Comparison and analyses of therapeutic effects between metabolic management center (MMC) and conventional management modes

AIMS

The past 3 decades witnessed the rapid growth of diabetes in China. To better serve large numbers of patients, the Chinese Medical Doctor Association launched metabolic management center (MMC) program which is featured with a one-stop and comprehensive diabetes management mode in 2016. It is worth exploring whether MMC model is better than conventional models in management.

METHODS

In this study, 228 patients with type 2 diabetes were recruited, and 193 patients completed the study. Therapeutic effects and health care costs were analyzed.

RESULTS AND CONCLUSIONS

Our results showed that decreases in HbA_1C and TG/HDL-C values were significantly greater in the MMC group than in the control group. The increase in HDL-C was significantly higher in the MMC group than in the control group. The percentage of patients whose HbA_1C lower than 7% was significantly higher in the MMC group. The results of the UKPDS model simulation showed that within 30 years, with the slight increases in treatment costs, the average life expectancy and total QALE of the MMC group are higher than those of the control group by 0.61 and 0.51 year, respectively. Further study showed that the drug intervention in the MMC group was significantly stronger. In addition, the questionnaires revealed that MMC group performed better in diabetes knowledge tests and have higher patient satisfaction rates of medical services. More patients in the MMC group adopted a more favorable diet strategy. These advantages enable MMC to achieve more short-term and long-term benefits in diabetes treatment than conventional mode.

Evaluation of a National Comprehensive Cancer Network Guidelines-Based Decision Support Tool in Patients With Non-Small Cell Lung Cancer: A Nonrandomized Clinical Trial

IMPORTANCE

The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known.

OBJECTIVE

To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction.

INTERVENTIONS

An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator.

MAIN OUTCOMES AND MEASURES

Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict.

RESULTS

Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03982459.

Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.

Nursing Care for Hospitalized Older Adults With and Without Cognitive Impairment

BACKGROUND

The presence of cognitive impairment (CI) among hospitalized older adults (aged 85 years and older) could interfere with the identification and treatment of other important symptoms experienced by these patients. Little is known, however, about the nursing care provided to this group. Contrasting the nursing care provided to patients with and without CI may reveal important insights about symptom treatment in the CI population.

OBJECTIVE

The aim of this study was to examine the relationship of CI to nursing care provided and length of stay for hospitalized older adults using standardized nursing data retrieved from electronic health records.

METHODS

We conducted a comparative secondary data analysis. A data set of standardized nursing plan of care data retrieved from electronic health record data of nine units at four hospitals was analyzed. The plan of care data for this study were previously transformed into one of eight categories (family, well-being, mental comfort, physical comfort, mental, safety, functional, and physiological care). Fisher exact tests were used to compare the differences in the nursing care for hospitalized older adults with and without CI. Mixed-effects models were used to examine associations of patient's cognitive status and nursing care, and cognitive status and length of stay.

RESULTS

We identified 4,354 unique patients; 746 (17%) had CI. We observed that older adults with CI were less likely to receive physical comfort care than those without CI for seven of nine units. Older adults' cognitive status was associated with the delivery of mental comfort care. In addition, a worsening in cognitive status was associated with an increase in length of stay for older adults with CI.

DISCUSSION

Older adults with CI appeared to be undertreated for symptoms of pain when compared to those without CI across units. There is a need for further research to improve symptom recognition and management for this population. The presence of CI was associated with variation in nursing care provided and length of stay. Future studies that include the analysis of nursing data merged with elements stored in the electronic health record representing the contributions of other health professions are expected to provide additional insights into this gap.

Evaluation of a comprehensive diabetic foot ulcer care quality model

AIMS

Diabetes-related amputations are typically preceded by a diabetic foot ulcer (DFU) but models to assess the quality of care are lacking. We investigated a model to measure inpatient and outpatient quality.

METHODS

Cohort study among adults hospitalized with a DFU to a safety-net hospital during 2016. We measured adherence to DFU-related quality metrics based on guidelines during and 12 months following hospitalization. Inpatient metrics included ankle-brachial index measurement during or 6 months prior to hospitalization, receiving diabetes education and a wound offloading device prior to discharge. Outpatient metrics included wound care ≤30 days of discharge, in addition to hemoglobin A1c (HbA1c) ≤8%, tobacco cessation, and retention in care (≥2 clinic visits ≥90 days apart) 12 months following discharge.

RESULTS

323 patients were included. Regarding inpatient metrics, 8% had an ankle brachial index measurement, 37% received diabetes education, and 20% received offloading prior to discharge. Regarding outpatient metrics, 33% received wound care ≤30 days of discharge. Twelve months following discharge, 34% achieved a HbA1c ≤8%, 13% quit tobacco, and 52% were retained in care. Twelve-month amputation-free survival was 71%.

CONCLUSIONS

Our model demonstrated large gaps in DFU guideline-adherent care. Implementing measures to close these gaps could prevent amputations.

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

METHODS

We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

RESULTS

The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

DISCUSSION

CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Quality assessment of clinical practice guidelines for management of type 2 diabetes mellitus: Assessment of type 2 diabetes mellitus guidelines

AIMS

Diabetes mellitus is one of the most significant global health emergencies of the 21st century. Every year, an increasing number of people succumb to the condition and therefore suffer life-changing complications. So management of this disease has an important role to prevent complications. In this study, our objective is to assess the quality of guidelines related to the significant public health problem diabetes that have been developed by international and national organizations using the AGREE II tool.

METHODS

This observational study assesses the quality of clinical practice guidelines used in the management of diabetes with AGREE II tool. Statistical analysis was performed using the SPSS 20 program package.

RESULTS

The overall quality score of the guidelines ranges between 3 and 6.25. While NICE's guidelines scored the highest, the guidelines of the National Diabetes Foundation scored the lowest.

CONCLUSION

More comprehensive studies are needed for assessing the quality of guidelines in every subject.

Comprehensive preventive care assessments for adults with intellectual and developmental disabilities: Part 2: 2003 to 2014

OBJECTIVE

To determine if there has been an increase in preventive care among adults with intellectual and developmental disabilities (IDD) as a result of the publication of the Canadian consensus guidelines on the care of adults with IDD in 2006 and 2011.

DESIGN

Ecological study.

SETTING

Ontario.

PARTICIPANTS

The study group consisted of community-dwelling adults with IDD between the ages of 40 and 64 living in Ontario identified in 2009-2010 through administrative health and social services data. The comparison group consisted of a propensity-score-matched sample of the remaining Ontario population.

MAIN OUTCOME MEASURES

A combined measure of a health examination or a Primary Care Quality Composite Score (PCQS) of 0.6 or greater, or both. Both measures were identified using administrative health data.

RESULTS

Adults with IDD were 2.04% more likely to have had a health examination or a PCQS of 0.6 or greater before 2011-2012 and 1.70% less likely after 2011-2012. Adults without IDD were 1.03% more likely before 2011-2012 and 13.74% less likely after 2011-2012 to have had a health examination or a PCQS of 0.6 or greater. Male patients with IDD were 15.60% more likely and male patients without IDD were 7.39% less likely to have had a health examination or PCQS of 0.6 or greater compared with female patients.

CONCLUSION

Despite the publication of the guidelines there has not been a corresponding increase in the uptake of the annual health examination or in the quality of preventive care among adults with IDD. More is required to reduce this documented inequity in care.

Underdocumentation of Obesity by Medical Residents Highlights Challenges to Effective Obesity Care

OBJECTIVE

The goal of this study was to determine attitudes and practices of physicians in training with respect to the evaluation and treatment of obesity.

METHODS

Resident-generated admission and discharge notes of all 1,765 general medicine hospital admissions during 4 nonconsecutive months were analyzed, and any references to weight, obesity, BMI, adiposity, and body fat were identified. The full general resident cohort was then surveyed for perceptions and behaviors related to obesity.

RESULTS

Obesity was considered a highly important medical issue by 98.5% of residents; 90% correctly identified a class II obesity Stunkard phenotype, and 80% accurately calculated a BMI given height and weight in metric units. Residents overestimated inpatient obesity prevalence (estimate = 75%; actual = 35%) and the rate of obesity recording in the hospital admission note (estimate = 94%; actual = 49.5%). A BMI or current weight in the admission note or discharge summary was reported in none of the 1,765 patient records, and only 6% of the patients with obesity had obesity noted in either the inpatient admission or discharge assessment or plan.

CONCLUSIONS

Though residents recognize obesity and its clinical implications, it is underreported in the assessment of inpatients. This low level of documenting obesity and its impact on clinical care planning underscores a missed opportunity to establish appropriate referrals and initiate treatment at a clinically opportune time.

A strategy for scaling up access to comprehensive care in adults with Chagas disease in endemic countries: The Bolivian Chagas Platform

Background

Bolivia has the highest prevalence of Chagas disease (CD) in the world (6.1%), with more than 607,186 people with Trypanosoma cruzi infection, most of them adults. In Bolivia CD has been declared a national priority. In 2009, the Chagas National Program (ChNP) had neither a protocol nor a clear directive for diagnosis and treatment of adults. Although programs had been implemented for congenital transmission and for acute cases, adults remained uncovered. Moreover, health professionals were not aware of treatment recommendations aimed at this population, and research on CD was limited; it was difficult to increase awareness of the disease, understand the challenges it presented, and adapt strategies to cope with it. Simultaneously, migratory flows that led Bolivian patients with CD to Spain and other European countries forced medical staff to look for solutions to an emerging problem.

Intervention

In this context, thanks to a Spanish international cooperation collaboration, the Bolivian platform for the comprehensive care of adults with CD was created in 2009. Based on the establishment of a vertical care system under the umbrella of ChNP general guidelines, six centres specialized in CD management were established in different epidemiological contexts. A common database, standardized clinical forms, a and a protocolized attention to adults patients, together with training activities for health professionals were essential for the model success. With the collaboration and knowledge transfer activities between endemic and non-endemic countries, the platform aims to provide care, train health professionals, and create the basis for a future expansion to the National Health System of a proven model of care for adults with CD.

Results

From 2010 to 2015, a total of 26,227 patients were attended by the Platform, 69% (18,316) were diagnosed with T. cruzi, 8,567 initiated anti-parasitic treatment, more than 1,616 health professionals were trained, and more than ten research projects developed. The project helped to increase the number of adults with CD diagnosed and treated, produce evidence-based clinical practice guidelines, and bring about changes in policy that will increase access to comprehensive care among adults with CD. The ChNP is now studying the Platform’s health care model to adapt and implement it nationwide.

Conclusions

This strategy provides a solution to unmet demands in the care of patients with CD, improving access to diagnosis and treatment. Further scaling up of diagnosis and treatment will be based on the expansion of the model of care to the NHS structures. Its sustainability will be ensured as it will build on existing local resources in Bolivia. Still human trained resources are scarce and the high staff turnover in Bolivia is a limitation of the model. Nevertheless, in a preliminary two-years-experience of scaling up this model, this limitations have been locally solved together with the health local authorities.

Bolivia has the highest prevalence of Chagas disease (CD) in the world (6.1%), with more than 607,186 people with Trypanosoma cruzi infection. In Bolivia, the management of CD has been declared a national priority. In 2009, the Chagas National Program (ChNP) had neither a protocol nor a clear directive for diagnosis and treatment of adults. The Chagas Platform has been built as a model for comprehensive care of adults with CD. From 2010 to 2015, a total of 26,227 patients were attended by the Platform, 69% (18,316) were diagnosed with T. cruzi, 8,567 initiated anti-parasitic treatment, more than 1,616 health professionals were trained. More than ten research projects were developed. The project has also produced evidence-based clinical practice guidelines, and brings about changes in policy that will increase access to comprehensive care among adults with CD. The ChNP is now studying the Platform’s health care model to adapt and implement it nationwide. It is an experience of collaboration and knowledge transfer between endemic and non-endemic countries.

A POST ANALYSIS OF A PREVENTIVE AND CHRONIC HEALTHCARE TOOL

This study uses the data set from Kaiser Permanente to examine the post implementation of a preventive and chronic care that utilizes clinical information system, delivery system design, and clinical decision support to maximize the office visit. The analysis suggests a significant positive relationship between frequency of utilization rates to address preventive and chronic care gaps. There is no implication of a significant positive relationship with the successfully captured rate, which satisfies closing the care gap within 45 days. The use of the preventive care tool will assist members in satisfying the preventive care gap, cervical cancer screening, within 45 days of the encounter.

Person-Specific Standardized Vulnerability Assessment in Health and Social Care

We describe an integrated person-specific standardized vulnerability assessment model designed to facilitate patient management in health and social care. Such a system is not meant to replace existing health and social assessment models but rather to complement them by providing a holistic picture of the vulnerabilities faced by a given patient. In fact, it should be seen as a screening tool for health and social care workers. One key aspect of the modeling framework is the ability to provide personalized yet standardized multi-dimensional assessments of risk based on incomplete information about the patient status, as is the case in screening situations. Specifically, we integrate a Markov chain model describing the evolution of patients in and out of vulnerable states over time with a Bayesian network that serves to customize the dynamic model. We present an application in the context of elder care.

Cystinosis in adult and adolescent patients: Recommendations for the comprehensive care of cystinosis

INTRODUCTION

Cystinosis is a rare lysosomal systemic disease that mainly affects the kidney and the eye. Patients with cystinosis begin renal replacement therapy during the first decade of life in absence of treatment. Prognosis of cystinosis depends on early diagnosis, and prompt starting and good compliance with cysteamine treatment. Kidney disease progression, extra-renal complications and shorter life expectancy are more pronounced in those patients that do not follow treatment. The objective of this work was to elaborate recommendations for the comprehensive care of cystinosis and the facilitation of patient transition from paediatric to adult treatment, based on clinical experience. The goal is to reduce the impact of the disease, and to improve patient quality of life and prognosis.

METHODS

Bibliographic research and consensus meetings among a multidisciplinary professional team of experts in the clinical practice, with cystinotic patients (T-CiS.bcn group) from 5 hospitals located in Barcelona.

RESULTS

This document gathers specific recommendations for diagnosis, treatment and multidisciplinary follow-up of cystinotic patients in the following areas: nephrology, dialysis,renal transplant, ophthalmology, endocrinology, neurology, laboratory, genetic counselling,nursing and pharmacy.

CONCLUSIONS

A reference document for the comprehensive care of cystinosis represents a support tool for health professionals who take care of these patients. It is based on the following main pillars: (a) a multi-disciplinary approach, (b) appropriate disease monitoring and control of intracellular cystine levels in leukocytes, (c) the importance of adherence to treatment with cysteamine, and (d) the promotion of patient self-care by means of disease education programmes. All these recommendations will lead us, in a second phase, to create a coordinated transition model between paediatric and adult care services which will contemplate the specific needs of cystinosis.

'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study

Background

Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders.

Objective

To develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency.

Design, Setting, and Participants

Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe.

Results and Limitations

Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts.

Conclusions

In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.

Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System

PURPOSE

High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer.

PATIENTS AND METHODS

Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories.

RESULTS

There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics.

CONCLUSION

This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.

[Standardized geriatric assessment or comprehensive gerontological assessment: where do we stand?]

The concept of comprehensive gerontological assessment is a foundation of modern geriatrics. Our focus was to try to clarify the underlying concepts, assess the level of evidence and clarify the issues still under debate. The concept implies the definition of an interdisciplinary process for a multidimensional assessment in order to produce a coordinated plan. The central notion is that the systematization of this multidimensionality and interdisciplinarity needs the establishment of dedicated process (meeting tools, clinical information system, etc.). Following dimensions should be covered: health, social, economic, environmental and psychological. Any assessment process that could lead to forgetting one of its dimensions cannot be viewed as a comprehensive gerontological assessment. The level of evidence is higher in hospital acute inpatient unit but it is still low in all other areas of health care but the scattered data in the literature argues for qualitative benefits (improved quality of care or quality of life). The questions that remain are numerous including the choice of strategy for initial evaluation (maximum versus minimum; from the outset by many professionals versus graduated based on the minimum initial evaluation), the choice of tool, the optimal location, the required intensity of monitoring and the ideal target population.

Comprehensive care

Comprehensive care (CC) represents the basic approach of orthogeriatric comanaged care with the overall objectives of improving results regarding physical and psychological functions and reducing hospitalization, long-term care placement and mortality. It is a two-stage process that includes the Comprehensive Geriatric Assessment (CGA) and the development and implementation of an interdisciplinary treatment plan based on priority interventions and unmet needs. In older hip fracture patients CC has to face crucial issues such as treatment choice and surgical options, clinical stabilization of patients before surgery and the prevention and treatment of complication in the postoperative phase. The main aim are to avoid inappropriate surgical delays and reduce the overall number of days of immobility endorsing an early ambulation with full weight bearing as tolerated. Multiprofessional CC must also ensure uninterrupted care for transition between the different care levels that patients need after fracture before returning home. Therefore another important issue is a structured discharge plan tailored to the individual patient identifying subjects that could benefit from a skilled or more intensive rehabilitation, identifying patients and family that will probably need a higher level of care even after rehabilitation, determining timing of discharge, defining the continuing care that needs to be provided and finally ensuring the patient has access to available services and resources. However, the implementation of a comprehensive and multidisciplinary co-care model in an orthopedic unit is a difficult task because it is necessary a great effort to change cultural attitudes related to traditional model of care.

Quality at Kaiser Permanente: using the population care model

The provision of high quality healthcare is facilitated by an integrated team of multi-specialty physicians who are supported by an advanced electronic medical record. This paper shows how Kaiser Permanente of the Mid-Atlantic States is able to provide proactive care to members through physicians and their teams, integrated with functional health information technology systems.

Evaluating Medical Home constructs for children with special needs: integrating theory and logic models

The Medical Home model for providing services to children with special healthcare needs has strong philosophical foundations, but the science supporting this theoretical model is not as well developed. The use of logic models and mixed method design provide systematic and rigorous approaches to observation while retaining the complexity, which tends to be lost with research designs intended to control and reduce the number of variables impacting a desired outcome, such as randomized controlled trials. This application provides a historical basis for applying logic models of evaluation and illustrates the utility of logic models.

Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development

Ambiguous genitalia of the newborn is the paradigm of a disorder of sex development that demands a multidisciplinary team approach to management. The problem is immediately apparent at birth. Abnormalities of the external genitalia sufficient to warrant genetic and endocrine studies occur in one in 4500 births. In recent decades there have been improvements in diagnosis and early management, particularly with respect to congenital adrenal hyperplasia, the commonest cause of ambiguous genitalia of the newborn. However, dissatisfaction with overall management remains. A Clinical Guidelines and Handbook for Parents generated by a partnership of health professionals and support groups is available on the internet. The professional societies representing paediatric endocrinology responded by organizing a consensus meeting on the management of intersex. This resulted in the publication of a Consensus Statement encompassing many aspects of management, extending from birth to adulthood.

Quality of integrated care for patients with head and neck cancer: Development and measurement of clinical indicators

BACKGROUND

To improve the quality of integrated care, we developed indicators for assessing current practice in a large reference center for head and neck oncology.

METHODS

We defined a set of indicators based on integrated care literature, national evidence-based guidelines for patients with head and neck cancer, and the opinions of professionals and patients. We tested this set regarding assessment of current practice and clinimetric characteristics.

RESULTS

The final set consisted of 8 integrated care indicators and 23 specific indicators for patients with head and neck cancer. Current practice assessment produced high scores for the integrated care indicators, but the specific indicators showed room for improvement. The practice test showed that 9 indicators had good applicability.

CONCLUSIONS

The indicators, while based on evidence-based guidelines and the principles of integrated care, should incorporate patients' opinions and include a practice test. Our results show that the quality of integrated care for patients with head and neck cancer could be improved.

More physicians are not the answer

The Association of American Medical Colleges has called for an increase of 30% in matriculation in United States medical schools to treat the growing number of elderly patients with chronic illnesses. However, increasing the physician supply is unlikely to address the underlying problem, that being the growth of chronic disease, which necessitates a shift in orientation from treatment to management and prevention. This shift will in turn require a change in the makeup of health care providers. Instead of more physicians, more nonphysician professionals must be trained so as to aggressively coordinate comprehensive chronic disease care. A disease management model led by physicians, but including advanced practice nurses and other professionals, offers the opportunity to enhance efficiency, improve quality, reduce hospitalization, and meet evidence-based mandates. Such a workforce transition can become the inaugural step in converting the entire health care system from treatment based to prevention and management based. In conclusion, the position of the Association of American Medical Colleges should be a platform for discussion.

Discordance in perceptions of barriers to diabetes care between patients and primary care and secondary care

OBJECTIVE

We sought to compare perceived barriers to diabetes care between people with diabetes and different health professional groups.

RESEARCH DESIGN AND METHODS

This was a cross-sectional, postal, open-questionnaire survey conducted in the Waikato district, New Zealand. A total of 3,890 individuals with diabetes participated, as well as 436 primary and secondary health professionals.

RESULTS

Barriers were reported in 69.7% of patients. Psychological barriers were most important (55.5%), followed by systems barriers (25.7%), and then knowledge as least important (15.3%). Psychological barriers were ranked first among general practitioners (91.0%), but systems barriers were ranked first by other health professionals (38.8-100%). General practitioner and patient barrier group rankings were similar (r(T) = 0.976, P < 0.05). Of specific barriers among individuals with diabetes, strictness of treatment regimen was the most frequently reported (42.3 vs. 0.1-16.8%) (P < 0.001) and 2.5 (95% CI 2.4-2.7)- to 3.4 (3.2-3.7)-fold more than the 2nd through 4th ranked barriers. Motivation was the most common specific barrier reported by general practitioners (86%), practice nurses (31.5%), and the diabetes team (85.7%). Practice and hospital nurse/dietitian rankings were most comparable with patients (r(T) = 0.457 and 0.466, respectively, both P < 0.05). A major area of patient-health professional discordance was the influence of other health problems, which was ranked 2nd among patients but 10th-18th among health professionals.

CONCLUSIONS

The most important barriers to diabetes care perceived by patients are psychological and particularly relate to the strictness of the regimen. Discordance between patients and different health professionals exists in the perception of the importance of different barriers to diabetes care.

Comprehensive geriatric assessment

This paper presents the essentials of the comprehensive assessment of the geriatric patient.

MISSION!: optimization of acute and chronic care for patients with acute myocardial infarction

BACKGROUND

Guideline implementation programs for patients with acute myocardial infarction (AMI) enhance adherence to evidence-based medicine (EBM) and improve clinical outcome. Although undertreatment of patients with AMI is well recognized in both acute and chronic phases of care, most implementation programs focus on acute and secondary prevention strategies during the index hospitalization phase only.

HYPOTHESIS

Implementation of an all-phase integrated AMI care program maximizes EBM in daily practice and improves the care for patients with AMI.

AIM

The objective of this study is to assess the effects of the MISSION! program on adherence to EBM for patients with AMI by the use of performance indicators.

DESIGN

The MISSION! protocol is based on the most recent American College of Cardiology/American Heart Association and European Society of Cardiology guidelines for patients with AMI. It contains a prehospital, inhospital, and outpatient clinical framework for decision making and treatment, up to 1 year after the index event. MISSION! concentrates on rapid AMI diagnosis and early reperfusion, followed by active lifestyle improvement and structured medical therapy. Because MISSION! covers both acute and chronic AMI phase, this design implies an intensive multidisciplinary collaboration among all regional health care providers.

CONCLUSION

Continuum of care for patients with AMI is warranted to take full advantage of EBM in day-to-day practice. This manuscript describes the rationale, design, and preliminary results of MISSION!, an all-phase integrated AMI care program.

Utilizing program evaluation as a strategy to promote community change: evaluation of a comprehensive, community-based, family violence initiative

This paper describes the authors' work in a community that received Federal funding for an integrated system of care to reduce the impact and incidence of exposure to violence for children less than six years of age. The paper includes a review of the conceptual framework that guided the work of the authors and provides a brief overview of the issue of family violence, the impact of this violence on young children, and the Federal response to this issue. In addition, a description of the Initiative and the community in which it was based is provided along with some aspects of the evaluation plan. Finally, the authors discuss how their work with this Initiative depicts an approach to facilitating change within communities.

[Registry of child information in the patient health record and the comprehensiveness of practice]

Having the basic principle of comprehensiveness as one of the main aspects for a healthcare attendance, the Patient Health Record was pointed as an indicator of reality. The objective was to analyze Patient Health Record from two different healthcare units with different healthcare models. One of the healthcare units organized its model on traditional basis (without-FHP) and the other based on "Family Health Program" (with-FHP). 194 child files under 5 years old were analysed. It was observed that the FHP unit records were more frequent, favoring a better comprehension of the health-disease process, the professional integration and a periodic follow-up of the child, promoting a continuous assistance, and as a consequence, a comprehensiveness attendance.

Comprehensive geriatric assessment for non-geriatricians

Comprehensive geriatric assessment (CGA) consists of medical history taking, medication review, physical examination with special attention to sensory and neurological evaluation, and use of assessment instruments to measure cognitive, affective, functional, social, and economic status. CGA is most often beneficial when applied to frail elders at risk of functional decline. Beneficial outcomes may include decreased risks of falls, cognitive decline, and nursing home placement--in addition to improved sense of well-being and satisfaction with care.

[Role of the medical institution in comprehensive medical care]

The diagnosis procedure combination (DPC) of Japan started in April 2003. It is a unique "per day" payment system that evolved from diagnosis-related group and prospective payment system, which was a "per case" system. After a trial of two years, various undesirable problems of DPC have been revealed. A review of those problems in major diagnostic classifications (16) is in progress. The main problems are: 1) the medical institution-specific coefficient; 2) up-coding; and 3) consideration for expensive medical equipment such as during cardiac catheterization. The inclusive payment system is described and the problems of DPC are discussed.

[The multidisciplinary breast cancer care team: promoting better care]

Breast cancer is the most commonly diagnosed form of cancer in women in the Western world. Various sorts of therapies are available and treatment plans are becoming more and more complex. The treatment of breast cancer is based on several prognostic and predictive factors, of which the TNM-classification is the best known. However, several new factors have been discovered and implemented over the past decade. As well as these, economic factors and doctor- and patient-related factors are also important. As a consequence of the multitude of factors and the ensuing complexity of treatment, it has become impossible for a single doctor to coordinate the complete treatment of a patient. Therefore, it seems obvious that patients with breast cancer should be managed by a breast cancer care team. Specialists and nurses from different disciplines are represented within this team, with the advanced practice nurse as the primary contact person. This type of team helps to lower mortality, improve quality of care and lower associated costs.

Indicators of substance abuse treatment demand in Cape Town, South Africa (1997-2001)

Few studies have investigated the demand for substance abuse treatment in South Africa. This article uses data collected from specialist substance abuse treatment centres to describe substance abuse treatment demand and patterns of service utilisation in Cape Town for the period January 1997 to December 2001. Findings suggest that although treatment demand for alcohol-related problems remains high, treatment demand for substances other than alcohol has increased over time. Patterns of treatment service utilisation suggest that women and black South Africans remain underserved. The need for comprehensive and accessible substance abuse treatment services in Cape Town is highlighted and recommendations are made for improving access to treatment services, and undertaking comprehensive evaluations of existing treatment facilities.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.