online Care Pathway Investigation Tool) was developed to overcome this difficulty and provides clinicians and health service managers with a web-based tool for Care Pathway Variance Analysis.

Assessment of implementation of integrated management of neonatal and childhood illness in India

At the current rate of decline in infant mortality, India is unlikely to achieve the Millennium Development Goal on child survival. Integrated Management of Neonatal and Childhood Illness (IMNCI), adapted from the global Integrated Management of Childhood Illness to enhance the focus on newborns and on community health workers, is the central strategy within the National Reproductive and Child Health Programme to address high infant mortality. This paper assessed the progress of IMNCI in India, identified the programme bottlenecks, and also assessed the effect on coverage of key newborn and childcare practices. Programme data were analyzed to ascertain the implementation status; rapid programme assessment was conducted for identifying the programme bottlenecks; and results of analysis of two rounds of district-level household surveys were used for comparing the change in the coverage of child-health interventions in IMNCI and control districts. More than 200,000 community health workers and first-level healthcare providers were trained during 2005-2009 at a variable pace across 223 districts. Of the reported births (n = 1,102,573), 65.5% were visited by a trained worker within 24 hours, and 63.1% were visited three times within 10 days. Poor supervision and inadequate essential supplies affected the performance of trained workers. During 2004-2008, 12 early-implementing districts had covered most key newborn and child practice indicators compared to the control districts; however, the difference was significant only for care-seeking for acute respiratory infection (net difference: 17.8%; 95% confidence interval 2.3-33.2, p < 0.026). Based on the early experience of IMNCI implementation in different states of India, measures need to be taken to improve supportive supervision, availability of essential supplies, and monitoring of the programme if the strategy has to translate into improved child survival in India.

The quality of diabetes care: a comparison between patients enrolled and not enrolled on a regional diabetes register

AIMS

To determine whether diabetic patients enrolled on a regional diabetes register that provides annual general practitioner audit and recall reports receive better care than diabetic patients not enrolled.

METHODS

Regional diabetes register enrolment status, demographic, clinical and laboratory data for the 2005 year were collected for identified diabetic patients attending 108 of 123 participating general practitioners. Means and standard deviations, or frequencies and percentages were calculated for the two study populations. Characteristics were compared with t-tests or the Chi square test.

RESULTS

3646 of 4749 identified diabetic patients were enrolled on the register and 1103 were not. The non-register population was younger by 1.8 years and for more than half of this population smoking status was unknown. Statistically significantly higher proportions of the register population had most recommended process measures (height, weight, feet, retina, urine ACR) completed within the audit interval. Higher proportions of the register population were prescribed ACE inhibitors (55 vs 47%), other antihypertensives (32 vs 27%) or lipid modifying medication (61 vs 54%). Co-morbidities were common in both groups.

CONCLUSIONS

Well-organised centralised diabetes registers provide additional benefits for people with diabetes care. Up to date primary care registers with good call-recall systems are necessary for the delivery of effective structured diabetes care.

Fewer hospitalizations result when primary care is highly integrated into a continuing care retirement community

Meeting the medical and social needs of elderly people is likely to be costly, disruptive, and at odds with personal preferences if efforts to do so are not well coordinated. We compared two different models of primary care in four different continuing care retirement communities. In the first model, used in one community, the physicians and two part-time nurse practitioners delivered clinical care only at that site, covered all settings within it, and provided all after-hours coverage. In the second model, used in three communities, on-site primary care physician hours were limited; the same physicians also had independent practices outside the retirement community; and after-hours calls were covered by all members of the practices, including physicians who did not practice on site. We found that residents in the first model had two to three times fewer hospitalizations and emergency department visits. Only 5 percent of those who died did so in a hospital, compared to 15 percent at the other sites and 27 percent nationally. These findings provide insight into what is possible when medical care is highly integrated into a residential retirement setting.

Measuring integrated care

The positive outcomes of coordination of healthcare services are to an increasing extent becoming clear. However the complexity of the field is an inhibiting factor for vigorously designed trial studies. Conceptual clarity and a consistent theoretical frame-work are thus needed. While researchers respond to these needs, patients and providers face the multiple challenges of today's healthcare environment. Decision makers, planners and managers need evidence based policy options and information on the scope of the integrated care challenges they are facing. The US managed care organization Kaiser Permanente has been put forward as an example for European healthcare systems to follow, although the evidence base is far from conclusive. The thesis has five objectives: 1) To contribute to the understanding of the concept of integration in healthcare systems and to identify measurement methods to capture the multi-dimensional aspects of integrated healthcare delivery. 2) To assess the level of integration of the Danish healthcare system. 3) To assess the use of joint health plans as a tool for coordination between the regional and local level in the Danish healthcare system. 4) To compare the inputs and performance of the Danish healthcare system and the managed care organization Kaiser Permanente, California, US. 5) To compare primary care clinicians' perception of clinical integration in two healthcare systems: Kaiser Permanente, Northern California and the Danish healthcare system. Further to examine the associations between specific organizational factors and clinical integration within each system. The literature was systematically searched to identify methods for measurement of integrated healthcare delivery. A national cross-sectional survey was conducted among major professional stake-holders at five different levels of the Danish healthcare system. The survey data were used to allow for analysis of the level of integration achieved. Data from the survey were additionally used to investigate the use of joint health planning as a tool for coordination of regional-local healthcare delivery. Analysis of secondary data from the Danish healthcare system and Kaiser Permanente, California were used to compare population characteristics, professional staff, delivery structure, utilisation, quality measures and direct costs. A cross-sectional survey among primary care clinicians in Denmark and in Kaiser Permanente, Northern California was completed to allow for comparison of clinical integration in the two systems and system specific associated factors. In this thesis a conceptual framework and a model for assessment of the conditions for integrations as an intermediate healthcare system outcome are presented. Furthermore, the results show that integrated healthcare delivery can be measured: 24 methods are available and some are highly developed. However, the field is still in its early phase and guidelines for how to proceed are devised. It was confirmed on a national level that integration of care is a widespread challenge, and that only half or less than half of patients in need of integrated services receive such care. Options for decision makers and managers are discussed. From a theoretical perspective joint health plans as applied in Denmark do not match the degree of complexity in the healthcare system. It was therefore in agreement with the theoretical findings when major stakeholders agreed that the joint health plans had not been effective as a tool for coordination. Joint health planning processes should actively engage all stakeholders and a high degree of recurrent feedback are warranted. When comparing Kaiser Permanente, California with the Danish healthcare system, our study suggest that Kaiser Permanente has a population with more documented disease and higher operating costs, and performs better than the Danish healthcare system on the observed quality measures. Substantial differences were found in the perception of clinical integration in the two settings. More primary care clinicians in the Northern California region of Kaiser Permanente reported being part of a clinical integrated environment than did Danish general practitioners. By measuring the level of clinical integration in Kaiser Permanente using the Danish healthcare system as a point of reference our findings support the literature that points to the importance of integrated healthcare delivery as a driver for the performance results of Kaiser Permanente. However caution must be advised before making concrete conclusions due to the complexity of the matter and until more studies have been conducted. With this thesis an initial step has been taken into a new research field. Ongoing research will make it possible to deliver the evidence needed by decision makers, planners and managers - ultimately to benefit the patients.