Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe

Time to Diagnosis and Presenting Symptoms of Patients Diagnosed With Cancer Through Emergency and Nonemergency Routes: A Large Retrospective Study From a High-Volume Center

PURPOSE

The symptoms with which a patient with cancer presents and the route taken to diagnosis (emergency v nonemergency) may affect the speed with which the diagnosis of cancer is made, thereby affecting outcomes. We examined time to diagnosis by symptom for cancers diagnosed through emergency and nonemergency routes (NERs).

METHODS

We performed a retrospective review of patients diagnosed with 10 solid cancers at Hospital Clínic of Barcelona between March 2013 and June 2023. Cancers were diagnosed through emergency presentation and admission (inpatient emergency route [IER]), emergency presentation and outpatient referral (outpatient emergency route [OER]), and primary care presentation and outpatient referral (NER). We assessed the effect of diagnostic routes on intervals to diagnosis for 19 cancer symptoms.

RESULTS

A total of 5,174 and 1,607 patients were diagnosed with cancer through emergency routes and NERs, respectively. Over 85% of patients presenting with alarm (localizing) symptoms such as hematuria through emergency routes were diagnosed with the expected cancer, whereas those with nonlocalizing symptoms such as abdominal pain had a more heterogeneous cancer-site composition. Median intervals were shorter for alarm than nonlocalizing symptoms and tended to be shorter in IERs than OERs. However, for most symptoms, intervals in both routes were invariably shorter than in the NER. For example, diagnostic intervals for hematuria and abdominal pain were 3 and 5 days shorter in IERs than OERs, but they were 5-8 and 17-22 days shorter than in the NER, respectively.

CONCLUSION

For patients with alarm symptoms, intervals were shorter than for those with nonlocalizing symptoms and, for most symptoms, intervals were shorter when patients were evaluated by emergency routes rather than NERs.

Patient satisfaction and outcomes of crisis resolution home treatment for the management of acute psychiatric crises: a study during the COVID-19 pandemic in Madrid

Background

Crisis Resolution Home Treatment (CRHT) seem to offer comparable results to the traditional hospitalization model, at a lower cost and offering greater flexibility and scope. However, in Madrid, its implementation in Mental Health did not occur until the midst of the COVID-19 pandemic. In this work we analysed the effectiveness of a mental health CRHT unit promoted during the COVID-19 pandemic, as well as the degree of satisfaction of patients and their families.

Methods

90 patients were treated by the CRHT unit in the period between October 2020 and June 2022. All patients met the inclusion criteria: (1) Acute psychopathological decompensation in patients suffering from psychotic disorders, major affective disorder, obsessive compulsive disorder, personality disorder and other severe mental disorders causing functional disability, according to ICD-10 diagnostic criteria; (2) Ages between 18-90 years old; (3) Living in the urban area of Vallecas, Madrid; and (4) Counting with sufficient social and family support. The effectiveness of the intervention was evaluated with the SF-36 health questionnaire, the caregiver burden with the Zarit questionnaire, and patient satisfaction with a survey specifically designed for this work.

Results

55 (61.1%) patients completed the SF-36 at baseline and at the end of hospitalization. Statistically significant improvements were observed in the 8 dimensions of the SF-36 (p < 0.05). However, CRHT did not achieve a statistically significant decrease in caregiver burden. Regarding the satisfaction of the patients with the attention and care received, an average score of 47.72/50 was obtained.

Conclusion

The Crisis Resolution Home Treatment intervention resulted in significant improvement in patients' quality of life with high satisfaction scores. However, it did not effectively reduce caregiver burden. Future research should focus on randomized controlled trials with long-term follow-up to assess the effectiveness of CRHT compared to traditional hospitalization and utilize specific assessment scales for different mental disorders.

Delays in Cancer Diagnostic Testing at a Quick Referral Unit in Spain during COVID-19

Although COVID-19 has had dire consequences on diagnosis of cancer, little data assessing its impact on the whole range of diagnostic activity relevant to cancer are available. We examined trends in the provision of full diagnostic tests for consecutive patients with suspected cancer referred to an academic hospital-based Quick Diagnosis Unit from January 2019 to December 2020. As weekly volumes declined, waiting times for endoscopic, imaging and biopsy/cytology procedures increased steeply during the COVID-impacted period (26 February-28 April 2020). The average weekly increase compared with the same period in 2019 was substantial for invasive procedures requiring admission (200.70%), CT scans (171.20%), GI endoscopy (161.50%), PET/CT scans (152.50%), ultrasonography (148.40%), and ambulatory biopsy/cytology procedures (111.20%). Volumes and waiting times to other procedures showed similar trends. There was a remarkable downward trend in cancer diagnosis during the COVID-impacted period, with a 54.07% reduction compared with the same weeks in 2019. Despite a modest recovery in the following months, the decline in weekly activity and cancer rates persisted until 30 December. Providing insight into how COVID-19 changed the full spectrum of diagnostic activity for suspected cancer informs resilience-building interventions to guarantee access to fast and efficient diagnostics ahead of new threats.

The role of patient navigators in ambulatory care: overview of systematic reviews

BACKGROUND

Patient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.

METHODS

An overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679  articles were included for full-text screening.

RESULTS

Eleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.

CONCLUSIONS

Patient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

The impact of Covid-19 on patients with suspected cancer: An analysis of ED presentation and referrals to a quick diagnosis unit

Purpose

Patients evaluated in the emergency department (ED) who have concerning symptoms suggestive of a cancer diagnosis are mostly referred to the quick diagnosis unit of our tertiary hospital. This study analyzed the impact of the Covid-19 pandemic on the volume, disease patterns, and accessibility to essential investigations of patients with suspected cancer referred by the ED to this unit.

Methods

Trends in referrals were analyzed from January 1 to July 8, 2020 and the corresponding dates of 2019. Only non-Covid-19 conditions were evaluated. Three time-based cohorts were defined: prepandemic (January 1–February 19), pandemic (February 19–April 22), and postpandemic (April 22–July 8). Along with descriptive statistics, linear regression was used to test for time trends with weekly referrals as the dependent variable.

Results

There were 384, 193, and 450 patients referred during the prepandemic, pandemic, and postpandemic periods, respectively. Following an increasing rate, referrals decreased to unprecedented levels in the pandemic period (average weekly slope: −2.1 cases), then increasing again until near normalization. Waiting times to most diagnostic procedures including radiology, endoscopic, nuclear medicine, and biopsy/cytology during the pandemic period were significantly delayed and time-to-diagnosis was considerably longer (19.72 ± 10.37 days vs. 8.33 ± 3.94 days in prepandemic and 13.49 ± 6.45 days in postpandemic period; P < 0.001 in both). Compared to other cohorts, pandemic cohort patients were more likely to have unintentional weight loss and fever of unknown origin as referral indications while anemia and lymphadenopathy were less common. Patients from the pandemic cohort had a significantly lower rate of malignancies and higher of benign gastrointestinal disorders (40.93% vs. 19.53% and 20.89% in prepandemic and postpandemic periods, respectively; P < 0.001 in both), most notably irritable bowel disease, and of mental and behavioral disorders (15.54% vs. 3.39% and 6.00% in prepandemic and postpandemic periods, respectively; P < 0.001 in both).

Conclusions

As our hospital switched its traditional care to one focused on Covid-19 patients, recognized indicators of healthcare quality of quick diagnosis units were severely disrupted. The clinical patterns of presentation and diagnosis of the pandemic period suggested that mass media-generated mental and behavioral responses with distressing symptoms played a significant role in most of these patients.

A comparative cost analysis between two quick diagnosis units of different levels of complexity

Aim: To compare by micro-costing the costs incurred by quick diagnosis units of tertiary and second-level hospitals. Patients & methods: We included 407 patients from a tertiary and secondary hospital unit. A bottom-up approach was applied. Results: Cost per patient was €577.5 ± 219.6 in the tertiary versus €394.7 ± 92.58 in the secondary unit (p = 0.0559). Mean number of visits and ratio of successive/first visits were significantly higher in the former (3.098 and 2.07 vs 2.123 and 1.12, respectively). Personnel and indirect costs including their percent contribution to overall costs accounted for the main differences. Conclusion: A greater volume of appointments, number of staff and staff time and a greater complexity of patients from the tertiary hospital unit justified the differences in cost outcomes.

What Really Matters? Organizational Versus Regional Determinants of Hospitals Providing Medical Service Centres

By adding medical service centres (MSCs) to their range of services, hospitals can participate in the outpatient sector. The aim of the MSC guideline (2004) was to ensure high quality health care in rural areas. It is unknown if organizational or regional factors influence hospitals providing services via MSCs. Our analyses focus on the identification of factors that explain the operation of an MSC by hospitals. The data are based on the mandatory structured quality reports of German hospitals (n = 1,605). These organizational data (teaching status, size and ownership) are supplemented by settlement structure and contextual data (e.g., location, doctor density). We estimated a cross-sectional multilevel logistic regression model to identify determinants of hospitals operating MSCs. In 2017, 27% of 1,605 hospitals had one or more MSCs. On an organizational level, for-profit ownership (-) and the number of beds (+) were significant determinants of providing MSCs. The analyses show that the interaction between settlement structure and ownership has an influence on the operation of an MSC. Organizational factors determine the provision of MSCs, with regional determinants playing a role as well. This indicates that hospital behaviour is difficult to predict and that individual factors shape both profit orientation and responsibility for sufficient health care in the region.

Trends in Hospitalization of Patients with Potentially Serious Diseases Evaluated at a Quick Diagnosis Clinic

Although quick diagnosis units (QDU) have become a cost-effective alternative to inpatient admission for diagnosis of potentially serious diseases, the rate of return hospitalizations among evaluated patients is unknown. This study examined the temporal trends in admissions of QDU patients through 15 years. Adult patients referred to QDU from 2004 to 2019 who were hospitalized between the first and last visit in the unit were eligible. Decisions about admissions were mainly based on the Appropriateness Evaluation Protocol and required independent validation by experienced clinicians using a customized tool. The final analysis included 825 patients. Patient characteristics and major reasons for admission were compared each year and linear trends were analyzed. Admission rates decreased from 7.2% in 2004–2005 to 4.3% in 2018–2019 (p < 0.0001). While a significant increasing trend was observed in the rate of admissions due to cancer-related complications (from 39.5% in 2004–2005 to 61.7% in 2018–2019; p < 0.0001), those due to anemia-related complications and scheduled invasive procedures experienced a significant downward trend. A likely explanation for these declining trends was the relocation of the unit to a new daycare center in 2013–2014 with recovery rooms and armchairs for IV treatments. The facts of this study could help in the provision of anticipatory guidance for the optimal management of patients at risk of clinical complications.

Hospital at Home: An Overview of Literature

The development of new management solutions is needed to generate great changes in the health sector, especially in addressing the current collision course between growing health care demands, rising costs, and limited resources. One of these solutions is the hospital at home (HAH). This article aims to explore the existing literature, regarding possible health gains and economical outcomes in HAH programs versus traditional inpatient hospitalization. A search of literature was conducted to identify papers regarding HAH programs and their respective health and economical outcomes. The concept of HAH encompasses different levels or care schemes. Several examinations and treatments can be carried out at home. Hospital at home may optimize patient flow and relieve pressure on hospital bed availability. However, questions are raised regarding the uncertainty of the efficacy of HAH and the limited evidence on which model setting is most appropriate.