An innovative approach for coordinating multiple sedated procedures in medically complex pediatric patients

Children and youth with special health care needs often undergo a higher frequency of sedated procedures, increasing their risk for complications, prolonged hospitalizations, as well as increased time and cost burdens. By consolidating multiple procedures requiring anesthetic sedation, the risk and cost can be reduced for both families and health care systems. In this paper, we discuss an innovative model to coordinate procedures across internal and external providers to improve quality of care for this vulnerable patient population. Although preliminary, our findings suggest this approach may be beneficial to both the patient, family, and health system.

Potential Access to Emergency General Surgical Care in Ontario

Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.

Effectiveness of the Transformation model, a model of care that integrates diabetes services across primary, secondary and community care: A retrospective study

AIMS

The primary aim was to evaluate the effectiveness of a model integrating diabetes services across primary, secondary and community care (Transformation model). The secondary aim was to understand whether changes resulted from the model.

METHODS

The model was implemented In Leicester, Leicestershire and Rutland (UK) across three clinical commissioning groups, the acute trust and accompanying stakeholders. One clinical commissioning group (Leicester City) implemented the entire model and was the primary evaluation population. A quasi-experimental interrupted time series design was employed. The primary outcome was number of Type 2 diabetes-related bed-days per 1000 patients.

RESULTS

In the primary population, the mean number of Type 2 diabetes-related bed-days per 1000 patients was increasing before model implementation by 0.33/month (95% confidence interval: -0.07, 0.72), whereas it was decreasing after implementation by a mean value of -0.14/month (-0.33, 0.06); a statistically significant difference (p = 0.04). Secondary analyses showed: nationally, there was no significant change between the pre- and post-periods so it is unlikely that large secular change drove the improvement; the other two Leicestershire clinical commissioning groups saw improvement or stability; underlying processes worked as hypothesised overall; diabetes biomedical markers deteriorated in the primary care population suggesting a change in case-mix due to moving some patients out of secondary care.

CONCLUSIONS

Given that the initial aim was to shift services from secondary to primary care without causing harm, an improvement is better than expected. This observational evaluation cannot show conclusively that improvements were due to the Transformation model, but secondary analyses support this.

The Challenges in the Development of Diabetes Prevention and Care Models in Low-Income Settings

In low- and middle-income countries (LMICs), the burden of non-communicable diseases such as diabetes is rapidly rising, overpassing the existing burden of communicable diseases. Patients with diabetes living in low-income communities face unique challenges related to lack of awareness, difficulty in accessing health care systems and medications, and consequently failure in achieving optimal diabetes management and preventing complications. Effective diabetes prevention and care models could help reduce the rising burden by standardizing guidelines for prevention and management, improving access to care, engaging community and peers, improving the training of professionals and patients and using the newest technology in the management of the disease. In this article, we review the latest research and evidence on effective models of diabetes prevention and diabetes care delivery in low- income settings. We also provide existing evidence relating to the effectiveness of these models in low-resource contexts, with the aim to highlight characteristics and strengths that make their implementation successful and long-lasting.

Sicily Network for Liver Cancer: A Multidisciplinary Network Model for the Management of Primary Liver Tumors

Background: The management of primary liver tumors requires the involvement of multiple specialist skills and the best possible treatment in terms of cost, risk, and benefit that could be provided by hepatobiliary or transplant surgeon, interventional radiologist, hepatologist, radiotherapist, or oncologist is needed to be chosen for each patient. This is particularly relevant for hepatocellular carcinoma (HCC), that is the most common primary liver tumor, and it occurs in more than 90% of cases in the setting of cirrhosis. Methods: To address the increasing complexity of cancer care, multidisciplinary tumor boards (MDTBs) have evolved to offer patients appropriate and tailored cancer treatments. In Sicily (Italy), MDTBs have been organized in a Regional Network, the Sicily Network for Liver Cancer, that answers to the need for an equal and fair access to cancer care, to improve the diagnostic and therapeutic appropriateness, to ease patients care, to improve the efficacy of cancer treatments, and finally to optimize the risk-cost-benefit ratio of therapies and follow-up. Results: It has been shown that multidisciplinary management is associated with significantly improved survival in patients with liver cancer. In this study, we present the aims, the organization, and the current and future activities of the Sicily Network for Liver Cancer, an integrated health care multidisciplinary network for the management of patients with primary liver tumors in Sicily. Conclusions: The coexistence of two diseases (HCC and cirrhosis) requires the expertise of many physicians to provide optimal care to patients with HCC. Treatment decisions should be discussed in multidisciplinary meetings, as no single treatment strategy can be applied to all patients, and treatment must be individualized to improve overall survival of patients with liver tumors.

A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination

INTRODUCTION

Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care.

METHODS

A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service - Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included.

RESULTS

Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters.

CONCLUSION

The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.

Follow-up of long-term survivors of breast cancer in primary care versus specialist attention

BACKGROUND

Hospitals have traditionally been the place where the follow-up of breast cancer patients occurs in Spain.

OBJECTIVE

To describe the evolution of long-term survivors of breast cancer according to type of follow-up received (in primary or specialist/hospital care), measuring impact of care type on health, cost, health-related quality of life (HRQL) and satisfaction results.

METHOD

Retrospective study of cohorts with disease-free patients followed up for at least 5 years in Oncology. Using personal questionnaires, the type and cost of the follow-up, events, HRQL and satisfaction were analysed.

RESULTS

Ninety-eight women were surveyed, 60 in primary and 38 in specialist care. There were no differences between groups in diagnosis of metastasis or new primary tumours. The number of annual visits per patient was 0.98 (0.48) in primary and 1.11 (0.38) in specialist care (P = 0.19). In primary, 44.6% were programmed and 55.4% on demand; in specialist, 94.6% were programmed and 5.4% on demand (P = 0.0001). The costs of follow-up in primary care were lower--€112.86 (77.54) versus €184.61 (85.87) per patient and year (P = 0.0001). No differences were reported in HRQL. Preference for specialist care was expressed by 80%, versus 10% for primary, with 10% indifferent. Patients showed greater satisfaction with specialist care in all questionnaire dimensions.

CONCLUSIONS

Compliance with follow-up protocol was high in both groups. In specialist care nearly all the visits were programmed and in primary almost half were on demand. In our locality, primary is more cost-effective than specialist care, but patients express greater satisfaction with specialist follow-up and hence prefer it.

Barriers to care for rural people living with HIV: a review of domestic research and health care models

Historically, the availability of heath care in rural areas has been sparse, and specialized care for people living with HIV (PLWH) has been especially problematic. Rural patients are faced with substantially greater barriers to care than their urban counterparts. A systematic review of empirical studies was conducted concerning barriers to care among patients infected with HIV in rural areas of the United States. This systematic review yielded 15 viable articles for analysis. Among the 27 barriers identified, the most commonly discussed were transportation needs, provider discrimination and stigma, confidentiality concerns, and affordability and lack of financial resources. Barriers to care must be addressed in conjunction with one another in order to alleviate their impacts. Key health care models addressing these concerns are highlighted and used to address the state of the field and provide suggestions for future research.