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Zhou K, Vidyarthi AR, Wong CH, Matchar D. Where to go if not the hospital? Reviewing geriatric bed utilization in an acute care hospital in Singapore. Geriatr Gerontol Int 2017; 17:1575-1583. [PMID: 28188966 DOI: 10.1111/ggi.12936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/25/2016] [Accepted: 09/20/2016] [Indexed: 11/29/2022]
Abstract
AIM Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25 years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients. METHODS We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns. RESULTS Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity = 62%; specificity = 88%). CONCLUSIONS In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.
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Affiliation(s)
- Ke Zhou
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Arpana R Vidyarthi
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Medicine, National University Health System, Singapore
| | - Chek Hooi Wong
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Geriatric Education and Research Institute, Singapore.,Department of Geriatric Medicine, Alexandra Health System, Singapore
| | - David Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Sanclemente-Ansó C, Salazar A, Bosch X, Capdevila C, Giménez-Requena A, Rosón-Hernández B, Corbella X. Perception of quality of care of patients with potentially severe diseases evaluated at a distinct quick diagnostic delivery model: a cross-sectional study. BMC Health Serv Res 2015; 15:434. [PMID: 26420244 PMCID: PMC4589195 DOI: 10.1186/s12913-015-1070-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 09/17/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although hospital-based outpatient quick diagnosis units (QDU) are an increasingly recognized cost-effective alternative to hospitalization for the diagnosis of potentially serious diseases, patient perception of their quality of care has not been evaluated well enough. This cross-sectional study analyzed the perceived quality of care of a QDU of a public third-level university hospital in Barcelona. METHODS One hundred sixty-two consecutive patients aged ≥ 18 years attending the QDU over a 9-month period were invited to participate. A validated questionnaire distributed by the QDU attending physician and completed at the end of the first and last QDU visit evaluated perceived quality of care using six subscales. RESULTS Response rate was 98 %. Perceived care in all subscales was high. Waiting times were rated as 'short'/'very short' or 'better'/'much better' than expected by 69-89 % of respondents and physical environment as 'better'/'much better' than expected by 94-96 %. As to accessibility, only 3 % reported not finding the Unit easily and 7 % said that frequent travels to hospital for visits and investigations were uncomfortable. Perception of patient-physician encounter was high, with 90-94 % choosing the positive extreme ends of the clinical information and personal interaction subscales items. Mean score of willingness to recommend the Unit using an analogue scale where 0 was 'never' and 10 'without a doubt' was 9.5 (0.70). On multivariate linear regression, age >65 years was an independent predictor of clinical information, personal interaction, and recommendation, while age 18-44 years was associated with lower scores in these subscales. No schooling predicted higher clinical information and recommendation scores, while university education had remarkable negative influence on them. Having ≥4 QDU visits was associated with lower time to diagnosis and recommendation scores and malignancy was a negative predictor of time to diagnosis, clinical information, and recommendation. DISCUSSION It is worthy of note that the questionnaire evaluated patient perception and opinions of healthcare quality including recommendation rather than simply satisfaction. It has been argued that perception of quality of care is a more valuable approach than satisfaction. In addition to embracing an affective dimension, satisfaction appears more dependent on patient expectations than is perception of quality. CONCLUSIONS While appreciating that completing the questionnaire immediately after the visit and its distribution by the QDU physician may have affected the results, scores of perceived quality of care including recommendation were high. There were, however, significant differences in several subscales associated with age, education, number of QDU visits, and diagnosis of malignant vs. benign condition.
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Affiliation(s)
- Carmen Sanclemente-Ansó
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Albert Salazar
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c/Villarroel 170, 08036, Barcelona, Spain.
| | - Cristina Capdevila
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Amparo Giménez-Requena
- Department of Quality, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Beatriz Rosón-Hernández
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Biomedical Research Institute (IDIBELL), Consultas Externas, Area de Gestión Administrativa, c/Feixa Llarga s/n, 08907-L'Hospitalet de Llobregat, Barcelona, Spain. .,Global Institute of Public Health and Health Policy, School of Medicine, International University of Catalonia, Barcelona, Spain.
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Ooi CK, Foo CL, Vasu A, Seow E. Community Stepdown Care: A Safe Alternative for Selected Elderly Patients Attending Emergency Department? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/410931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background. The Community Stepdown Care Initiative attempts to provide right siting of care for elderly emergency department attendees whose main need is rehabilitation. Objectives. The aim of this study was to compare reattendance and rehospitalisation rates, length of stay, medical complication rates, and discharge destination between the community hospital cohort and the acute hospital cohort. Methods. A retrospective cohort study was conducted from June 2007 to November 2008. Results. Two hundred and thirty patients were enrolled in the study. 68 patients were successfully transferred to stepdown care; 162 patients were admitted to acute hospital. The odds ratio of reattendance was similar in both cohorts at 2 weeks, 6 months, and 12 months. The odds ratio of rehospitalisation was similar in both cohorts at 2 weeks, 3 months, 6 months, and 12 months. There was no statistical difference in the medical complication rates between the cohorts. Patients were more likely to be discharged home from the community hospital compared to acute hospital (adjusted OR 4.11, P=0.03). 14% of patients from the acute hospital cohort was discharged to community hospital. Conclusions. For selective elderly emergency department attendees whose predominant need is rehabilitation, stepdown care is a safe alternative compared to usual acute hospital care.
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Affiliation(s)
- Chee Kheong Ooi
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Chik Loon Foo
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Alicia Vasu
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Eillyne Seow
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
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Mytton OT, Oliver D, Mirza N, Lippett J, Chatterjee A, Ramcharitar K, Maxwell J. Avoidable acute hospital admissions in older people. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/bjhc.2012.18.11.597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - David Oliver
- Medicine and Elderly Care, Royal Berkshire NHS Foundation Trust
| | | | - Janet Lippett
- Medicine and Elderly Care, Royal Berkshire NHS Foundation Trust
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Estey A, Ness K, Saunders LD, Alibhai A, Bear RA. Understanding the causes of overcrowding in emergency departments in the Capital Health Region in Alberta: a focus group study. CAN J EMERG MED 2012; 5:87-94. [PMID: 17475097 DOI: 10.1017/s1481803500008216] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To determine the perceptions of health care professionals and service providers with regard to emergency department (ED) overcrowding, including definitions of overcrowding, characteristics of an overcrowded ED, and causes of overcrowding, and secondarily to solicit potential solutions to the problem. METHODS Focus groups were conducted with front-line staff, physicians and managers from 7 EDs within an integrated health region. Participants received questions before the sessions, and an experienced moderator conducted the sessions and prepared transcripts from audio tapes. Analyses included identification of key themes and the interrelationships between those themes. RESULTS Focus group participants defined service pressures that result in overcrowding as "anything that impedes the flow of patients through the ED, affects the quality of care delivered or results in patient frustration and stress to staff." Overcrowding, which can occur at any time of the day, was perceived to have many causes, including some seasonal factors. Two key problems were identified as causing many spin-off pressures: inefficient access to ED beds (stretchers) because of slow throughput of patients and staff shortages. Other perceived causes included the changing role and use of EDs and limited access to services such as home care, diagnostic imaging, laboratory services, social services and specialist care. Participants generally believed that the characteristics and causes of overcrowding could not be viewed independently; rather, in the search for remedies, they should be considered as interrelated variables. CONCLUSION Qualitative studies of this complex issue can identify and describe complex interactions in real-world settings. The findings of such studies can lead to quantitative studies involving objective measurement.
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Affiliation(s)
- Angela Estey
- Clinical Performance, Information and Research, Capital Health Authority, Edmonton, Alberta, Canada
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Liotta G, Mancinelli S, Scarcella P, Emberti Gialloreti L. Determinants of acute hospital care use by elderly patients in Italy from 1996 to 2006. Arch Gerontol Geriatr 2012; 54:e364-9. [DOI: 10.1016/j.archger.2011.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/29/2011] [Accepted: 08/01/2011] [Indexed: 11/16/2022]
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Johansen IH, Morken T, Hunskaar S. How Norwegian casualty clinics handle contacts related to mental illness: A prospective observational study. Int J Ment Health Syst 2012; 6:3. [PMID: 22520067 PMCID: PMC3434113 DOI: 10.1186/1752-4458-6-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 04/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-threshold and out-of-hours services play an important role in the emergency care for people with mental illness. In Norway casualty clinic doctors are responsible for a substantial share of acute referrals to psychiatric wards. This study's aim was to identify patients contacting the casualty clinic for mental illness related problems and study interventions and diagnoses. METHODS At four Norwegian casualty clinics information on treatment, diagnoses and referral were retrieved from the medical records of patients judged by doctors to present problems related to mental illness including substance misuse. Also, routine information and relation to mental illness were gathered for all consecutive contacts to the casualty clinics. RESULTS In the initial contacts to the casualty clinics (n = 28527) a relation to mental illness was reported in 2.5% of contacts, whereas the corresponding proportion in the doctor registered consultations, home-visits and emergency call-outs (n = 9487) was 9.3%. Compared to other contacts, mental illness contacts were relatively more urgent and more frequent during night time. Common interventions were advice from a nurse, laboratory testing, prescriptions and minor surgical treatment. A third of patients in contact with doctors were referred to in-patient treatment, mostly non-psychiatric wards. Many patients were not given diagnoses signalling mental problems. When police was involved, they often presented the patient for examination. CONCLUSIONS Most mental illness related contacts are managed in Norwegian casualty clinics without referral to in-patient care. The patients benefit from a wide range of interventions, of which psychiatric admission is only one.
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Affiliation(s)
- Ingrid H Johansen
- National Centre for Emergency Primary Health Care, Uni Health, Uni Research, Kalfarveien 31, 5018, Bergen, Norway.
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Bosch X, Palacios F, Inclán-Iríbar G, Castañeda M, Jordán A, Moreno P, Coca A, López-Soto A. Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: a paradigm shift in public health systems? Eur J Intern Med 2012; 23:159-64. [PMID: 22284247 DOI: 10.1016/j.ejim.2011.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 02/10/2011] [Accepted: 02/16/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute hospital bed utilisation is a growing concern for health care systems in most countries with public health models, as it represents a significant share of health costs. Anaemia with haemoglobin levels below 8 g/l has traditionally been a criterion used to hospitalise patients in our centre for diagnosis. METHODS We conducted a longitudinal study with a prospective and retrospective cohort to investigate the usefulness of a Quick Diagnosis Unit (QDU) for the evaluation of patients with severe anaemia as compared with hospitalisation in a tertiary public hospital. We recorded pretransfusion haemoglobin and haematocrit values, Charlson comorbidity index, waiting time for the first visit, time to diagnosis (length-of-stay in hospitalised patients), final diagnosis, costs, and responses to an opinion survey. RESULTS QDU patients were significantly younger [65.63 years (17.44)] than hospitalised patients [76.11 years (12.68)] (P<.0001). No significant differences were observed regarding time to diagnosis/length-of-stay, haemoglobin concentrations and Charlson index. Iron-deficiency anaemia was the commonest type of anaemia in both cohorts and benign digestive lesions accounted for most cases. The mean cost per process (admission-discharge episode) was 2920.62 Euros in the QDU and 18,278.01 Euros in hospitalised patients. If further diagnostic tests were required, 85% of patients would prefer the QDU care model to conventional hospital admission. CONCLUSIONS For diagnostic purposes, patients with severe anaemia can be managed similarly in a QDU or in-hospital setting, but the QDU model is more cost-saving than traditional hospitalisation. Most QDU patients preferred the QDU model to hospital admission.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigació Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
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Bosch X, Jordán A, Coca A, López-Soto A. Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain. J Hosp Med 2012; 7:41-7. [PMID: 22135217 DOI: 10.1002/jhm.931] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/20/2011] [Accepted: 03/21/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We describe the functioning of a quick diagnosis unit (QDU) in a Spanish public university hospital to ascertain the utility and cost of the model compared to conventional hospitalization. DESIGN Observational study with a prospective and retrospective cohort. SETTING Spanish tertiary public university hospital. PATIENTS Two thousand consecutive patients evaluated between December 2007 and July 2010 with potentially severe diseases normally requiring hospitalization for diagnosis. For comparative purposes, we analyzed a randomized, retrospective cohort of 1454 hospitalized patients. MEASUREMENTS Variables measured included source of referral, reason for consultation, time to diagnosis and length-of-stay, hospitalizations avoided, Charlson comorbidity index, costs, and patient satisfaction using a telephone survey. RESULTS Suspected anemia, cachexia-anorexia syndrome, febrile syndrome, adenopathies and/or palpable masses, abdominal pain, diarrhea, and lung abnormalities accounted for 88% of QDU patients. The most-frequent diagnoses were cancer (26.3%) and iron-deficiency anemia. QDU patients with anemia were significantly younger than hospitalized patients with the same diagnosis (P < 0.0001). Other parameters were similar between QDU and hospitalized patients. The mean cost of treatment was 3153.87 Euros for hospitalization and 702.33 Euros for the QDU. Patients expressed a high degree of satisfaction with QDU care. CONCLUSIONS QDUs can manage the diagnosis of patients with potentially severe diseases equally as well as traditional hospitalization, and saves costs. QDU patients expressed a high degree of satisfaction, with most preferring this model to hospitalization.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
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Bosch X, Foix A, Jordan A, Coca A, López-Soto A. Outpatient Quick Diagnosis Units for the evaluation of suspected severe diseases: an observational, descriptive study. Clinics (Sao Paulo) 2011; 66:737-41. [PMID: 21789373 PMCID: PMC3109368 DOI: 10.1590/s1807-59322011000500005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/02/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospitals in countries with public health systems have recently adopted organizational changes to improve efficiency and resource allocation, and reducing inappropriate hospitalizations has been established as an important goal. AIMS Our goal was to describe the functioning of a Quick Diagnosis Unit in a Spanish public university hospital after evaluating 1,000 consecutive patients. We also aimed to ascertain the degree of satisfaction among Quick Diagnosis Unit patients and the costs of the model compared to conventional hospitalization practices. DESIGN Observational, descriptive study. METHODS Our sample comprised 1,000 patients evaluated between November 2008 and January 2010 in the Quick Diagnosis Unit of a tertiary university public hospital in Barcelona. Included patients were those who had potentially severe diseases and would normally require hospital admission for diagnosis but whose general condition allowed outpatient treatment. We analyzed several variables, including time to diagnosis, final diagnoses and hospitalizations avoided, and we also investigated the mean cost (as compared to conventional hospitalization) and the patients' satisfaction. RESULTS In 88% of cases, the reasons for consultation were anemia, anorexia-cachexia syndrome, febrile syndrome, adenopathies, abdominal pain, chronic diarrhea and lung abnormalities. The most frequent diagnoses were cancer (18.8%; mainly colon cancer and lymphoma) and Iron-deficiency anemia (18%). The mean time to diagnosis was 9.2 days (range 1 to 19 days). An estimated 12.5 admissions/day in a one-year period (in the internal medicine department) were avoided. In a subgroup analysis, the mean cost per process (admission-discharge) for a conventional hospitalization was 3,416.13 Euros, while it was 735.65 Euros in the Quick Diagnosis Unit. Patients expressed a high degree of satisfaction with Quick Diagnosis Unit care. CONCLUSIONS Quick Diagnosis Units represent a useful and cost-saving model for the diagnostic study of patients with potentially severe diseases. Future randomized study designs involving comparisons between controls and intervention groups would help elucidate the usefulness of Quick Diagnosis Units as an alternative to conventional hospitalization.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacio Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
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Wong ELY, Yam CHK, Chan FWK, Cheung AWL, Wong FYY, Griffiths S, Yeoh EK. Perspective from health professionals on delivery of sub-acute care in Hong Kong: a qualitative study in a health system. Health Policy 2010; 100:211-8. [PMID: 21109327 DOI: 10.1016/j.healthpol.2010.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/29/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The perception and understanding of health professionals of the role of sub-acute care in the health system will have an impact on the potential effectiveness in preventing unnecessary hospitalization. This study aims to explore the perceived role and quality of sub-acute care services in the context of Hong Kong from the perspective of health service providers and to identify barriers to effectiveness. METHODS Seven focus groups were conducted and the discussion was led by a guide covering three main areas: definition/component/role of sub-acute, difficulties in the sub-acute care services provision, and suggestion for further improvement in the provision of sub-acute care. RESULTS The participants highlighted the positive role of sub-acute to promote patient's health and quality of life so as to reduce unnecessary hospitalization. The potential barriers in the sub-acute care identified were interrelated and focused mainly on systemic issues including lack of service coordination, specialist input and resources. The participants also suggested a number of practical ways to improve the quality of sub-acute care services. CONCLUSIONS The findings showed a need for further improvement in the process of sub-acute care by developing operation guideline and re-evaluating the allocation of resources to support the sub-acute care provision.
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Affiliation(s)
- Eliza L Y Wong
- Division of Health Systems, Policy and Management, School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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Bosch X, Aibar J, Capell S, Coca A, López‐Soto A. Quick diagnosis units: a potentially useful alternative to conventional hospitalisation. Med J Aust 2009; 191:496-8. [DOI: 10.5694/j.1326-5377.2009.tb02912.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 07/01/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jesús Aibar
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Antonio Coca
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Alfons López‐Soto
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Hammond CL, Phillips MF, Pinnington LL, Pearson BJ, Fakis A. Appropriateness of acute admissions and last in-patient day for patients with long term neurological conditions. BMC Health Serv Res 2009; 9:40. [PMID: 19250523 PMCID: PMC2653500 DOI: 10.1186/1472-6963-9-40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 02/27/2009] [Indexed: 11/16/2022] Open
Abstract
Background To examine the appropriateness of admissions and in-patient stay for patients with long term neurological conditions (LTNCs). To identify variables predictive of appropriateness and explore management alternatives. Methods Adults admitted as acute patients to Derby Hospitals NHS Foundation Trust (England). Data were collected prospectively and examined by a multi-disciplinary expert panel to determine the appropriateness of admission and length of stay (LoS). Management alternatives were discussed. Results A total of 119 participants were recruited. 32 admissions were inappropriate and 83 were for an inappropriate duration. Whether a participant lived in their own home was predictive of an inappropriate admission. The number of LTNCs, number of presenting complaints and whether the participant lived alone in their own home were predictive of an inappropriate LoS. For admissions judged to be inappropriate, the panel suggested management alternatives. Conclusion Patients with LTNCs are being admitted to hospital when other services, e.g. ambulatory care, are available which could meet their needs. Inefficiencies in hospital procedures, such as discharge planning and patient transfers, continue to exist. Recognition of the need to plan for discharge at admission and to ensure in-patient services are provided in a timely manner may contribute towards improved efficiency.
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Affiliation(s)
- Christina L Hammond
- Rehabilitation Research and Education Group, School of Community Health Sciences, University of Nottingham, UK.
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Heaney D, Black C, O'Donnell CA, Stark C, van Teijlingen E. Community hospitals--the place of local service provision in a modernising NHS: an integrative thematic literature review. BMC Public Health 2006; 6:309. [PMID: 17184517 PMCID: PMC1769373 DOI: 10.1186/1471-2458-6-309] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 12/21/2006] [Indexed: 11/10/2022] Open
Abstract
Background Recent developments within the United Kingdom's (UK) health care system have re-awakened interest in community hospitals (CHs) and their role in the provision of health care. This integrative literature review sought to identify and assess the current evidence base for CHs. Methods A range of electronic reference databases were searched from January 1984 to either December 2004 or February 2005: Medline, Embase, Web of Knowledge, BNI, CINAHL, HMIC, ASSIA, PsychInfo, SIGLE, Dissertation Abstracts, Cochrane Library, Kings Fund website, using both keywords and text words. Thematic analysis identified recurrent themes across the literature; narrative analyses were written for each theme, identifying unifying concepts and discrepant issues. Results The search strategy identified over 16,000 international references. We included papers of any study design focussing on hospitals in which care was led principally by general practitioners or nurses. Papers from developing countries were excluded. A review of titles revealed 641 potentially relevant references; abstract appraisal identified 161 references for review. During data extraction, a further 48 papers were excluded, leaving 113 papers in the final review. The most common methodological approaches were cross-sectional/descriptive studies, commentaries and expert opinion. There were few experimental studies, systematic reviews, economic studies or studies that reported on longer-term outcomes. The key themes identified were origin and location of CHs; their place in the continuum of care; services provided; effectiveness, efficiency and equity of CHs; and views of patients and staff. In general, there was a lack of robust evidence for the role of CHs, which is partly due to the ad hoc nature of their development and lack of clear strategic vision for their future. Evidence for the effectiveness and efficiency of the services provided was limited. Most people admitted to CHs appeared to be older, suggesting that admittance to CHs was age-related rather than condition-related. Conclusion Overall the literature surveyed was long on opinion and short of robust studies on CHs. While lack of evidence on CHs does not imply lack of effect, there is an urgent need to develop a research agenda that addresses the key issues of health care delivery in the CH setting.
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Affiliation(s)
- David Heaney
- Centre for Rural Health, University of Aberdeen, The Green House, Beechwood Business Park, Inverness IV2 2BL, UK
| | - Corri Black
- Department of Public Health, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Catherine A O'Donnell
- General Practice & Primary Care, Division of Community-based Sciences, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK
| | - Cameron Stark
- NHS Highland and Department of Public Health, University of Aberdeen, Aberdeen AB25 2ZD, UK
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Lyon D, Miller J, Pine K. The Castlefields Integrated Care Model: The Evidence Summarised. JOURNAL OF INTEGRATED CARE 2006. [DOI: 10.1108/14769018200600003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rentsch D, Luthy C, Perneger TV, Allaz AF. Hospitalisation process seen by patients and health care professionals. Soc Sci Med 2003; 57:571-6. [PMID: 12791498 DOI: 10.1016/s0277-9536(02)00404-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Appropriate use of hospitalisation is an important concern in most countries. Previous studies have relied on professional opinion regarding the appropriateness of hospital stays, neglecting the patients' point of view. The purpose of this cross-sectional study was to assess the patients' point of view about the appropriateness of their hospital stay and to evaluate agreement with health care providers' opinions. It was undertaken in a medical rehabilitation division of the University Hospitals of Geneva in Switzerland. Patients reported their opinion on the justification of their hospital stay on the day of the interview, the reason why they judged their stay to be appropriate, and the place where they should be if not. The patients' health care providers answered the same questions. Two-hundred and fifty-four patients contributed to the evaluation of 314 days of hospitalisation. Only 20 hospital days (6%) were considered unjustified by patients, compared to 63 (20%) by health care providers (p<0.001). There was no agreement between these two judgements (Kappa=0.00,95% CI: -0.09 to +0.09). Similarly, there was little or no agreement concerning the reasons justifying the stay (Kappa=0-0.47) and concerning discharge planning. These results suggest that the definition of an appropriate hospital stay is complex and depends upon each actor's point of view. Better communication between patients and health care providers about decisions related to the hospitalisation process would be desirable.
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Affiliation(s)
- Denis Rentsch
- Department of Internal Medicine, Clinic of Internal Medicine of Rehabilitation, Beau-Séjour, University Hospitals of Geneva, CH-1211 Geneva 14, Switzerland.
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Abstract
Research on inappropriate hospital admissions has tended to neglect the views of the referring doctors and the patients. In this study, the Appropriateness Evaluation Protocol was applied to a random sample of 102 emergency medical admissions. The patients and doctors were then presented with a list of possible alternatives to admission that might have been used at the point of referral. Case notes were available for 88 patients. As judged by these, 28% of admissions were inappropriate, the commonest reason being the potential for treatment or tests to have been performed as outpatient procedures; next commonest was the possibility of lower level care. The response rate to the questionnaires was about two-thirds, for both doctors and patients. Of the general practitioners and casualty doctors who responded, 60% specified alternatives to admission that they would have considered, and the equivalent figure for patients was 70%. For both groups the major preferences were same-day outpatient assessment and admission to a community hospital. Referring doctors and patients, in this survey, favoured alternatives to acute medical care in proportions much higher than that of supposedly inappropriate admission.
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Affiliation(s)
- J Campbell
- Bishop's Castle Medical Practice, Schoolhouse Lane, Bishop's Castle, Shropshire SY9 5BP, UK.
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18
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Glasby J, Littlechild R. Inappropriate hospital admissions: patient participation in research. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2001; 10:738-41. [PMID: 12048492 DOI: 10.12968/bjon.2001.10.11.10436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/01/2001] [Indexed: 11/11/2022]
Abstract
Although political interest in reducing the number of inappropriate hospital admissions is mounting, methods for researching the rate of inappropriate admissions have several major limitations. Whereas traditional studies have tended to be predominantly subjective, more recent studies using clinical review instruments also have a number of limitations. Chief among these is the failure to consider the potential input of the individual patient. To illustrate some of the possible benefits of patient participation, this article cites findings from a study in Birmingham, which sought to involve individual older people in a research study into emergency hospital admissions.
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Affiliation(s)
- J Glasby
- Department of Social Policy and Social Work, University of Birmingham
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Boston NK, Boynton PM, Hood S. An inner city GP unit versus conventional care for elderly patients: prospective comparison of health functioning, use of services and patient satisfaction. Fam Pract 2001; 18:141-8. [PMID: 11264263 DOI: 10.1093/fampra/18.2.141] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND GP units are generally nurse-led wards, where GPs have direct admitting rights and retain clinical responsibility for their patients. While GP-led wards are not new, they are relatively uncommon in urban areas. In addition, there has been little comparative evaluation of this type of service. OBJECTIVES The aim of the present study was to compare patients admitted to an inner city GP unit with comparable patients in conventional care (e.g. district nursing, nursing/residential homes, acute care of the elderly wards) in terms of mental and physical functioning, use of health and social services and patient satisfaction. METHODS Study group patients were those admitted to the GP unit; comparison group patients were identified by GP practices or conventional services who had agreed to participate in the study. Suitable patients were aged 65 years or over and fitted the eligibility criteria for the GP unit. Patients were interviewed at three time points: admission to either the GP unit or conventional care, and at 1 and 3 months after admission. Baseline comparability was assessed by demographic and medical data, cognitive function, mental state, social support, use of health and social services, and mental and physical functioning (SF-12). Mental and physical functioning and use of health and social services were compared between the groups over time. Patient satisfaction with their care was also compared between groups. RESULTS Change in the mental and physical functioning between patients on the GP unit (n = 67) and those in conventional care (n = 60) did not differ when the groups were compared at any of the three time points. However, the mental function of patients in the GP unit significantly improved between admission and 1 month after admission (P: < 0.05). This effect was not sustained at 3 months after admission. GP unit patients were consistently more positive about the care they received than patients receiving conventional care; this included communication and information, staff, care and the facilities. Both groups of patients were high users of health and social services, with similar patterns of use in both groups, which did not alter over time. CONCLUSIONS Patients who received care on the GP unit experienced a similar physical outcome to patients in conventional settings; however, they appeared to enjoy a short-term improvement in mental functioning and were consistently more positive about the quality of their care. This study has important policy implications with regard to planning future intermediate care services and will be of particular interest to health service planners and those responsible for clinical governance.
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Affiliation(s)
- N K Boston
- Department of R&D, Kensington & Chelsea and Westminster Health Authority, 50 Eastbourne Terrace, London W2 6LX, UK
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20
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Victor C, Hastie I, Christodoulou G, Millard P. The inappropriate placement of older people in nursing homes in England and Wales: a national audit. QUALITY IN AGEING AND OLDER ADULTS 2001. [DOI: 10.1108/14717794200100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Glasby J, Littlechild R. Fighting fires?--emergency hospital admission and the concept of prevention. JOURNAL OF MANAGEMENT IN MEDICINE 2001; 14:109-18. [PMID: 11184672 DOI: 10.1108/02689230010346501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the UK's health and social care system has always been geared towards dealing with crises, evidence suggests that this is becoming increasingly the case. Changes in health care and the prioritisation of scarce resources have resulted in a situation where those with low level needs are often left unsupported until they experience a major life crisis. To rectify this situation, the government has introduced a range of policies designed to emphasise the need for preventive work. Against this background, this paper focuses on the issue of emergency hospital admissions, critiquing the research methodologies that have been used to investigate the scope for preventive work in this area. Despite the use of more sophisticated and objective research tools, there is a need to develop new ways of researching emergency admissions which build on the strengths of existing approaches while at the same time incorporating more of a user perspective.
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Affiliation(s)
- J Glasby
- Department of Social Policy and Social Work, University of Birmingham, UK
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Hider P, O'Hagan J, Bidwell S, Kirk R. The rise in acute medical admissions. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 2000; 30:252-60. [PMID: 10833119 DOI: 10.1111/j.1445-5994.2000.tb00816.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- P Hider
- Department of Public Health and General Practice, Christchurch, New Zealand
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23
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Degeling P. Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability. Int J Health Plann Manage 2000; 15:3-16. [PMID: 10947566 DOI: 10.1002/(sici)1099-1751(200001/03)15:1<3::aid-hpm568>3.0.co;2-r] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The paper critically appraises current efforts to bolster the accountability of clinicians. The paper opens with an examination of the values, meaning and rules which underpin different accountability systems. Against this background we canvass conceptual, practical and ethical issues which need to be addressed if efforts to extend the accountability of clinicians are to meet with success.
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Affiliation(s)
- P Degeling
- Centre for Hospital Management and Information Systems Research, University of New South Wales, Sydney
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24
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Hensher M, Fulop N, Coast J, Jefferys E. The hospital of the future. Better out than in? Alternatives to acute hospital care. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1127-30. [PMID: 10531112 PMCID: PMC1116910 DOI: 10.1136/bmj.319.7217.1127] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M Hensher
- London School of Hygiene and Tropical Medicine, London WC1E 7HT.
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25
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Eriksen BO, Kristiansen IS, Nord E, Pape JF, Almdahl SM, Hensrud A, Jaeger S. The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine. J Intern Med 1999; 246:379-87. [PMID: 10583709 DOI: 10.1046/j.1365-2796.1999.00526.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES High rates of inappropriate hospital admissions have been found in numerous studies, suggesting that a high percentage of hospital resources are, in effect, wasted. The degree to which this is true depends on how costly inappropriate admissions are compared to other admissions. This study aimed to estimate both the percentage and cost of inappropriate admissions. SETTING Department of internal medicine at a teaching hospital. SUBJECTS Consecutively admitted patients during a six-week study period. MAIN OUTCOME MEASURES Assessments of inappropriateness were based on estimates of health benefit and necessary care level. These estimates were made by expert panels using a structured consensus method. Health benefit was estimated as gain in quality-adjusted life years, or degree of short-term improvement in quality of life during or shortly after the hospital stay. The direct costs to the hospital of each stay were estimated by allocating the costs of labour, 'hotel' and overhead according to length of stay and adding to this the cost of ancillary resources used by each individual patient. RESULTS A total of 422 admissions were included. The 102 (24%) judged to be inappropriate had a lower mean cost (US$ 2532) than the other 320 (US$ 5800) (difference 3268; 95% confidence interval 1025-5511). The inappropriate admissions accounted for 12% of the total costs. CONCLUSIONS Denying care for inappropriate admissions does not generate cost reductions of the same magnitude. Policy makers should be cautious in projecting the cost savings potential of excluding inappropriate admissions.
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Affiliation(s)
- B O Eriksen
- Department of Medicine, University Hospital of Tromsø, Norway.
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26
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Krakau I, Hassler E. Provision for clinic patients in the ED produces more nonemergency visits. Am J Emerg Med 1999; 17:18-20. [PMID: 9928690 DOI: 10.1016/s0735-6757(99)90006-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.
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Affiliation(s)
- I Krakau
- Research Center of General Medicine, Department of Internal Medicine, Karolinska Hospital, Stockholm, Sweden
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Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow MA. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ (CLINICAL RESEARCH ED.) 1998; 316:1796-801. [PMID: 9624070 PMCID: PMC28580 DOI: 10.1136/bmj.316.7147.1796] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital. DESIGN Pragmatic randomised controlled trial. SETTING Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people. SUBJECTS 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate. INTERVENTIONS Patients' received hospital at home care or routine hospital care. MAIN OUTCOME MEASURES Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months. RESULTS There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme. CONCLUSIONS The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.
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Affiliation(s)
- S H Richards
- Department of Social Medicine, University of Bristol, Bristol BS8 2PR.
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28
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Smith LF. Primary care education centres: educational innovation for all of the primary health care team is needed. Br J Gen Pract 1998; 48:1215-6. [PMID: 9692276 PMCID: PMC1410171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Olesen F, Jensen PB, Grinsted P, Henriksen JS. General practitioners as advisers and coordinators in hospitals. Qual Health Care 1998; 7:42-7. [PMID: 10178150 PMCID: PMC2483575 DOI: 10.1136/qshc.7.1.42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- F Olesen
- Research Unit for General Practice, University of Aarhus, Denmark
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30
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Maggs-Rapport F, Kinnersley P, Owen P. In-house referral: changing general practitioners' roles in the referral of patients to secondary care. Soc Sci Med 1998; 46:131-6. [PMID: 9464674 DOI: 10.1016/s0277-9536(97)00154-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Innovative approaches to patient management are needed to ensure that only those patients who would benefit most are referred from primary to secondary care. This report describes an exploratory study in which general practitioners adopted the role of reviewing the management of patients who would otherwise be referred to hospital. Patients in eight general practices in South Wales were referred In-house by general practitioners to a colleague in the practice who reviewed the need for hospital care. Qualitative data from interviews and questionnaires is presented. In-house referral appears to be acceptable, practical and of value to both general practitioners and patients.
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Affiliation(s)
- F Maggs-Rapport
- Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Maelfa, Cardiff, UK
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31
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Denman-Johnson M, Bingham P, George S. A confidential enquiry into emergency hospital admissions on the Isle of Wight, UK. J Epidemiol Community Health 1997; 51:386-90. [PMID: 9328544 PMCID: PMC1060506 DOI: 10.1136/jech.51.4.386] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To quantify the proportion of potentially avoidable emergency short term admissions to hospital and to identify ways in which they could have been avoided. DESIGN Confidential enquiry by peer review group. SETTING St Mary's Hospital, Newport, Isle of Wight. SUBJECTS All emergency, short term admissions (discharged home within five days) to medicine, general surgery, orthopaedics, gynaecology, ENT, and ophthalmology specialties for 28 (24 hour) days over a six month period in 1994. MAIN OUTCOME MEASURES Appropriateness of admissions decided by the peer group, the peer group's opinion of ideal management, and the patients' views on the appropriateness of their admission. RESULTS Altogether 139 cases satisfied the inclusion criteria. Complete data were collected on 123 cases and the peer group considered 81 in the time available. Twenty one of the 81 cases were judged "potentially avoidable". These represent 9.5% (95% CI 6.3%, 13.5%) of short term admissions to the specialties studied. The peer group considered that seven of 10 patients referred by a general practitioner (GP) could have been managed by the GP alone and that the remaining three had been referred appropriately but need not have been admitted had a consultant opinion been available in the accident and emergency (A&E) department. Two of the 10 would have required home support to avoid hospital admission. Five of 11 patients who referred themselves to A&E could have been discharged home without admission and without recourse to a specialist opinion. The remaining six could have been discharged had a consultant opinion been available in A&E. CONCLUSIONS Urgent consultant opinion, either in A&E or in an outpatient clinic, would have prevented most of these inappropriate admissions, and home support would have expedited the ability to discharge some patients. Further research into the costs and benefits of methods for providing these services is needed urgently.
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McCulloch P, Bowyer J, Fitzsimmons T, Johnson M, Lowe D, Ward R. Emergency admission of patients to general surgical beds: attitudes of general practitioners, surgical trainees, and consultants in Liverpool, UK. J Epidemiol Community Health 1997; 51:315-9. [PMID: 9229063 PMCID: PMC1060479 DOI: 10.1136/jech.51.3.315] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine (a) whether doctors involved in the process of emergency surgical admission could agree about which patients should be admitted, (b) whether there were consistent differences between doctors in different specialty groups, and (c) whether these opinions were greatly influenced by non-clinical factors. DESIGN Independent assessment of summarised case histories by three "expert" clinicians (two consultant surgeons and one general practitioner (GP)), by a group of 10 GPs, and by a group of 10 junior and senior surgeons. Experts, but not other observers, scored admissions both independently and as a consensus group. Observers indicated for each patient whether they would admit, would not admit, or were unsure. SETTING An urban general hospital with teaching status. SUBJECTS Fifty consecutive patients admitted to the general surgical unit as emergencies during 1995. MAIN OUTCOME MEASURES Proportion of admissions considered unnecessary or uncertain: agreement between observers on these proportions: effect of social and procedural factors on the admission decision. RESULTS Between 8 and 34% of admissions were considered unnecessary and 20-38% of unclear necessity. Agreement between the groups of clinicians was not good. GPs and consultant surgeons showed the poorest agreement (kappa = 0.08 to 0.25, 4 comparisons), and the GPs scored a higher percentage of admissions as unnecessary (34 v 8-12%). After discussion, the consensus group achieved good to very good agreement (kappa 0.61-0.84). CONCLUSIONS Different groups of doctors vary widely in their views about the need for emergency surgical admission. Good agreement can be reached by consensus discussion. GPs are less likely than surgeons to consider emergency surgical admission necessary.
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Affiliation(s)
- P McCulloch
- Department of Surgery, University of Liverpool
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Shanks J, Hossain M, Brown E, Ashley C. Primary care provision of specialist services. Br J Gen Pract 1997; 47:199-200. [PMID: 9196958 PMCID: PMC1312940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Maclean JR, Ritchie LD, Grant AM. Telemedicine: 'communication' by any other name? Br J Gen Pract 1997; 47:200-1. [PMID: 9196959 PMCID: PMC1312941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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35
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Pollard AJ, Booy R. Keeping the meningococcus out of the media. Br J Gen Pract 1997; 47:201-3. [PMID: 9196960 PMCID: PMC1312942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Sylvester N. Alternatives to hospital care. Study's results may not apply elsewhere. BMJ (CLINICAL RESEARCH ED.) 1996; 312:1102. [PMID: 8616443 PMCID: PMC2350918 DOI: 10.1136/bmj.312.7038.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Coleman H, Finlay F. Alternative's to hospital care. Emergency consultation clinic's avert unnecessary admissions. BMJ (CLINICAL RESEARCH ED.) 1996; 312:1102. [PMID: 8616442 PMCID: PMC2350901 DOI: 10.1136/bmj.312.7038.1102a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
The aim of routine utilisation review is to identify patients who are inappropriately placed in an acute unit and who could be alternatively treated in a lower technology facility. Utilisation review was designed as a means of cost control in the USA. but problems with rising emergency admissions and consequent acute bed shortages in the UK have led to a substantial and growing interest in the concept of appropriateness and in the development of utilisation review instruments. Appropriate care is not necessarily the same as efficient care, however, and inappropriate care could potentially be more cost-effective than the alternative. This will depend on, first, whether the design of utilisation review instruments is such that they will encourage efficiency, and second. whether efficiency objectives would be met by the application of utilisation review in the context of the UK health care system. The first issue is discussed in relation to the effectiveness of alternative forms of care. The second is discussed in relation to the potential for reductions in cost, the issue of institutional resistance in the UK, and the validity of utilisation review instruments. The paper concludes that the potential impact of utilisation review on technical efficiency in the UK is ambiguous and questions its purpose in the National Health Service.
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Affiliation(s)
- J Coast
- Department of Social Medicine, University of Bristol, UK
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40
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Houghton A, Hopkins A. Acute medical admissions: results of a national audit. JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON 1996; 30:551-9. [PMID: 8961211 PMCID: PMC5401490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The rising number of emergency admissions and the increasing specialisation of medicine sometimes cause problems in the organisation of care for patients admitted as emergencies to medical beds. A multidisciplinary working group from general practice and the hospital sector identified five main areas in which problems occurred-communication, appropriateness of referral, finding beds, waiting by patients, and the organisation of clinical care. Guidelines and standards were suggested. We then carried out an audit of acute care in 42 hospitals with 400 or more acute beds. The most significant problems that emerged were the suboptimal involvement of consultants in acute care, the frequent lack of appropriateness of the admitting specialty to the patient's condition, and confusion about policies for admitting elderly patients.
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