Journal articles: 'Outcome Assessmet (Health Care)' – Grafiati (2024)

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AbstractA broad range of health problems are related to disasters. Insight into these health problems is needed for targeted disaster management. Disaster health outcome assessment can provide insight into the health effects of disasters.During the 15th World Congress on Disaster and Emergency Medicine in Amsterdam (2007), experts in the field of disaster epidemiology discussed important aspects of disaster health outcome assessment, such as: (1) what is meant by disaster health outcome assessment?; (2) why should one conduct a disaster health outcome assessment, and what are the objectives?, and (3) who benefits from the information obtained by a disaster health outcome assessment?A disaster health outcome assessment can be defined as a systematic assessment of the current and potential health problems in a population affected by a disaster. Different methods can be used to examine these health problems such as: (1) rapid assessment of health needs; (2) (longitudinal) epidemiological studies using questionnaires; (3) continuous surveillance of health problems using existing registration systems; (4) assessment of the use and distribution of health services; and (5) research into the etiology of the health effects of disasters.The public health impact of a disaster may not be immediately evident. Disaster health outcome assessment provides insight into the health related consequences of disasters. The information that is obtained by performing a disaster health outcome assessment can be used to initiate and adapt the provision of health care. Besides information for policy-makers, disaster health outcome assessments can contribute to the knowledge and evidence base of disaster health outcomes (scientific objective). Finally, disaster health outcome assessment might serve as a signal of recognition of the problems of the survivors.Several stakeholders may benefit from the information obtained from a disaster health outcome assessment. Disaster decision-makers and the public health community benefit from performing a disaster health outcome assessment, since it provides information that is useful for the different aspects of disaster management. Also, by providing information about the nature, prevalence, and course of health problems, (mental) health care workers can anticipate the health needs and requirements in the affected population.It is important to realize that the disaster is not over when the acute care has been provided. Instead, disasters will cause many other health problems and concerns such as infectious diseases and mental health problems. Disaster health outcome assessments provide insight into the public health impact of disasters.

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Objective To present a framework that facilitates quality assessment of pharmaceutical care (PC) so that the profession and the public may identify pharmacists in ambulatory settings who provide quality care in all aspects of their practices. Data Sources A MEDLINE search augmented by a review of International Pharmacy Abstracts was used to identify pertinent quality assessment and pharmacy practice literature; indexing terms included quality assurance, healthcare, pharmacists, community pharmacy services, ambulatory, pharmacy, and process and outcome assessment. Study Selection All identified quality assessments of community pharmacy practice were considered. Studies that documented the effectiveness of specific pharmacist activities and patient satisfaction were also included. Data Extraction The literature was independently reviewed by the primary author. Data Synthesis The structure–process–outcome paradigm is presented as a framework for quality assessment of PC. Structure should be assessed at periodic intervals because it identifies the potential for the provision of quality care. Process, the care that pharmacists provide, must be documented and linked to outcomes before either structure or process can be used to make inferences about the quality of PC. Technical and interpersonal processes should be examined. Outcomes require an interdisciplinary approach that not only considers other medical care inputs but also recognizes the psychologic, economic, and social factors that affect health status and quality of life. Process and outcome must both be assessed to distinguish the contribution of pharmacists from that of other healthcare providers. Examples of criteria are provided and a model to integrate PC within the healthcare system is discussed. Conclusions It is pharmacists’ duty to ensure that patients receive an acceptable level of PC. The structure-process-outcome paradigm provides a framework to identify and link pharmacists’ processes with patients’ outcomes.

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To provide adequate care, students from all health-care professions require education regarding palliative and end-of-life (EOL) care prior to entering professional practice. In particular, students need proper training to be equal members of interprofessional teams providing palliative and EOL care. However, limited information is currently available about the effectiveness of educational interventions relating to palliative and EOL care. Thus, an assessment of educational interventions to utilize in providing this education is warranted. The purpose of this integrative review was to critically evaluate the impact of palliative or EOL care interventional studies on learning outcomes for prelicensure health-care students. Articles published from 2001 to present that utilizied palliative or EOL care educational interventions for prelicensure students from any health-care profession and also evaluated preidentified learning outcomes were included in the review. The final sample comprised 34 articles. Four studies utilized interprofessional interventions, whereas the remaining taught students from a single profession. Trends in sample sizes, teaching interventions, learning outcomes, and outcome measures are discussed. Teaching interventions reviewed were primarily focused on student learning outcomes specific to knowledge and attitudes. Future studies should implement interprofessional educational interventions, utilize reliable and valid outcome measures, and evaluate their impact on different learning outcomes, such as self-efficacy, comfort, and communication.

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Objective: The purpose of this paper is to examine a number of issues in the assessment of outcome in mental health. Method: Issues are considered in terms of a number of dichotomies or choices. These include: intervention-dependent versus intervention-independent definitions of outcome, focussing on inputs or processes versus outcomes; individual versus organisational outcomes; outcomes for patients versus outcomes for significant others; pure versus mixed outcomes; care versus cure; direct versus indirect measures; objective versus subjective measures; descriptive versus prescriptive measures; global versus specific assessment; and assessing at significant times points versus assessing at fixed intervals. Conclusions: Guiding principles are formulated in terms of the foregoing issues.

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SummaryObjective – The assessment of outcome for any purpose is not undertaken routinely in European mental health services. This paper discusses the merits of using outcome data to inform the planning of mental health care for individual patients, and provides practical advice to support the implementation of this new approach to working. Method – The use of outcomes in North America and Europe is briefly reviewed. A conceptual basis is proposed for routine outcome assessment – the ongoing measurement and use of outcome data to inform decisions about whether to continue, change or curtail treatment. A cognitive psychology model is developed which indicates that the routine use of outcomes will improve mental health care. Perceived problems with routine outcome assessment are discussed, and principles for implementation are identified. Results – Outcomes are used mainly for generating local-level (rather than patient-level) data in North America, and rarely used in Europe. The use of outcome data routinely may facilitate reflective clinical practice, a model of decision-making which leads to a higher quality of clinical care than automated problem-solving. One issue relates to the use of standardised assessments designed for research purposes in clinical settings, and this is being addressed through the development of a new generation of outcome measures which are explicitly designed for clinical use. However, most clinicians remain unconvinced of the benefits of routine outcome assessment, and relevant research is currently underway across Europe which will address this concern. Scientific principles to maximise quality and pragmatic principles to maximise the chances of successful implementation are identified. Conclusions – The routine use of outcomes will become increasingly prominent in European mental health services. This provides clinicians with an opportunity to improve the quality of clinical care offered to patients.

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BackgroundTargeting resources on cost-effective care strategies is important for the global mental health burden.AimsTo demonstrate cost–outcome methods in the evaluation of mental health care programmes in low-income countries.MethodFour rural populations were screened for psychiatric morbidity. Individuals with a diagnosed common mental disorder were invited to seek treatment, and assessed prospectively on symptoms, disability, quality of life and resource use.ResultsBetween 12% and 39% of the four screened populations had a diagnosable common mental disorder. In three of the four localities there were improvements over time in symptoms, disability and quality of life, while total economic costs were reduced.ConclusionEconomic analysis of mental health care in low-income countries is feasible and practicable. Our assessment of the cost-effectiveness of integrating mental health into primary care was confounded by the naturalistic study design and the low proportion of subjects using government primary health care services.

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BACKGROUND AND CONTEXT: The Nurse-Led Healthy Lifestyle Clinics focussed on lifestyle issues for patients with known health inequalities. Much of the nursing was educative and preventative care. This evaluation assessed patient experiences and opinions, as well as clinical outcomes. ASSESSMENT OF PROBLEM: Information came from clinical outcome data for 2850 individuals and 424 patient satisfaction surveys. Results: Patients were aged 0–95 years (45% between 40 and 59 years); 60% Pakeha/European, 31.4% Maori, 4.2% Pacific and 4.4% other ethnicities. Only 19% of claimants (approximately 40% were Maori or Pacific) came from quintile 5 addresses, suggesting the target population was not reached effectively. Ninety-four percent of patients had a better understanding of their diagnosis, medication and treatment plan, and were more motivated to self-manage their health needs. This increase in patient empowerment is a significant outcome of the project. Clinical outcome data showed no significant differences between first and last clinic visits for average weight, blood pressure, smoking, glycosylated haemoglobin levels, waist circumference or cardiovascular risk. Significant improvements were shown in the Dartmouth Primary Care Cooperative Information results for social activity, change in health, and overall health (n=89). STRATEGIES FOR IMPROVEMENT: More effective techniques to access the target population have been implemented, as has an extended period for review of clinical outcomes. LESSONS: More focussed evaluation of clinical outcomes is necessary to provide quantitative data on the clinics. The large percentage of patients who felt more empowered to self-manage their health needs suggests the clinics were effective in this area. KEYWORDS: Nurse-led clinics; life style; program evaluation; patient satisfaction; health status disparities

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Measuring and interpreting outcome is more difficult in mental health services than in some other areas of health care, for at least five reasons. First, the effect of the treatment may be to slow decline or to maintain the current level, so the score on the outcome measure itself may not improve (or may even get worse) despite best quality clinical care. Secondly, the best available evidence in the United Kingdom indicates that clinical and social variables predict no more than 30% of the variance in an individual's quality of life (UK700 Group, 1999). Thirdly, different types of outcome are desynchronous (e.g. Drury et al. 1996), changing at different rates during an intervention. Fourthly, there may not be agreement regarding what is a positive change in outcome – the patient who has fewer episodes of mania as a result of treatment may see this as a negative outcome. Finally, three levels of mental health service can be differentiated: treatment (specific interventions); programme (combination of different treatment components); and system (all programmes for a defined target group in a given area) (Burns & Priebe, 1996). The outcome data needed to evaluate each level will be very different.

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BackgroundThe National Board of Health and Welfare (NBHW) has developed a multi-dimensional performance assessment framework for open comparisons and assessment of health care. The framework includes the dimensions effectiveness, safety, patient-centeredness, timeliness, equity and efficiency.ObjectiveTo apply the framework to the area of psychiatric care in Sweden.AimTo identify disparities in the treatment and health outcomes of psychiatric patients in order to stimulate improvements.MethodsMore than 30 process and outcome indicators were developed using nationwide health data registers and were compared among regions or between patient groups.ResultsAmong other results the study shows large disparities in somatic care between patients with and without comorbid psychiatric disease (equity), low compliance to antidepressant treatment with small regional variations (effectiveness), decreasing suicidal rates (safety), regional variations concerning timeliness of care, lack of national data to asses patient-centeredness and no obvious relationship between costs of psychiatric care and outcome (efficiency).ConclusionsThe study indicates that the quality of psychiatric care in Sweden does not differ to any great extent between regions. However, there are large disparities in somatic care between patients with and without comorbid psychiatric disease. The framework is a useful starting point for assessing psychiatric care but improved reporting to existing registers and development of new data sources, particularly related to psychiatric health care outcomes, could lead to more adequate and comprehensive assessments including all the six dimensions of the framework.

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Background Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15–30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. Objectives To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. Design An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. Setting The trial took place in 14 NHS physiotherapy departments. Participants People identified as being at high risk of a poor outcome after knee arthroplasty. Interventions A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. Main outcome measures The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. Results In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4–7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2–6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval –0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. Limitations The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. Conclusions This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. Trial registration Current Controlled Trials ISRCTN13517704. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

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Interstitial lung disease (ILD) confers a high mortality and symptom burden, substantially impacting quality of life. Studies evaluating palliative care in ILD are rapidly expanding. Uniform outcome measures are crucial to assessing the impact of palliative care in ILD. This scoping review evaluates existing outcome measures in general health-related quality of life (HRQoL), physical health, mental health, social health and advance care planning (ACP) domains in patients with ILD. Articles in English with quantitative assessment of at least one measure of general HRQoL, physical health, mental health, social health or ACP in patients with ILD were included. Searches across three databases yielded 3488 non-duplicate articles. 23 met eligibility criteria and included three randomised controlled trials (RCTs) or secondary analysis of an RCT (13%), three cross-sectional studies or secondary analysis of cross-sectional study (13%), one prospective study (4%) and 16 retrospective studies (70%). Among eligible articles, 25 distinct instruments were identified. Six studies assessed general HRQoL (26%), 16 assessed physical health (70%), 11 assessed mental health (48%), six assessed social health (26%) and 16 assessed ACP (70%). The ability to compare results across studies remains challenging given the heterogeneity in outcome measures. Future work is needed to develop core palliative care outcome measures in ILD.

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As health systems strive to achieve improvements in quality, equity and efficiency, systems of performance assessment are increasingly being introduced. To function effectively as tools for internal quality improvement, they need to be aligned with staff and organisational objectives, foster insight into practice and provide a focus for learning leading to improvement. Adopting such a "coalface" perspective, we developed a conceptual framework to underpin the potential development of a quality system for a large primary health care program. The Framework for Performance Assessment in Primary Health Care (FPA_PHC) is grounded in evaluation theory and explicitly identifies the processes of primary health care articulated by the World Health Organization (WHO). It is based on Donabedian's (1998) now classic "structure", "process", "outcome" model for assessment of quality of care. The FPA_PHC specifies the development of objectives that are focused on patients/families/communities and has four indicator levels relating to stewardship, organisational structures and processes, processes of care and intermediate outcomes. Equity can be assessed by asking of processes of care and intermediate outcomes: "is it the same for everyone?" The indicators can be mapped to higher order system performance frameworks such as the National Health Performance Framework. The FPA_PHC has been adopted for the National Quality and Performance System for Divisions of General Practice and its application in this and a second setting are described.

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Infant and maternal mortality are important indicators for assessing the quality of healthcare systems. The World Health Organization underscores the importance of proper health care system in reducing preventable mortality through early intervention. Early intervention includes availability, accessibility and affordability of health care systems for children and mothers. While there are several studies that assess the immediate and underlying drivers of child mortality, literature on the role of policy measures are limited and inconsistent. Thus, robust empirical analysis of the determinants of maternal and infant mortality remains inconclusive in the era of achieving the Sustainable Development Goals (SDG). Here, we examined the influence of health expenditure on infant and maternal deaths for the period 2000–2015 across 177 countries. Using panel Quantile Regression with bootstrapping, this study accounted for the 2007–2008 financial crisis in an empirical relationship between health outcome and health expenditure. We found a negative effect of health expenditure on mortality across all percentiles. Infant mortality rate declines between 0.19% - 1.45% while maternal mortality rate declines ranging from 0.09% - 1.91%. To attain the goal of ensuring healthy lives and wellbeing of all people (SDG 3), this study infers that health expenditure potentially reduces maternal and infant mortality across lower and middle income countries. We highlight the need for an enhanced health care expenditure, especially in developing countries to curb the levels of infant and maternal deaths.

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BackgroundFactors related to the outcome of depression and anxiety in primary care are not fully understood.MethodAdult patients in general practice with depressive, anxiety or panic disorder (n=148; DSM–III–R criteria) were studied prospectively for six months to determine the factors most closely associated with outcome. The Psychiatric Assessment Schedule, Hamilton Depression Rating Scale, Clinical Anxiety Scale and Life Events and Difficulties Schedule interviews were performed at index consultations and repeated six months later. Variables associated with outcome were assessed by multiple regression analysis.ResultsGood outcome was predicted by mild depression at initial assessment, high educational level, and being in employment. At follow-up the most important predictor of improvement was reduction in marked difficulties over the six months. Recognition and management by the GP was most frequent in patients with severe disorder; such patients were least likely to improve because of the severity of their depression and marked social difficulties.ConclusionsThis naturalistic study helps to provide a framework for further studies with more precisely defined groups of people with depression. An effective treatment strategy for people with marked depression and ongoing social difficulties is especially needed.

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This paper examines quality of life as a scientific construct with a wide range of applications. The assessment of patients' quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition and ability to fulfill occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to ageing populations both for healthy elderly and for those who develop chronic diseases where maintenance of quality of life rather than cure may be the primary goal of treatment. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that approaches to quality of life assessment in the elderly should incorporate advances in knowledge about the psychological adaptation to ageing. Consequently, the unique perspective of the individual on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care. Incorporating measures of subjective outcome such as quality of life into policy decisions on resource allocation in health care will prove one of the major challenges for health services over the next decade.

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ObjectivesCare gaps in asthma may be highly prevalent but are poorly characterised. We sought to prospectively measure adherence to key evidence-based adult asthma practices in primary care, and predictors of these behaviours.DesignOne-year prospective cohort study employing an electronic chart audit.SettingThree family health teams (two academic, one community-based) in Ontario, Canada.Participants884 patients (72.1% female; 46.0±17.5 years old) (4199 total visits; 4.8±4.8 visits/patient) assigned to 23 physicians (65% female; practising for 10.0±8.6 years).Main outcome measuresThe primary outcome was the proportion of visits during which practitioners assessed asthma control according to symptom-based criteria. Secondary outcomes included the proportion of: patients who had asthma control assessed at least once; visits during which a controller medication was initiated or escalated; and patients who received a written asthma action plan. Behavioural predictors were established a priori and tested in a multivariable model.ResultsPrimary outcome: Providers assessed asthma control in 4.9% of visits and 15.4% of patients. Factors influencing assessment included clinic site (p=0.019) and presenting symptom, with providers assessing control more often during visits for asthma symptoms (35.0%) or any respiratory symptoms (18.8%) relative to other visits (1.6%) (p<0.01). Secondary outcomes: Providers escalated controller therapy in 3.3% of visits and 15.4% of patients. Factors influencing escalation included clinic site, presenting symptom and prior objective asthma diagnosis. Escalation occurred more frequently during visits for asthma symptoms (21.0%) or any respiratory symptoms (11.9%) relative to other visits (1.5%) (p<0.01) and in patients without a prior objective asthma diagnosis (3.5%) relative to those with (1.3%) (p=0.025). No asthma action plans were delivered.ConclusionsMajor gaps in evidence-based asthma practice exist in primary care. Targeted knowledge translation interventions are required to address these gaps, and can be tailored by leveraging the identified behavioural predictors.Trial registration numberNCT01070095; Pre-results.

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Background. The predictive value of frailty assessment is still debated. We analyzed the predictive value of frailty of independent living elderly. The outcomes variables were visits to the general practitioner, hospital admission, and occurrence of new health problems.Methods. A one-year follow-up study was executed among 215 community-living old Romanians. General practitioners reported the outcome variables of patients, whose frailty was assessed one year before, using the Groningen Frailty Indicator. The predictive validity is analyzed by descriptive and regression analysis.Results. Three-quarters of all participants visited their general practitioner three times more last year and one-third were at least once admitted to a hospital. Patients who scored frail one year before were more often admitted to a hospital. Visits to the general practitioner and occurrence of new health problems were not statistically significant related to frailty scores. The frailty items polypharmacy, social support, and activities in daily living were associated with adverse outcomes.Conclusions. The predictive value of frailty instruments as the Groningen Frailty Indicator is still limited. More research is needed to predict health outcomes, health care utilization, and quality of life of frailty self-assessment instruments. Validation research on frailty in different “environments” is recommended to answer the question to what extent contextual characteristics influence the predictive value.

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Health self-efficacy, a measure of one’s self-assurance in taking care of their own health, is known to contribute to a range of health outcomes that has been under examined among African American men. The purpose of this investigation was to identify and contextualize predictors of general health self-efficacy in this population. A cross-sectional sample of surveys from 558 African American was examined. These men were older than 18 years, could read and write English, and attended a hospital-based community health fair targeting minority men in 2011. The outcome of interest was health self-efficacy, which was assessed by asking, “Overall, how confident are you in your ability to take good care of your health?” Responses ranged from 1 ( not confident at all) to 5 ( completely confident). Covariates included age, self-rated health, health insurance status, having a regular physician, and being a smoker. The mean age of participants was 54.4 years, and 61.3% of participants indicated confidence in their ability to take good care of their health. Older age and being a smoker were inversely associated with the outcome. Good self-rated health, having health insurance, and having a regular doctor were positively associated with reports of health self-efficacy. Findings suggest that multiple points of connection to the health care system increase the likelihood of health self-efficacy for this sample and interventions to support older African American men who may evaluate their own health status as poor and who may face barriers to health care access are implicated.

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Abstract Introduction Health outcome goals are the results individuals seek from healthcare. These may incorporate holistic themes including function, mood, and quality of life. People living with frailty have poorer outcomes from even short hospital stays. They benefit from person-centred, goal-directed care over protocol-driven pathway approaches. This could be improved by monitoring attainment of health outcome goals. Methods A systematic review for older people’s health outcome goals in emergency care was conducted using narrative synthesis. A qualitative study based on grounded theory expanded the outcome framework to include people living with frailty. People with cognitive and communication barriers were included in semi-structured interviews. Discussions focussed on the events and outcomes sought from emergency care. Results Older people’s health outcome goals for emergency care were classified as efficient and comprehensive care, sensitivity towards vulnerability, and person-centred informed care. The importance of understanding individual perceptions was explicit. Research generally recruited based on age rather than physiological and functional state, and did not assess for impact of frailty on healthcare perceptions. The interview study was paused due to the COVID-19 pandemic. Initial results showed a predominance of person-centred and holistic care themes among health outcome goals. Participants’ most common goal for emergency care was relief of symptoms: people often had pain. Participants mostly had severe frailty and wanted their mobility to be assessed, with goals of recovering their functional baseline. While participants had confidence in healthcare professionals and were generally willing to “do as we are told to feel better”, they expected to undergo at least basic tests in order to receive a working diagnosis for their problem. People wanted to understand their illness and for explanations to be communicated to their relatives. Next steps Patient-reported outcome measures (PROMs) for this range of emergency care outcomes are being identified for field-testing in acute settings.

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Aim: To review the role of Health Related Quality of Life (HRQL) assessments in the management of patients with venous ulceration. Method: A search of electronic databases and reference lists delivered numerous articles containing a variety of HRQL assessments for venous ulcer treatment. Synthesis: The salient points from the literature were collaborated in order to establish which outcome measures best reflect the quality of care delivered. The treatment of chronic venous leg ulceration is often prolonged and a permanent cure is frequently unattainable. An improvement in a patient's condition needs to be demonstrated in order to determine the benefit of a surgical treatment. The assessment of HRQL is increasingly recognised as a valuable surgical outcome measurement. Conclusion: The combination of ‘standard’ clinical outcome measures, the generic SF-36 and a specific ‘venous ulcer’ HRQL questionnaire can produce a more complete treatment outcome assessment in patients with venous ulceration.

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The paper explores ways of how measurable indicators of quality of health care might be specified in health care contracts of NHS providers. The paper assesses the likelihood of defining formal outcome-related indicators. If outcome-related indicators are not measurable, then process or input-related quality indicators should be used as a second best choice. These should have certain desirable properties. The paper spells out these properties and points to examples.

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BackgroundChildren in care often have poor outcomes. There is a lack of evaluative research into intervention options.AimsTo examine the efficacy of Multidimensional Treatment Foster Care for Adolescents (MTFC-A) compared with usual care for young people at risk in foster care in England.MethodA two-arm single (assessor) blinded randomised controlled trial (RCT) embedded within an observational quasi-experimental case–control study involving 219 young people aged 11–16 years (trial registration: ISRCTN 68038570). The primary outcome was the Child Global Assessment Scale (CGAS). Secondary outcomes were ratings of educational attendance, achievement and rate of offending.ResultsThe MTFC-A group showed a non-significant improvement in CGAS outcome in both the randomised cohort (n= 34, adjusted mean difference 1.3, 95% CI −7.1 to 9.7,P= 0.75) and in the trimmed observational cohort (n= 185, adjusted mean difference 0.95, 95% CI −2.38 to 4.29,P= 0.57). No significant effects were seen in secondary outcomes. There was a possible differential effect of the intervention according to antisocial behaviour.ConclusionsThere was no evidence that the use of MTFC-A resulted in better outcomes than usual care. The intervention may be more beneficial for young people with antisocial behaviour but less beneficial than usual treatment for those without.

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e18310 Background: Aim of the study was to develop a system to measure the value of health care services delivered to osteosarcoma patients, through developing a standardized set of patient-centered outcomes for Osteosarcoma and using a consistent approach to measure the costs of Osteosarcoma care throughout all care cycles. Methods: The Porter’s Outcomes Measurement Hierarchy was used to define the domains of outcomes reporting for Osteosarcoma, which included three levels of measuring outcomes; health status achieved or retained, process of recovery, and sustainability of health. Time-driven activity-based costing (TDABC) approach was used a guide to determine the actual costs of healthcare services delivered to Osteosarcoma patients throughout their journey of cure. Results: Osteosarcoma outcome measurement tools and questionnaires were standardized based on the following domains: survival, degree of health or recovery, time to recovery and return to normal activities, disutility of care and treatment processes, sustainability of health and nature of recurrences, and the long-term consequences of therapy. The standardized outcome reporting tools under each domain included: toxicity reporting using NCI-Common Toxicity Criteria version 4.0, Pediatric Quality of Life Inventory (PedsQL) Cancer module, Musculoskeletal Tumour Society Score (MSTS) for functional outcome assessment, Palliative Care Outcomes Scale (POS). Process mapping was done for each step involved in the delivery of health care services to children with Osteosarcoma at Children’s Cancer hospital Egypt (57357 Hospital). Conclusions: Developing a standardized system for measuring the health outcomes of Osteosarcoma and the total costs for delivering the health care services is fundamental to measure and improve the value of health care delivered to Osteosarcoma patients.

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It is well documented that primary care physicians encounter many patients in then-practices who suffer psychiatric morbidity, especially affective, anxiety and substance abuse disorders. These physicians have been unable to effectively address the needs of these patients, over half of whom receive care exclusively in the primary care sector. Five years after implementing a curriculum to train family practice physicians to assume a comprehensive psychiatric role with patients in their practices, the authors undertook an outcome evaluation. The focus was on psychiatric disorder recognition, diagnosis, documentation, and management, including referral. It was hoped that biopsychosocial and community mental health orientations emphasized during training would be incorporated into the subsequent primary care practices of physicians in the study. In the research design, physician-generated diagnoses were compared with DIS/DSM-III diagnoses; physician interviews and chart audits enabled processes of care delivery to be evaluated. Unexpectedly, physicians were not found to assume an appropriately active or comprehensive mental health role in their practices following the training intervention. Of ninety-four DIS-generated diagnoses in the study population of fifty-one patients, 79 percent were unrecognized. Patients were assumed to function well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of cases. The physicians did diagnose and treat a number of patients with mental symptoms who were not identified by the DIS. These patients had high, but sub-diagnostic, DIS symptom counts. Most received a diagnosis of adjustment disorder in response to medical illness. Though this finding underscores shortcomings of present psychiatric nosology when applied in the general medical setting, the foremost consideration was the large number of DIS-identified patients with serious psychopathology, needing active assessment and intervention, who were unrecognized, undiagnosed or untreated. Implications of these findings for the psychiatric training of primary care physicians are examined.

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BackgroundPatients treated in primary care settings report better mental outcomes when they agree with practitioners about the nature of their core presenting problems. However, no study has examined the impact of staff–patient agreement on treatment outcomes in specialist mental health services. We investigated whether a better staff–patient agreement on needs for care predicts more favourable outcome in patients receiving community-based psychiatric care.MethodA 3-month prevalence cohort of 188 patients with the full spectrum of psychiatric conditions was assessed at baseline and at 4 years using the Camberwell Assessment of Need (CAN), both staff (CAN-S) and patient versions (CAN-P), and a set of standardized outcome measures. Baseline staff–patient agreement on needs was included among predictors of outcome. Both clinician-rated (psychopathology, social disability, global functioning) and patient-rated (subjective quality of life and satisfaction with services) outcomes were considered.ResultsControlling for the effect of sociodemographics, service utilization and changes in clinical status, better staff–patient agreement makes a significant additional contribution in predicting treatment outcomes not only on patient-rated but also on clinician-rated measures.ConclusionsMental health care should be provided on the basis of a negotiation process involving both professionals and service users to ensure effective interventions; every effort should be made by services to implement strategies aiming to increase consensus between staff and patients.

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IntroductionThe objectives of this study were to systematically review published research on the relationship between nursing staff coverage, care hours, and quality of care (QoC) in long-term care (LTC) facilities; and to conduct a real world evidence (RWE) analysis using Alberta real world data (RWD) to inform policy makers on whether any amendments could be made to current regulations.MethodsA systematic review (SR) of research evidence published between January 2000 and May 2018 on the relationship between nursing staff coverage, care hours, and QoC in LTC facilities was conducted. Panel data regressions using available RWD from Alberta, Canada, were performed to assess associations between nursing care hours and LTC outcomes. Outcomes of interest included quality indicators related to resident outcomes, hospital admissions, emergency room visits and family satisfaction. Nursing care hours considered in SR and RWE analysis included those provided by registered nurses (RNs) and licensed practical nurses (LPNs).ResultsThe SR found inconsistent and poor quality evidence relevant to the questions of interest, indicating a great uncertainty about the association between nursing staff time and type of coverage and QoC. Although some positive indications were suggested, major weaknesses of reviewed studies limited interpretation of SR results. RWE analysis found that impact of care hours on LTC outcomes was heterogeneous, dependent on outcome measurements. There was evidence that total staff, RN, and LPN hours had positive effects on some resident outcomes and magnitude of effect differed for different nursing staff.ConclusionsNo definitive conclusion could be drawn on whether changing nursing staff time or nursing staff coverage models would affect residents’ outcomes based on the research evidence gathered in the SR. RWE analysis helped to fill a gap in the available published literature and allowed policy makers to better understand the impact of revising current regulations based on actual outcomes.

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SummaryBackground: The implementation of a technology such as health information exchange (HIE) through a Regional Health Information System (RHIS) may improve the mobilization of health care information electronically across organizations. There is a need to coordinate care and bring together regional and local stakeholders.Objectives: To describe how HIE had influenced health care delivery in one hospital district area in Finland.Method: Trend analysis was used to evaluate the influence of a regional HIE. We conducted a retrospective, longitudinal study for the period 2004–2008 for the eleven federations of municipalities in the study area. We reviewed statistical health data from the time of implementation of an RHIS. The t-test was used to determine statistical significance. The selected outcomes were the data obtained from the regional database on total appointments, emergency department visits, laboratory tests and radiology examinations, and selected laboratory tests and radiology examinations carried out in both primary care and special health care.Results: Access to HIE may have influenced health care delivery in the study area. There are indications that there is a connection between access to regional HIE and the number of laboratory tests and radiology examinations performed in both primary care and specialized health care, as observed in the decreased frequency in outcomes such as radiology examinations, number of appointments, and emergency department visits in the study environment. The decreased frequencies of the latter suggest an increased efficiency of outpatient care, but we were not able to estimate to what extent the readily available comprehensive clinical information contributed to these trends.Conclusion: Outcome assessment of HIE through an RHIS is essential for the success of health information technology (HIT) and as evidence to use in the decision-making process. As health care information becomes more digital, it increases the potential for a strong HIE effect on health care delivery.

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AbstarctThe Uniform Data System for Medical Rehabilitation (UDSmr) provides a method for uniform assessment of the severity of patient disability and the outcomes of medical rehabilitative care. The effectiveness and efficiency of medical rehabilitation services may be analyzed using the Functional Independence Measure (FIM), the functional assessment component of the UDS, and other data. Program evaluation models based on the UDSMR and the FIM are useful for measuring resource cost of disability.

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SynopsisThe chapter describes the professional and regulatory landmarks which have influenced the development of the quality movement in health care in the UK and the USA. They reflect the similarities and differences in the approach to quality which have evolved within the National Health Service in Britain when compared with a free market system of health care such as that in North America.A conceptual framework is used to approach the definition and assessment of quality of health care, noting in particular Donabedian's seminal triad of structure, process and outcome as well as the outcomes movement and other theoretical approaches to defining quality.The characteristics of criteria, standards, guidelines and protocols are described and the terminological problems in this field are discussed. The use of standards for improving quality includes their application in clinical audit, for accreditation and re-accreditation, in contracting for health services and in regulation and inspection.There is a new and unfolding relationship between clinical standard setting and management. Concepts such as continuous quality improvement and total quality management are challenging traditional assumptions about the need for a separation between professional, consumer and managerial approaches to improving quality. The National Health Service, following implementation of an internal market for public health care provision in Britain, is well placed to absorb and synthesise the many differing philosophies in the health care quality movement to the benefit of both patients and the health professions alike.

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Aims and methodImplementation of evidence-based psychosocial interventions in accordance with National Institute of Health and Care Excellence guidelines and quality standards has been incomplete. This project involved allocation of adults under mental health services to six guideline categories, completion of a clinician- and patient-rated outcome measure, and individual assessment against clinical standards.ResultsIn the first 3 months of the project, 5048 patients were allocated to a pathway and 3734 (73%) were assessed against at least one of the relevant standards. All were assessed using the Health of the Nation Outcome Scales (91–93% of scales completed) and 1866 (36%) completed the patient-rated outcome measure, DIALOG.Clinical implicationsClinicians will allocate patients to pathways, complete outcome measures and assess against standards, providing data to guide practice, service design and costing of mental health systems with supporting technology to assist data entry and presentation. This has the potential to provide much improved and readily accessible information about individual outcomes and standards for people with mental health problems and those working with them. It could also provide a method for payment for services which directly support good clinical practice.

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The multitude of comorbidities and disabilities that are prevalent among diabetic patients make their care very challenging for providers. This, in turn, may have a negative effect on measures of patient satisfaction, quality, and outcomes. This study examines the correlation between diabetes ratio as a primary diagnosis in home health agencies (HHAs) with the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey and the Outcome and Assessment Information Set (OASIS) star ratings. Our result indicates that HHAs with a higher proportion of patients with diabetes have lower ratings in health outcomes (bathing, breathing, moving from the bed, moving around, and controlling pain). The association was stronger in the case of diabetic cases with complications.

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We quantified the effectiveness of an oral health intervention among home care recipients. Seven German insurance funds invited home care recipients to participate in a two-arm randomized controlled trial. At t0, the treatment group (TG) received an intervention comprising an oral health assessment, dental treatment recommendations and oral health education. The control group (CG) received usual care. At t1, blinded observers assessed objective (Oral Health Assessment Tool (OHAT)) and subjective (Oral Health Impact Profile (OHIP)) oral health and the objective periodontal situation (Periodontal Screening Index (PSI)). Of 9656 invited individuals, 527 (5.5%) participated. In the TG, 164 of 259 (63.3%) participants received the intervention and 112 (43.2%) received an outcome assessment. In the CG, 137 of 268 (51.1%) participants received an outcome assessment. The OHAT mean score (2.83 vs. 3.31, p = 0.0665) and the OHIP mean score (8.92 vs. 7.99, p = 0.1884) did not differ significantly. The prevalence of any periodontal problems (77.1% vs. 92.0%, p = 0.0027) was significantly lower in the TG than in the CG, but the prevalence of periodontitis was not (35.4% vs. 44.6%, p = 0.1764). Future studies should investigate whether other recruitment strategies and a more comprehensive intervention might be more successful in improving oral health among home care recipients.

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Background: International oncology societies recommend early palliative care. Specific models to integrate early palliative care efficiently into clinical practice are debated. The authors designed a study to look at the quantitative and qualitative outcomes of an early palliative care intervention in oncological care to decrease stress and improve quality of life. Aims: To compare a single structured early palliative care intervention added to a usual oncology care in terms of distress and health-related quality of life at baseline compared to 6 months after enrollment. Design: This multicenter randomized controlled trial (NCT01983956) enrolled adult patients with advanced cancer. Participants were either randomly assigned to usual oncology care alone or usual care plus a structured early palliative care intervention. Setting/participants: One hundred fifty adult patients with a variety of advanced cancer diagnoses were randomized. Seventy-four participants were in the intervention and 76 participants in the control group. The primary outcome was the change in patient distress assessed by the National Comprehensive Cancer Network distress thermometer at 6 months. Health-related quality of life, the secondary outcome, was assessed by the Functional Assessment of Cancer Therapy–General Questionnaire. Results: The results showed no significant effect of the early palliative care intervention neither on patient distress nor on health-related quality of life. Conclusion: The addition of an early intervention to usual care for patients with advanced cancer did not improve distress or quality of life. Thus, patients may need more intensive early palliative care with continuous professional support to identify and address their palliative needs early.

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We integrated and optimized patient-reported outcome measures into the electronic health record to provide quantitative, objective data regarding patients’ health status, which is important for patient care, payer contracts, and research. With a multidisciplinary team from information technology, clinical informatics, population health, and physician champions, we used formal human–computer interaction techniques and user-centered design to integrate several technology platforms and computerized adaptive testing for the National Institutes of Health Patient-Reported Outcomes Measurement Information System. The patient-reported outcome measure system leverages software frequently used by health systems and provides data for research and clinical care via a mobile-responsive web application using Symfony, with REDCap for configuring assessments and de-identified data storage. The system incorporates Oracle databases and Epic flowsheets. Patients complete patient-reported outcome measures, with data viewable in MyChart and Epic Synopsis Reports. Researchers can access data portals. The highly usable, successful patient-reported outcome measures platform is acceptable to patients and clinicians and achieved 73 percent overall completion rates.

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BackgroundLittle is known about the impact of personality pathology on the treatment outcome of major depressive illness in primary care in the UK.MethodPatients meeting criteria for DSM–III major depressive disorder were randomly allocated to one of four treatments each lasting 16 weeks, then followed up for 18 months. Assessments were made of depressive symptoms, personality and social functioning. Personality was assessed at maximum improvement or 16 weeks.ResultsThe prevalence of personality disorder (PD) in the sample of 113 patients was 26%. Patients with a PD were significantly younger and rated more depressed at entry than patients with no personality disorder (NoPD). On completion of treatment patients with a PD were significantly more depressed and had poorer social functioning than the NoPD group. After 18 months there were no differences in ratings of depression or social functioning between the groups.ConclusionsThere was substantial improvement in both the PD and NoPD groups. The presence of personality pathology delays recovery from major depressive illness.

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Background Despite the acceptability and efficacy of e–patient-reported outcome (ePRO) systems, implementation in routine clinical care remains challenging. Objective This pragmatic trial implemented the PROMPT-Care (Patient Reported Outcome Measures for Personalized Treatment and Care) web-based system into existing clinical workflows and evaluated its effectiveness among a diverse population of patients with cancer. Methods Adult patients with solid tumors receiving active treatment or follow-up care in four cancer centers were enrolled. The PROMPT-Care intervention supported patient management through (1) monthly off-site electronic PRO physical symptom and psychosocial well-being assessments, (2) automated electronic clinical alerts notifying the care team of unresolved clinical issues following two consecutive assessments, and (3) tailored online patient self-management resources. Propensity score matching was used to match controls with intervention patients in a 4:1 ratio for patient age, sex, and treatment status. The primary outcome was a reduction in emergency department presentations. Secondary outcomes were time spent on chemotherapy and the number of allied health service referrals. Results From April 2016 to October 2018, 328 patients from four public hospitals received the intervention. Matched controls (n=1312) comprised the general population of patients with cancer, seen at the participating hospitals during the study period. Emergency department visits were significantly reduced by 33% (P=.02) among patients receiving the intervention compared with patients in the matched controls. No significant associations were found in allied health referrals or time to end of chemotherapy. At baseline, the most common patient reported outcomes (above-threshold) were fatigue (39%), tiredness (38.4%), worry (32.9%), general wellbeing (32.9%), and sleep (24.1%), aligning with the most frequently accessed self-management domain pages of physical well-being (36%) and emotional well-being (23%). The majority of clinical feedback reports were reviewed by nursing staff (729/893, 82%), largely in response to the automated clinical alerts (n=877). Conclusions Algorithm-supported web-based systems utilizing patient reported outcomes in clinical practice reduced emergency department presentations among a diverse population of patients with cancer. This study also highlighted the importance of (1) automated triggers for reviewing above-threshold results in patient reports, rather than passive manual review of patient records; (2) the instrumental role nurses play in managing alerts; and (3) providing patients with resources to support guided self-management, where appropriate. Together, these factors will inform the integration of web-based PRO systems into future models of routine cancer care. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12616000615482; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370633 International Registered Report Identifier (IRRID) RR2-10.1186/s12885-018-4729-3

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BackgroundThe main objectives of the survey were: (a) to analyse the sociological, clinical and illness-related correlates of mental illness in primary care; (b) to study, during one-year follow-up, outcome and use of health resources.MethodThe survey comprised a two-phase cross-sectional study. In the first phase patients were classified using the GHQ-28 or by the general practitioner (GP). In the second phase they were assessed by the SCAN system.ResultsThe prevalence rate of mental illness (in attenders) using the GHQ was 33.2%. The corresponding rate for the GP was 14.1%, and for the SCAN 31.5%. Mental illness mainly comprised depression, anxiety and alcohol-related diagnoses. The presence of mental illness and the use of health resources during follow-up were dependent on demographic characteristics and on their original psychiatric status.ConclusionsIn primary care, mental illness constitutes a major health problem. Despite this fact. GPs do not recognise a substantial proportion of these health problems.

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Background Sciatica has a substantial impact on patients and society. Current care is ‘stepped’, comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. Objectives The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. Design This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Setting Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Participants Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. Interventions In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. Main outcome measures The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost–utility analysis was undertaken over 12 months. A qualitative study explored patients’ and clinicians’ views of the fast-track care pathway to a spinal specialist. Results A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. Conclusions The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Limitations Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Future work Other approaches to stratified care may provide superior outcomes for sciatica. Trial registration Current Controlled Trials ISRCTN75449581. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

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IntroductionAnorexia nervosa (AN) is characterized by self-induced starvation coupled with fear of gaining weight and a distorted body image. Its treatment is complex and challenging, and sometimes hospitalization is needed.Santa Maria Hospital's Eating Disorders Unit (SMH-EDU) is a multidisciplinary team, formed in 1989, that provides both outpatient and inpatient treatment.ObjectiveTo present and discuss SMH-EDU's AN treatment and its results.MethodsRevision and statistical analysis of all hospitalized AN’ patients’ clinical files, from 1 January 2014 to 31 December 2014. Treatment outcome was assessed by BMI variation.ResultsA total of 45 admissions (41 patients) were analysed: 75.65% had AN restricting type and 24.45% had AN purging type. All patient were females, with median age of 27 years old (range 12–57 years). Average admission BMI was 14.51 kg/m2 (ranging from 11.19 to 17.77 kg/m2). The mean lengths of stay were 39 days. Thirty-six percent of the patients had at least one previous hospitalization. Only 2 patients were readmitted at SMH-EDU: triple readmissions. The mean time between the beginning of the disorder and the admission was 111 months (ranging 2 to 408 months). Average discharged BMI was 16.32 kg/m2 (ranging from 13.24 to 19.11 kg/m2).ConclusionInpatient treatment for AN at SMH-EDU is considered only for those patients whose disorder has not improved with appropriate outpatient treatment. Therefore, most inpatients at SMH-EDU have disorders of high severity, as demonstrated in our results.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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The University of British Columbia (UBC) has partnered with community primary care providers to implement a shared care pilot project for the management of depression. The National College Health Assessment survey conducted at UBC in 2004 identified a significant gap in the management of depression. This finding highlighted a need to better integrate existing resources and strengthen the capacity of primary care providers to effectively recognize, assess, and treat depression. This article outlines the development and evaluation of a shared care collaborative approach to the primary care of depression in the UBC campus community.

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Life expectancy in patients with schizophrenia is reduced by 20 years for men and 15 years for women compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being dominant. The aim of this trial was to improve the cardiovascular risk profile.MethodsThe CHANGE trial was an investigator-initiated, randomised, parallel-group, superiority, multi-centre trial with blinded outcome assessment. Patients diagnosed with schizophrenia spectrum disorders and increased waist circumference according (>88 cm for women, >102 cm for men), were recruited and centrally randomised 1:1:1 to 12-months of lifestyle coaching plus care coordination versus care coordination alone versus treatment as usual. The primary outcome was 10-year risk of cardiovascular disease assessed post-treatment and standardised to age 60, secondary outcomes included cardiorespiratory fitness and physical activity. Clinical.Trials.gov NCT01585493.FindingsA total of 428 participants were randomly assigned to the CHANGE intervention (n = 138); care coordination (n = 142); or treatment as usual (n = 148). At 12 months, the mean 10 years risk of cardiovascular disease was 8.4% (SD 6.7) in the CHANGE group, 8.5% (SD 7.5) in the care coordination group and 8.0% (SD 6.5) in the treatment as usual group (P = 0.41). We found no intervention effects for any secondary or explorative outcomes, including weight, cardiorespiratory fitness, physical activity, diet or smoking.InterpretationThe CHANGE trial did not support individual lifestyle coaching or care coordination as superior compared with treatment as usual in reducing the cardiovascular risk in patients with schizophrenia and increased waist circumference.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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BackgroundDuring pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circ*mstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study.Objectives(1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools ‘Community Assessment Tools’ and ‘Pandemic Medical Early Warning Score’ to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons.DesignProspective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs.SettingThirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink.ParticipantsAll people presenting with ILI.InterventionsNone.Main outcome measuresStudy outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital – if admitted, the need for higher levels of care and length of hospital stay.Data sourcesLinked anonymised data from a web-based structured clinical assessment and primary care EHRs.ResultsIn the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation.ConclusionsWe have developed processes that allow capture and near real-time automated analysis of GP’s clinical assessments and management decisions of people presenting with ILI.Future workWe will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak.Study registrationThis study is registered as ISRCTN87130712 and UK Clinical Research Network 12827.FundingThe National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections.

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BackgroundFailure to demonstrate the effect of integration on service users using conventional outcome measures suggests that research to date has failed to measure the outcomes that actually matter to people with complex long-term conditions and that might result from integrated health and social care. Developing outcome measures that capture the important issues for service users may also help to better reflect the particular ways integrated teams work and what such teams strive to achieve in addressing service user outcomes.ObjectivesThe objectives of this research were to (1) identify factors that affect integration between health and social care; (2) identify outcomes important to people with long-term neurological conditions (LTNCs) who are clients of an ‘integrated’ service; (3) develop these outcomes into a checklist and explore whether or not these outcomes can be assessed in practice; and (4) understand how different models of integration affect outcomes.Design, methods and participantsA case study approach, using in-depth, semistructured interviews, was adopted. The cases were four English primary care trusts (PCTs) and their associated local authorities. Case sites had a neurological-rehabilitation team (NRT), each with a different approach to health and social care integration. The research took place in three stages. In stage 1, interviews with 43 commissioners, managers, NRT staff and social care practitioners, and documentary analysis, helped to understand service contexts and approaches to assessment. Interviews, guided by earlier outcomes work, were held with 35 people with LTNCs to identify important outcomes. Interviews with 13 carers illustrated relationships between NRTs and carers. In stage 2, these outcomes were developed into a checklist in partnership with NRTs. NRTs used the outcomes checklist (OC) as part of their routine assessment, and we monitored its use. In stage 3, we conducted interviews and focus groups with 21 NRT staff and 12 clients to evaluate the use of the OC in practice.AnalysisQualitative data were managed and analysed thematically using the framework approach.ResultsPerson, service and structural-level factors influenced integration between health and social care. Relationships between practitioners and services often drove integration in practice. However, wider structural arrangements were important and could facilitate these relationships. We identified 20 outcomes important to people with LTNCs. These were grouped into three outcome domains: personal comfort, economic and social participation, and autonomy. Use of the OC in practice was viewed differently by the NRTs. One NRT felt that it duplicated existing assessments, one felt that it covered issues outside their remit and two felt that the OC worked for them. Some of the outcomes could be difficult for staff and clients to raise but clients felt that they should all be included in assessments. Use of the OC was sometimes challenging due to staffing and caseload pressures, changes to service structures and remit, and competing demands of other compulsory paperwork. All NRTs thought that the OC had potential value as a benchmarking or training tool. Larger, more interdisciplinary models of integrated NRTs appeared to give more scope for interpreting, assessing and potentially achieving outcomes.ConclusionsMany of the outcomes that are important to service users with LTNCs are not addressed in validated ‘outcome measures’. This has implications for commissioners and practitioners to ensure that service users’ needs are met in practice. Turning the OC into a measurement tool could go some way to addressing this. Many of the outcomes are interdependent; an impact on one particular outcome will have a ‘knock-on’ effect on other outcomes. These inter-relationships demonstrate the complexity of what is important in the lives of people with LTNCs. Service changes can affect integrated arrangements negatively. More research is needed to explore the longer-term effects of organisational change on integrated service provision.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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12011 Background: Older people experience significant adverse effects of cancer and anti-cancer therapy due to age-related vulnerabilities, including medical, functional, cognitive, nutritional and psychosocial issues. Comprehensive geriatric assessment and management (CGAM) provides a powerful framework to assess an older person’s health status and offers a coordinated, person-centered approach to care. Despite its effectiveness, the uptake of CGAM in oncology has been limited due to a lack of randomized evidence in this setting. This study evaluated the effectiveness of CGAM in older people with cancer. Methods: INTEGERATE is a prospective, randomized, parallel group, open-label study in patients aged >70 years with cancer planned for chemotherapy, targeted therapy or immunotherapy. Patients were randomly assigned (1:1) to receive either geriatrician-led CGAM integrated with usual care (integrated oncogeriatric care) or usual care alone, using minimization to balance treatment intent, cancer type, age, sex and performance status. Health-related quality of life (HRQOL) was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-ELD14 at 0, 12, 18 and 24 weeks. The primary outcome was HRQOL measured by the validated Elderly Functional Index (ELFI) score. Major secondary outcomes included function, mood, nutrition, health utility, treatment delivery, healthcare utilization and survival. Results: Of the 154 patients who underwent randomization, 13 died by week 12 and 130 (92.2% of the remaining patients) completed at least two primary outcome assessments. For the primary outcome, patients in the intervention group had significantly better ELFI score than the usual care group across all followup timepoints, with a maximal difference at week 18 (estimated marginal mean ELFI score 72.0 vs 58.7, p= 0.001). In addition, significant differences favoring the intervention group over the usual care group were seen in HRQOL (domains: physical, role and social functioning; mobility, burden of illness and future worries), unplanned hospital admissions (-1.2 admissions per person-years, p< 0.001) and early treatment discontinuation (32.9% vs 53.2%, p = 0.01). Conclusions: Integrated oncogeriatric care led to improvements in HRQOL, unplanned hospital admissions and treatment discontinuation in older people receiving systemic anti-cancer therapy. Older people (>70 years) planned for anti-cancer therapy should receive CGAM to optimize their clinical care and health outcomes. Clinical trial information: ACTRN12614000399695 .

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SUMMARYClosing the gap between research and clinical practice is nowadays considered a priority in outcome studies. Survey studies in community settings having as their main aim the multidimensional measure of outcome of mental health care interventions, including the use of standardised instruments administered as part of the routine clinical activities in mental health services, have recently started to be planned in various countries, but have encountered several difficulties. A naturalistic, longitudinal study aimed to assess the outcome of care provided by a community-based mental health service, the South Verona Outcome Project, has been conducted in Italy starting from the beginning of the 90's and is running since then. This paper: a) describes a series of methodological aspects of the South Verona Outcome Project, such as instruments, study design, inclusion and exclusion criteria, training of the staff, and focuses on strategies used so to ensure feasibility of the assessment and good quality of the data; b) summarises some results of the study, characteristics of feed-back provided, and outputs; c) discusses the problems faced, the impact of this approach on service provision, its limitations and future perspectives.

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In a changing economy and a changing industry, health care providers need to complete thorough, comprehensive, and efficient assessments that provide both an accurate depiction of the patient's deficits and a blueprint to the path of treatment for older adults. Through standardized testing and observations as well as the goals and evidenced-based treatment plans we have devised, health care providers can maximize outcomes and the functional levels of patients. In this article, we review an interdisciplinary assessment that involves speech-language pathology, occupational therapy, physical therapy, and respiratory therapy to work with older adults in health care settings. Using the approach, we will examine the benefits of collaboration between disciplines, an interdisciplinary screening process, and the importance of sharing information from comprehensive discipline-specific evaluations. We also will discuss the importance of having an understanding of the varied scopes of practice, the utilization of outcome measurement tools, and a patient-centered assessment approach to care.