A case vignette study to refine the target group of an intermediate care model: the Acute Geriatric Community Hospital

PURPOSE

To refine the admission criteria of the Acute Geriatric Community Hospital (AGCH) by defining its target group boundaries with (geriatric) hospital care and other bed-based intermediate care models in the Netherlands.

METHODS

A qualitative study consisting of a three-phase refinement procedure with case vignettes. Physicians, medical specialists, nurse practitioners, and physician assistants in hospitals (n = 10) or intermediate care facilities (n = 10) in the Netherlands participated. They collected case vignettes from clinical practice (phase one). The referral considerations and decisions for each case were then documented through surveys (phase two) and two focus groups (phase 3). For thematic data analysis, inductive and deductive approaches were used.

RESULTS

The combination of medical specialist care (MSC) and medical generalist care (MGC), is unique for the AGCH compared to other intermediate care models in the Netherlands. Compared to (geriatric) hospital care, the AGCH offers a more limited scope of MSC. Based on these findings, 13 refined admission criteria were developed such as 'The required diagnostic tests to monitor the effectiveness of treatment are available at the AGCH'. Besides admission criteria, additional clinical and organizational considerations played a role in referral decision-making; 10 themes were identified.

CONCLUSION

This case vignette study defined the target group boundaries between the AGCH and other care models, allowing us to refine the AGCH admission criteria. Our findings may help to determine the required competencies of the interdisciplinary AGCH team and to develop triage instruments. The identified consideration themes can be used as conceptual framework in further research. The findings may also be of interests for healthcare systems outside the Netherlands who aspire to design integrated care for older people closer to home.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.