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OBJETIVE To characterise the impact of the COVID-19 pandemic on psychiatric hospitalisations in the Latin American and Caribbean (LAC) region. METHODS Descriptive study. 85 semi-structured interviews were conducted with health workers involved with psychiatric hospitalisations in general hospitals (GHs) and specialised psychiatric hospitals (SHs) from 18 LAC countries. The interviews were done between 8 May and 30 June 2020. The data were analysed quantitatively and qualitatively. RESULTS An initial decrease in the demand for hospitalisation is reported, attributed to the population's fear of approaching health services as well as restrictions on mobility. Stricter criteria for hospitalisation were reported with a double focus on the acute within the acute. The length of hospitalisations were mixed, with both increases and decreases in GHs and SHs. The therapeutic offer was drastically reduced, and interaction between hospitalised people and their support networks was restricted. CONCLUSIONS In the COVID-19 context, hospitalisation seems to be not the last but the only alternative for psychiatric treatment. The decrease in the number of beds in SHs could be a positive aspect for the reform of psychiatric care, but it is questioned since this reduction also occurs in GHs.

Background Given low base rates of suicidal thoughts and behaviors (STBs) in national samples of adolescents, clarifying the sociodemographic and clinical correlates among psychiatric inpatients may afford insights into potential risk factors that predict STBs onset. Method Adolescents (N = 970; ages 12-19 years) admitted for acute, psychiatric inpatient care completed baseline clinical interviews and self-report measures assessing demographics and early life adversity. Lifetime and 12-month STBs prevalence were obtained, allowing for the estimate of STBs persistence (i.e., rates of those with both current and past STBs) and transition rates (i.e., proportion of ideators that transition to plans or attempts). Univariate and multivariate logistic regression tested sociodemographic and clinical correlates of STBs. Results Age-of-onset for STBs occurred in early adolescence. Most patients reported suicide ideation with nearly half of patients making a plan and one-third a suicide attempt. Although relatively modest, the strongest correlates of lifetime attempts were depressive disorders, physical abuse, and non-suicidal self-injury. Knowing a peer that had attempted suicide also increased the likelihood of a suicide attempt, especially among attempters who transitioned from ideation to planned attempts. Conclusion STBs are highly prevalent among adolescents admitted for acute psychiatric inpatient treatment. The modest effects suggest that correlates, particularly those related to suicide attempts, are widely distributed. As a history of physical abuse and knowing a peer with a suicide attempt history are related to transitioning from ideation to action, these may be critical factors to target in the deployment of future suicide prevention and treatment programs. HIGHLIGHTSOne-third of adolescent inpatients report a lifetime history of suicide attempts.Approximately 65% of adolescent inpatients with a lifetime plan attempt suicide.Knowing peers who attempt suicide may facilitate the transition from ideation to action.

Background Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients’ reported needs. Objectives The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service. Methods The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service. Results Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n = 22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy). Conclusions Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population.The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries.NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers.Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children.III.Case Control Study.

Ambulatory surgery has proven benefits in patient wellbeing and cost reduction in healthcare systems. However, some patients referred for ambulatory surgery are refused and directed instead towards inpatient care, which generates several drawbacks. The reasons for this refusal have not been yet studied. The aim of this study is to identify, retrospectively, significant variables associated with patient refusal for ambulatory surgery and develop a mathematical tool able to predict with strong accuracy those who will be rejected.Over a 5-year period (2014 - 2018), all patients that underwent abdominal hernia repair in our hospital in an inpatient setting, and that had been previously refused for ambulatory surgery, were analysed for a total of 94 variables. A multivariate logistic regression model was developed to identify risk factors associated with refusal using data from 136 patients (65 refused vs 71 accepted). A prediction index for refusal in ambulatory surgery - IRAS - was derived and tested (n = 62 patients).The risk index included five significant risk factors: type 2 diabetes mellitus [OR 14.669 (2.982; 72.154)], physical status [OR 49.155 (15.532; 155.555)], prior malignancy [OR 14.518 (2.653; 79.441)], prior abdominal surgery [OR 3.455 (1.006; 11.866)] and usage of antiplatelet agents [OR 25.600 (4.309; 152.066)]. All risk factors were associated with a high risk of refusal (OR between 3.455 for history of prior abdominal surgery and 49.155 according to the American Society of Anaesthesiologists physical status classification). Defining five points as the maximum IRAS score that predicts suitability for ambulatory surgery resulted in a positive predictive value of 93.55% and negative predictive value of 87.10%.Significant patient variables for refusal of an ambulatory procedure were determined and an easy to use risk index - IRAS - was built that is able to predict with good accuracy which patients will be refused.IRAS is a useful tool that can contribute to reduce time to surgery and improve patients' quality of life.Introdução: A cirurgia de ambulatório tem benefícios comprovados no bem-estar dos doentes e na redução de custos dos sistemas de saúde. Porém, alguns doentes referenciados para cirurgia de ambulatório são recusados e encaminhados para internamento. Os motivos desta recusa ainda não foram estudados. Neste trabalho identificámos, retrospectivamente, variáveis significativas na recusa dos doentes e fornecemos uma ferramenta matemática capaz de prever de forma precisa aqueles que serão rejeitados. Material e Métodos: Ao longo de cinco anos (2014 - 2018), todos os doentes submetidos a correção cirúrgica de hérnia abdominal em regime de internamento no nosso centro hospitalar previamente recusados para cirurgia de ambulatório foram analisados para um total de 94 variáveis. Um modelo de regressão logística multivariada foi desenvolvido para identificar os fatores de risco para recusa usando dados de 136 doentes (65 recusados vs 71 aceites). Um índice preditivo para recusa de cirurgia em ambulatório, IRAS, foi criado e testado (n = 62 doentes). Resultados: O IRAS incluiu cinco fatores de risco significativos: diabetes mellitus tipo 2 [OR 14,669 (2,982; 72,154)], estado físico [OR 49,155 (15,532; 155,555)], neoplasia maligna prévia [OR 14,518 (2,653; 79,441)], cirurgia abdominal prévia [OR 3,455 (1,006; 11,866)] e uso de agentes antiplaquetários [OR 25,600 (4,309; 152,066)]. Todos os fatores de risco foram associados a elevado risco de recusa (OR entre 3,455 para história de cirurgia abdominal prévia e 49,155 de acordo com a classificação do estado físico segundo a American Society of Anaesthesiologists). A definição de cinco pontos como a pontuação máxima do IRAS que prevê adequação para cirurgia de ambulatório resultou num valor preditivo positivo de 93,55% e um valor preditivo negativo de 87,10%. Discussão: Foram determinadas variáveis significativas para recusa de um doente para cirurgia de ambulatório e construído um índice de risco de fácil utilização, IRAS, capaz de predizer que doentes serão recusados com boa precisão. Conclusão: O índice IRAS é uma ferramenta útil que pode contribuir para a redução dos tempos de espera e melhorar a qualidade de vida dos doentes.

Objectives To characterize the utilization trends associated with the Aarogyasri health insurance scheme in Andhra Pradesh, India. Methods This is a retrospective cross-sectional study including participants enrolled in the Aarogyasri health insurance scheme, with recorded claims pertaining to inpatient care from quarter 3, 2014 through quarter 2, 2018. The main outcome measure, was annual utilization by service category, trended to characterize changes in the mean claim amount and the median length of stay. Mortality by service category was also trended. Mann-Kendall correlation was used to evaluate trends. Additionally, interdistrict migration for care in 2014 versus 2018 was examined to evaluate changes in access to care. Results The distribution of claims by caste significantly shifted over time, with members of backward castes and scheduled tribes filing more claims, and members of other castes and scheduled castes filing fewer claims. The median age of patients significantly increased, rising from 44.0 years in 2014 to 46.0 years in 2018. The nominal mean claim amount in 2018 was 105.4% of the 2014 average, but the 2018 real mean claim amount was 90.3% of the 2014 average. The median length of stay significantly decreased from 5 to 4 days. Mortality rates after procedures significantly decreased from 2.4% to 2.1%. Interdistrict migration to access care remained high among beneficiaries from the districts YSR Kadapa and West Godaveri in 2014 and 2018. Conclusions Over time, the value delivered by Aarogyasri improved. More patients received care at lower real per claim cost, with a concurrent decline in mortality.

The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery. For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization. Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy. There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving. Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures. We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.

Existing research on hospital charges is primarily focused on hospital admissions, but not on hospital readmissions. Our research fills this gap. We utilize the 2017 Hospital Readmissions database from the Agency for Healthcare Research and Quality (AHRQ) to empirically study factors that impact hospital charges for hospital readmissions. We focus on psychosis (DRG = 885) which has 609,360 records in 2017 in the AHRQ database. We employ regression analyses using patient demographics, inpatient care variables, and hospital characteristics to explain variance in hospital charges. Results show that inpatient care (diagnoses, procedures, length of stay), hospital ownership, and younger patients result in higher hospital charges.

Many studies provide evidence for the so-called weekend effect by demonstrating that patients admitted to hospital during weekends show less favourable outcomes such as increased mortality, compared with similar patients admitted during weekdays. The underlying causes for this phenomenon are still discussed controversially. We analysed factors influencing weekend effects in inpatient care for acute stroke in Austria. The study analysed secondary datasets from all 130 public acute care hospitals in Austria between 2010 and 2014 (Austrian DRG Data). The study cohort included 86,399 patient cases admitted with acute ischaemic stroke. By applying multivariate regression analysis, we tested whether patient, treatment or hospital characteristics drove in-hospital mortality on weekends and national holidays. We found that the risk to die after an admission at weekend was significantly higher compared to weekdays, while the number of admissions following stroke was significantly lower. Adjustment for patient, treatment and hospital characteristics substantially reduced the weekend effect in mortality but did not eliminate it. We conclude that the observed weekend effect could be explained either by lower quality of health care or higher severity of stroke admissions at the weekend. In depth analyses supported the hypothesis of higher stroke severity in weekend patients as seen in other studies. While DRG data is useful to analyse stroke treatment and outcomes, adjustment for case mix and severity is essential.

Background: Patients with amyotrophic lateral sclerosis (ALS) need a large amount of healthcare services. Knowledge on use of and satisfaction with healthcare is, however, scarce. Objective: The objectives were to explore use and satisfaction of healthcare in patients with ALS. Methods: The sample consisted of patients with ALS, recruited from the ALS clinic at the Karolinska University Hospital, Stockholm, Sweden, participating in a three-year observational study. Data on healthcare utilisation were retrieved from the computerised register at Region Stockholm, Sweden. Information regarding disability, contextual factors and satisfaction with care was collected by home visits. Results: Over time, half, or less of the patients used inpatient care, whereas all used outpatient care. Half of all outpatient contacts were with providers of advanced healthcare in the home and one-fifth with allied health professionals. Nurses performing home visits composed the largest proportion of outpatient contacts. A small amount of the utilised outpatient care emerged from the ALS clinic. Patients with severe disease and longer time since diagnosis had fewer contacts with the ALS clinic. Satisfaction with care was in general stable over time with around two-thirds or more of patients being satisfied. Most patients wanted to participate in care planning, but few had. Conclusion: Patients with ALS use hospital-based specialist care and other outpatient care in parallel with many healthcare providers involved. Our findings highlight the need for implementation of person-centred care to improve both coordination of care, care transitions and satisfaction with healthcare services.

Background Survey studies have found that vaccinated persons tend to report more side effects after being given information about side effects rather than benefits. However, the impact of high media attention about vaccine-related side effects on the utilization of health care is unknown. We aimed to assess whether utilization of health care services for newly vaccinated health care workers changed after media attention about fatal side effects of the AstraZeneca vaccine on March 11th, 2021, and whether changes differed by age, sex, or occupation. Methods We utilized individual-level data on health care use, vaccination, employment, and demographics available in the Norwegian emergency preparedness register Beredt C19. In all 99,899 health care workers in Norway who were vaccinated with AstraZeneca between February 11th and March 11th, we used an event-study design with a matched comparison group to compare the change in primary and inpatient specialist care use from 14 days before to 14 days after the information shock on March 11th, 2021. Results Primary health care use increased with 8.2 daily consultations per 1000 health care workers (95% CI 7.51 to 8.89) the week following March 11th for those vaccinated with AstraZeneca (n = 99,899), compared with no increase for the unvaccinated comparison group (n = 186,885). Utilization of inpatient care also increased with 0.8 daily hospitalizations per 1000 health care workers (95% CI 0.37 to 1.23) in week two after March 11th. The sharpest increase in daily primary health care use in the first week after March 11th was found for women aged 18–44 (10.6 consultations per 1000, 95% CI 9.52 to 11.68) and for cleaners working in the health care sector (9.8 consultations per 1000, 95% CI 3.41 to 16.19). Conclusions Health care use was higher after the media reports of a few cases of fatal or severe side effects of the AstraZeneca vaccine. Our results suggest that the reports did not only lead vaccinated individuals to contact primary health care more, but also that physicians referred and treated more cases to specialist care after the new information.

Background The Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees’ access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable. Methods A cross‐sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors. Results We found pro-rich inequality and horizontal inequity in the probability of refugees’ outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures. Conclusion Our results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

Introduction Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in Italy, accounting for 22% of total deaths. Lowering low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of cardiovascular (CV) events; thus, lipid-lowering therapy (LLT) is the first-line treatment for patients with ASCVD and hypercholesterolaemia. However, many patients with ASCVD fail to reach LDL-C treatment thresholds, leaving them at greater risk of CV events. Inpatient care accounts for 51% of total expenditure on cardiovascular disease in the European Union, but healthcare resource utilization (HCRU) data for ASCVD in Italy is limited. Methods The study analysed healthcare claims data for 17,881 patients with acute coronary syndrome, ischemic stroke or peripheral artery disease from the Umbria 2 and Marche regions of Italy. LLT treatment patterns and CV event rates were collected and HCRU estimated in the year before and after the index event. Results High-intensity LLTs were prescribed to 44.3% of patients and 49.6% received moderate-/low-intensity LLTs during the 6 months after the index event. The first year CV event rate was 18.0/100 patient-years for patients receiving high-intensity LLTs and 17.2/100 patient-years for those on moderate-/low-intensity LLTs. Higher costs were associated with patients untreated with LLT 6 months post-index event (€8323) than patients prescribed high-intensity (€6278) or moderate-/low-intensity LLTs (€6270). Hospitalization accounted for most of the total costs. Conclusions This study found that CV events in secondary prevention Italian patients are associated with substantial HCRU and costs. More intensive LDL-C lowering can prevent CV events, easing the financial burden on the healthcare system. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01960-y.

Objective To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID-19 infection as compared with patients on other antipsychotic drugs. Methods In this register-based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from March 1, 2020 to January 14, 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID-19 infection) were: inpatient care, care within intensive care unit or death due to COVID-19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex, and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. Conclusions Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID-19 pandemic with careful monitoring and readiness to alter drug doses as needed.

Purpose Consultation is crucial for patient care and a primary responsibility of fellows. Understanding the cognitive load associated with the complex skill of consultation would enhance fellow learning. The authors aimed to determine themes describing the fellow experience during inpatient consults specifically, align these themes with Consult Cognitive Load (CCL) scores, and identify strategies to manage cognitive load to enhance fellow education and performance, and, consequently, patient care. Method The authors studied 16 fellows using mixed methods. Fellows who accepted an invitation completed an inpatient consult followed by the CCL, a measure of cognitive load during consults, and an interview. Three authors conducted a thematic analysis. Member checks and triangulation supported theme trustworthiness. Subsequently, 3 authors rated the extent and cognitive demand of each theme expressed in each transcript. The authors measured interrater reliability and used Spearman correlation to describe the association of these ratings with CCL scores. The authors examined themes to identify strategies that educators might use. Results Analysis revealed four themes: "nature and scope," which conceptually aligned with intrinsic cognitive load (IL); "leveraging resources," which had elements of both IL and extraneous cognitive load (EL); "extraneous factors," which aligned with EL; and "drivers," which aligned with germane cognitive load (GL). Interrater reliability for extent and demand ratings ranged from 0.57 to 0.79. The correlation between "nature and scope" and IL was 0.37, "extraneous factors" and EL 0.71, and "drivers" and GL 0.32. "Leveraging resources" did not correlate with IL (0.06) or EL (-0.09). Potential strategies based on themes included offering level-appropriate assistance to match IL, focusing the fellow's attention to reduce EL, and providing succinct teaching to promote GL. Conclusions This study provided deep insight into the fellow consult experience and suggested strategies for educators to guide consult learning. The theme "leveraging resources" merits further exploration.

Objective This work examined the secondary use of clinical data from the electronic health record (EHR) for screening our healthcare worker (HCW) population for potential exposures to patients with coronavirus disease 2019 (COVID-19). Materials and Methods We conducted a cross-sectional study at a free-standing, quaternary care pediatric hospital comparing first-degree, patient-HCW pairs identified by the hospital’s COVID-19 contact tracing team (CTT) to those identified using EHR clinical event data (EHR Report). The primary outcome was the number of patient-HCW pairs detected by each process. Results Among 233 patients with COVID-19, our EHR Report identified 4116 patient-HCW pairs, including 2365 (30.0%) of the 7890 pairs detected by the CTT. The EHR Report also revealed 1751 pairs not identified by the CTT. The highest number of patient-HCW pairs per patient was detected in the inpatient care venue. Nurses comprised the most frequently identified HCW role overall. Conclusions Automated methods to screen HCWs for potential exposures to patients with COVID-19 using clinical event data from the EHR (1) are likely to improve epidemiological surveillance by contact tracing programs and (2) represent a viable and readily available strategy that should be considered by other institutions.

Introduction:The care of children with invasive home mechanical ventilation (HMV) is challenging and insufficiently described in the literature. Objectives:Our objective regarding this unique and growing population is to describe our institution's pediatric chronic HMV program and discuss our current understanding of best care practices. Methods: In addition to characterizing the clinical landscape of our program, we describe demographics for our roughly 223 current HMV patients with comparisons to available national data. We discuss evidence and expert opinion regarding various elements of care including initiation of HMV, caregiver education, equipment concerns, inpatient care, and longitudinal care.Results: Data was collected but not statistically analyzed for our roughly 223 current patients and historical cohort. Descriptive data included demographic information, patient medical characteristics and complexity, and reasons for rehospitalizations.Conclusions:While we have provided institutional expertise regarding the care of this complex population, the evidence base remains insufficient and there are many areas which need future research to develop standardized care practice guidelines for children with HMV.

Group-based physical activity brings high and long-term added value for the participants. Especially for older adults in need of care, this development is dependent on interdisciplinary thinking and the networking of local structures. Studies underline the consideration of the communication and access options that are needed to be able to promote the target group’s health through exercise programmes. Sports clubs are repeatedly mentioned as competent partners in health promotion, but in municipal practice—possibly due to very different basic structures to the system of care—they receive less attention. The project Moving Nursing Homes and Care Providers (2019–2022) is coordinated by the State Sports Federation of North Rhine-Westphalia, Germany. Local sports clubs cooperate with providers of outpatient and inpatient care to start new sports programs for older adults in need of care. As part of the scientific evaluation, the perspectives involved are equally considered and their motives and needs are analysed. For this paper, four conducted qualitative interviews with representatives of sports clubs were analysed with the focus on opportunities and barriers for local partnerships between sports clubs and care. Results show structural and personal parameters that have to be looked at from the beginning. Local networks are essential for sports clubs to get in contact with potential partners and to reflect initiated processes. Although aspects of (financial) organisation is an often named topic, sports clubs have the opinion that they have the social responsibility to influence developments in their neighbourhood for all generations positively., German journal of exercise and sport research;Bd 51. 2021, H. 4, S. 468-473

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that affects social interactions and behavior. The number of children and adolescents with ASD treated in mental health services has been growing in recent years. Knowing clinical and familial characteristics of hospitalized patients with ASD and multidisciplinary approach are crucial for children and adolescents mental health professionals. In this study, 253 Turkish children and adolescents, with and without ASD, treated in psychiatry inpatient care unit were examined. Applied approaches such as medical consultation areas, psychiatric management of mothers, and pharmacological treatment during hospitalization, were studied. In addition to familial and clinical characteristics of patients with ASD, the benefits and the hospitalization conditions were evaluated. Patients with ASD showed a higher tendency on having relatives with a psychiatric disorder than the patients without ASD. A significant difference was found in terms of age, sex, and intellectual functioning, whereas length of stay did not differ drastically. Also, suicide attempts were significantly higher in patients without ASD than in patients with ASD. This study eases the management of hospitalized ASD patients with giving important information of clinical and familial characteristics.

Background There are limited data on the effectiveness of the vaccines against symptomatic coronavirus disease 2019 (Covid-19) currently authorized in the United States with respect to hospitalization, admission to an intensive care unit (ICU), or ambulatory care in an emergency department or urgent care clinic. Methods We conducted a study involving adults (≥50 years of age) with Covid-19–like illness who underwent molecular testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed 41,552 admissions to 187 hospitals and 21,522 visits to 221 emergency departments or urgent care clinics during the period from January 1 through June 22, 2021, in multiple states. The patients’ vaccination status was documented in electronic health records and immunization registries. We used a test-negative design to estimate vaccine effectiveness by comparing the odds of a positive test for SARS-CoV-2 infection among vaccinated patients with those among unvaccinated patients. Vaccine effectiveness was adjusted with weights based on propensity-for-vaccination scores and according to age, geographic region, calendar time (days from January 1, 2021, to the index date for each medical visit), and local virus circulation. Results The effectiveness of full messenger RNA (mRNA) vaccination (≥14 days after the second dose) was 89% (95% confidence interval [CI], 87 to 91) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization, 90% (95% CI, 86 to 93) against infection leading to an ICU admission, and 91% (95% CI, 89 to 93) against infection leading to an emergency department or urgent care clinic visit. The effectiveness of full vaccination with respect to a Covid-19–associated hospitalization or emergency department or urgent care clinic visit was similar with the BNT162b2 and mRNA-1273 vaccines and ranged from 81% to 95% among adults 85 years of age or older, persons with chronic medical conditions, and Black or Hispanic adults. The effectiveness of the Ad26.COV2.S vaccine was 68% (95% CI, 50 to 79) against laboratory-confirmed SARS-CoV-2 infection leading to hospitalization and 73% (95% CI, 59 to 82) against infection leading to an emergency department or urgent care clinic visit. Conclusions Covid-19 vaccines in the United States were highly effective against SARS-CoV-2 infection requiring hospitalization, ICU admission, or an emergency department or urgent care clinic visit. This vaccine effectiveness extended to populations that are disproportionately affected by SARS-CoV-2 infection. (Funded by the Centers for Disease Control and Prevention.)

OBJECTIVE: To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data. DATA SOURCES: 2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data. STUDY DESIGN: Secondary data analysis. DATA COLLECTION/EXTRACTION METHODS: We calculated the percentage of each contract's total hospitalizations in Encounter data after identifying total inpatient stays from Encounter and MedPAR data. We constructed each contract's ambulatory visits and emergency department (ED) visits per 1000 enrollees using Encounter data and compared those visit counts with the counts from HEDIS. We defined high data completeness as having less than 10% missing hospital stays and less than ±10% difference in ambulatory and ED visits between Encounter and HEDIS data. We used TM payments as standardized prices of services to examine resource use among MA enrollees with cancer in the contracts with high data completeness. PRINCIPAL FINDINGS: We identified 83 of 380 MA contracts with high data completeness. Total resource use per enrollee with cancer in the 83 contracts was $14,715 in 2015. Service‐specific resource use was $5342 for inpatient care, $5932 for professional services and $3441 for outpatient facility services. These represent what an MA enrollee with cancer would have cost on average if MA plans paid providers at TM payment rates, holding the observed utilization constant. CONCLUSIONS: Checking the completeness of Encounter data is an important step to ensure the validity of research on MA resource use. Using Encounter data to measure MA resource use is feasible. It can compensate for the lack of payment information in Encounter data. It will be important to identify and refine ways to best use Encounter data to learn about care provision to MA enrollees.

É considerado sobrevivente de câncer o paciente com história de convivência com neoplasia, do diagnóstico da mesma até o fim de sua vida, não incluindo somente aqueles que se submeteram à realização de tratamentos oncológicos e sobreviveram. A vida após o câncer se converte numa experiência disruptiva que demanda resiliência do indivíduo, no sentido de transformar a experiência ameaçadora à integridade da vida em uma fonte de sentido. Este relato descreve a vivência de uma idosa sobrevivente enfrentando complicação do tratamento oncológico em internamento hospitalar, no qual apresentou experiência anômala. A relação da paciente descrita no relato com seu deus foi a característica preponderante de sua experiência, sendo este deus bondoso e misericordioso, uma fonte de amparo e segurança. Estudos recentes reforçam a importância da vinculação positiva com a divindade nesse contexto, demonstrando que tais relações são catalisadoras de paz, calma e esperança nesses pacientes. Evidências do impacto da espiritualidade na saúde de forma global e instrumentos para sua avaliação junto ao paciente têm sido descritos e merecem maiores investigações. Este trabalho objetivou apresentar uma temática complexa e de difícil inserção acadêmica, discutindo a dimensão espiritual do indivíduo como constituinte de suas vivências e chamando a atenção do setor saúde, com vistas ao cuidado integral do ser humano.

Acute hypercapnic respiratory failure accounts for 50 000 hospital admissions each year in the UK. This article discusses the pathophysiology and common causes of acute hypercapnic respiratory failure, and provides practical considerations for patient management in acute medical settings. Non-invasive ventilation for persistent acute hypercapnic respiratory failure is widely recognised to improve patient outcomes and reduce mortality. National audits highlight a need to improve patients' overall care and outcomes through appropriate patient selection and treatment initiation. Multidisciplinary involvement is essential, as this underpins inpatient care and follow up after hospital discharge. New non-invasive ventilation modalities may offer better patient comfort and compensate better for sleep-related changes in respiratory mechanics. Emerging therapies, such as nasal high flow, may offer an alternative treatment approach in those who cannot tolerate non-invasive ventilation, but more research is required to completely understand its effectiveness in treating acute hypercapnic respiratory failure.

Background Hematopoietic cell transplantation (HCT) is a potentially curative therapy as well as a costly procedure. Published studies have examined the cost of HCT in the US and the complications that follow but little is known about the cancer-related healthcare costs and resource utilization prior to the procedure and none of the studies have examined the variability in cost based on the type of hematologic malignancy involved. The aim of this study was to estimate mean cancer-related costs and resources incurred before the HCT is performed from the time the hematologic malignancy first develops. Methods The IBM® MarketScan® Research Databases were used to identify adult patients ≥18 years of age with commercial or Medicare supplemental insurance who had undergone allogeneic HCT for hematologic malignancies from January 1, 2008 to December 31, 2017. Healthcare utilization and costs were assessed during the 6 months prior to diagnosis (pre-diagnostic period) and the follow-up period from diagnosis just prior to the HCT (pre-HCT period). Multivariable regression models were constructed to estimate total all-cause costs and cancer-related costs as well as healthcare utilization by type in each time period. Results A total of 2663 commercially insured patients and 266 with Medicare supplemental insurance were included in the study population. The mean-adjusted incremental cancer-related costs for commercially insured patients was $399,011 in the overall observation period including the pre-diagnostic and pre-HCT periods combined, 9% of which was incurred in the pre-diagnostic period. The corresponding mean-adjusted incremental cancer-related costs for Medicare supplemental patients was $195,575 for the same time period but the patterns of healthcare utilization were similar to the commercially insured population. Inpatient care accounted for approximately one-half the cost in both patient populations. By type of hematologic malignancy, costs were lowest for myeloproliferative disorders ($211,561) and highest for acute lymphocytic leukemia ($462,072) in the commercially insured population. Conclusion This study demonstrates that overall patients with hematologic malignancies requiring HCT have considerable cancer-related healthcare resource utilization and costs leading up to HCT compared to the period of time prior to developing cancer.

Background In Germany, skin diseases are mainly treated in the 115 dermatological hospitals. Methods Health care and health economic analysis of dermatological inpatient care and prediction of future care needs based on primary and secondary data. Results Outpatient and inpatient care for dermatologic treatment indications is predominantly provided by dermatology specialists. Inpatient treatment was provided for 833,491 cases in 2018, corresponding to 4.21 % of all inpatient cases (19,808,687). Most common treatment cases were: epithelial skin cancer (total 87,386, of which dermatology clinics 52,608), followed by melanoma (23,917/17,774), psoriasis (19,291/13,352), erysipelas (73,337/11,260), other dermatitis (12,671/10,842), atopic dermatitis (AD) (11,421/9,734), and herpes zoster (26,249/9,652). With an average length of stay of 5.69 days, dermatology hospitals were in the bottom third. The proportion of inpatient indications cared for in dermatology hospitals was highest for prurigo (95.2 %), pemphigus (94.9 %), parapsoriasis (94.6 %), pemphigoid (90.3 %), eczema other than AD (85.6 %), and AD (85.2 %). While the total number of inpatient treatment cases in Germany has increased by an average of 17.5 % between 2000 and 2018, this is the case for 26.6 % of skin diseases and over 150 % for individual ones. The projection of current to future inpatient care suggests a continued high demand for inpatient care by dermatology hospitals. Conclusion Inpatient dermatological care will continue to be an indispensable component of qualified, socially necessary care in Germany.

The article describes a clinical case of vaccination with the drug "Kovivac" of a patient of an older age group with an established diagnosis of bullous pemphigoid. Scientific data on the prevalence of bullous dermatoses in the Russian Federation (true pemphigus, Lever's bullous pemphigoid, Dhring's herpetiformis dermatitis) are presented. There is a good tolerance of the Kovivac vaccine in a patient suffering from bullous pemphigoid, which allows vaccination, in fact, without interrupting patients from their daily activities and without diverting the resources of the healthcare system to unreasonable inpatient care. The decision to vaccinate should be made on the basis of data on the available indications / contraindications for drugs, taking into account the individual anamnestic data of patients. In addition, it should be borne in mind that until now, all links of the infectious process caused by SARS-CoV-2 have not been fully studied. In this regard, before vaccination, patients must be informed of the need to comply with the anti-epidemic measures recommended for the prevention of coronavirus infection (COVID-19), even after full vaccination, as well as dynamic observation by specialist doctors.

Objective The LACC (Laparoscopic Approach to Cervical Cancer) study revealed advantages in terms of overall survival and relapse risk favouring abdominal radical hysterectomy over the laparoscopic procedure. The present paper will compare the two surgical techniques from the economic point of view based on a process cost calculation. Material/Methods A retrospective cost analysis of all radical hysterectomies from the year 2018 was done at the Hanover University Medical School based on the bottoms-up method and guided by the clinical treatment pathway. Result Of 51 primary cases treated, 19 patients underwent radical hysterectomies, of which 8 were performed using the abdominal technique and 11 as endoscopic surgeries. 89.4% of the cancers were FIGO IB1 carcinomas. The total cost of a laparoscopic radical hysterectomy with an average hospital stay of 4.6 days came to € 2512.34, compared to an abdominal radical hysterectomy at € 2586.78 with an average hospital stay of 7.6 days. The greatest cost factor in which the laparoscopic method exceeded abdominal radical hysterectomy was the surgical procedure itself (€ 1836.75 vs. € 1411.21). Personnel represented the largest cost item in the surgical theatre (59%), so that surgery time was a significant multiplying factor. Average surgical time required for abdominal radical hysterectomy was 154 minutes, whereby the laparoscopic procedure required an average of 220.1 minutes. Inpatient care in the abdominal radical procedure cases was more costly by € 499.98 due to the longer hospitalization and additional medication required. Profit levels, including the DRG revenues, were higher with the abdominal method than with the laparoscopic method by € 186.21 despite longer hospital stays. Conclusion The present paper shows slightly greater profitability for the abdominal radical hysterectomy. On the other hand, this method entails longer hospitalization and a higher level of personnel deployment. Adequate occupancy management could make up for the revenue shortfall observed with the laparoscopic method.

While Publicly Funded Health Insurance Schemes (PFHIS) can be an effective strategy to achieve Universal Health Coverage by offering financial protection, the extent to which they facilitate gender equity has been less explored. Women constitute one of the main vulnerable groups owing to a combination of health and economic vulnerabilities to access inpatient care services. Gender health equity requires that healthcare resources, such as PFHIS effectively reach women. This study investigates the gender differences in utilisation of Chief Ministers’ Comprehensive Health Insurance Scheme (CMCHIS) by looking at a large volume of claims data covering 2012 to 2014 in the southern Indian state, Tamil Nadu. Previous studies indicate that women in the state had a higher hospitalisation rate than men and are entitled equally to CMCHIS. By disaggregating the data on number of beneficiaries, claim status, average and total claim value, type of procedures based on gender on a random selection of 230265 cases, the paper points out that women’s utilization of CMCHIS is significantly lesser than men. Women constitute only 36% of all beneficiaries and received only half of the total claim value disbursed through the scheme. This pro-male bias was found to be statistically significant and consistent across the scheme years, age group and type of procedures. The study concludes that the gender inequity in utilization of CMCHIS is conspicuous and needs immediate attention from policy makers and administrators. With recent inclusion of COVID19 testing and treatment under PFHIS, the paper urges for further research lest more women are left behind. © 2021 Australasian College of Health Service Management. All Rights Reserved.

Many countries are trying to achieve Universal Health Coverage. Indonesia wanted to do this by implementing National Health Insurance in 2014. The purpose of this study is to explore the demand for health services based on visits to service providers, for both outpatient and inpatient care. This study used secondary data from wave five of the Indonesia Family Life Survey (IFLS). The sample used in this study comprised 34,177 individuals who were aged >15 years old. In this study, the demand for health services was measured based on whether respondents had visited a healthcare facility and their number of visits to healthcare facilities. Data was analysed using bivariate analysis with chi-square and multivariate analysis using the negative binomial regression model and probit model. The proportion of respondents visiting healthcare facilities for outpatient care was 16%, while for inpatient visits it was 5%. Both models produced almost the same effect in indicating the probability of individuals visiting a healthcare facility and their number of visits. Age, gender, marital status, education level, economic level, having health insurance, region, health status, chronic disease, and the number of diseases were statistically significant (P < 0.001) in influencing outpatient service demand. Age, gender, marital status, education level, economic level, having health insurance, regional status, health status, and the number of diseases were statistically significant (P < 0.001) in influencing inpatient service demand. Individual characteristics, demographics, and health status were independent factors associated with demand for healthcare services. The government should consider these factors in expanding health service demand in Indonesia.

Background: Patients with Coronavirus Disease of 2019 (COVID-19) infection can develop varying degrees of illness severity. A critical decision point for all frontline providers affects to whether a given patient is at high risk for severe illness and thus needs inpatient care as opposed to recovery at home. Aim of the study: The aim of the current study is to assess the outcomes of the suspected Covid-19 patients who were swabbed after presenting to the Emergency Department at King Abdullah Medical City and their result came positive for Covid-19. Subjects and Methods: A retrospective pilot study was conducted at KAMC, Holy Makkah-Saudi Arabia. Fifty-one positive covid-19 patients were included at this study. The demographic data, presenting complaint, The Canadian Triage and Acuity Scale (CTAS), comorbidities, discharging vital signs, and hospital revisits were extracted from the electronic medical records (EMR) using Trakcare system. Patients were followed up by phone calls after discharge from the ER for 14 days. Information regarding KAMC hospital revisit or other hospital revisit, quarantine location and length, seeking medical advice, and non-hospital revisit were obtained from the patients or their relatives. Data was collected from15th of March 2020 till 15th of June 2020. Then the outcomes were assessed. Chi-square test and independent sample t-test were used to compare proportions and continuous variables, respectively. The binary logistic regression calculated odds ratios (OR) and 95% confidence intervals (95% CI for the interested predictors. P

Background Admission rates to child and adolescent mental health inpatient units in Germany are substantial (58.831 admissions in 2019). Historically, different treatment pathways have not been available. The evidence suggests that home treatment could be an alternative. The objective of this study was to assess the long‐term stability of treatment gains among children and adolescents treated for serious mental health problems with home treatment (HT) as compared with inpatient treatment‐as‐usual (TAU). Methods Hundred patients were enrolled and randomized into an intervention (HT n = 54) and control group (TAU n = 46). Follow‐up data were available after 8.4 months (n = 78) (T3) and after 4.3 years (n = 51) (T4). The primary outcome measured was overall level of functioning, for which the Children’s Global Assessment Scale (CGAS) was used. Secondary outcomes included severity of patient impairment and parental competency in dealing with their child's symptoms, measured using the Health of the Nation Outcome Scales (HoNOSCA). A qualitative interview with parents was performed at T3 and T4. Results Treatment effects remained stable for both groups at T3 and T4 (p < .001). After 4.3 years 70% of the parents in the intervention group stated satisfaction with the treatment received, while only 36.8% of the parents within the control group rated themselves as satisfied. 43.7% of parents in the home treatment group reported that the most helpful aspect of this pathway was the prompt and intensive professional help and advice they received as primary caregivers at home. Conclusions Home treatment may be considered a viable alternative to inpatient care., publishedVersion

Objectives Identify risk factors associated with increased hospital admission and mortality due to dengue fever (DF), and estimate the risk magnitude associated with each individual variable. Methods Records of patients diagnosed with dengue were obtained from the Mexican National Epidemiological Surveillance System. Descriptive statistics were performed in all variables. Demographic characteristics and comorbidities were compared between patients based on type of care and mortality. Multivariable analysis was done with a logistic regression model, using two different outcomes: hospitalization and mortality. Results A total of 24,495 patients were included in the analysis, with a DF case fatality rate of 0.58%. Patients younger than 10 and older than 60, were found to have a greater risk of both hospitalization and mortality due to DF. Comorbidities associated with a higher risk for hospital admission include cirrhosis, CKD, immunosuppression, diabetes, and hypertension. For mortality, CKD, diabetes, and hypertension were identified as risk factors, along with pregnancy. Conclusion Identification of risk factors associated with increased hospitalization and mortality due to DF can help categorize patients that require close monitoring and inpatient care. Early identification of warning signs and patients at increased risk is key to avoiding delay of supportive care.

Due to the increasing prescription of oral anticancer therapies, the inpatient care pathway has shifted to an outpatient care pathway. This transformation requires an interdisciplinary coordination to provide a continuum of care and ensure therapeutic monitoring, as well as patient safety. To better support patients on oral anticancer therapies, a task group named "hospital-to-community pharmacist coordination" has been set up to create tools aiming at standardising the information exchanged between ambulatory and hospital pharmacists. A retrospective study examined the utilisation of the tools over a period of one year. The task group identified the expectations of all parties regarding the care pathways of patients undergoing oral chemotherapy, which lead to the creation of computerised exchange tools (integrated into the computerised patient's medical file). Over the course of this study, the cancer centre's pharmaceutical team contacted 425 ambulatory pharmacists regarding the prescription of oral chemotherapy to patients. Forty-two follow-ups from ambulatory pharmacists, gathering information on 34 patients, were submitted to the cancer centre pharmacists (7,7%). These first follow-ups allowed pharmaceutical responses regarding patient compliance, drug interaction and toxicities.

Acute gastroenteritis (AGE) causes significant health and economic burden on society. The aim of this study is to estimate households’ direct and indirect expenditures on AGE and its predicted factors. This cross-sectional study was conducted between December 2019 and March 2020 using a bilingual proforma distributed using Survey Monkey among individuals with self-reported AGE in all 14 states of Malaysia. The finding revealed the average expenditure for a single episode of AGE was RM395.58 (± SD 798.02). The mean indirect expenditure was higher at RM259.14 (± SD 379.92) vs. direct expenditure of RM136.44 (± SD 596.47). The highest expenditure was seen among those who obtained inpatient care. The multiple linear regression analysis showed that household income (RM0.13; 95% CI: 0.01, 0.27; p=0.043) and type of healthcare facility (private vs government) (RM1842.05; 95% CI: 395.13, 3288.98; p=0.014) had a significant association with households’ total health expenditure on AGE. Acute gastroenteritis incurred substantial costs on all affected households regardless of care-seeking modalities. Interestingly, the main economic burden of AGE was the indirect cost of productivity loss; interpreted in terms of days away from work. In conclusion, AGE instigated an economic burden on both households and employers. The household income and type of facility were found to be significant factors associated with the households’ health expenditures due to AGE. This study recommends food safety awareness among the public and enforcement of safe food handling practices among food vendors and industries.

BACKGROUND Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [

ObjectiveAllogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment associated with high morbidity and mortality. It is often necessary for family caregivers to become highly involved in the care, especially when patients return home after a long period of inpatient care. Family caregivers’ preparedness for the tasks and demands of the caregiving role prior to allo-HSCT might help them during this distressing time. The aim of this study was to explore whether demographic factors are associated with preparedness for caregiving prior to allo-HSCT and if such preparedness for caregiving is associated with caregiver outcomes in terms of caregiver burden, anxiety/depression, competence, self-efficacy, and general health among family caregivers.MethodThis correlational cross-sectional study included 86 family caregivers of patients to undergo allo-HSCT, who completed a self-administered questionnaire on preparedness, caregiver burden, anxiety/depression, competence, self-efficacy, and general health. Descriptive statistics and multiple regression models (linear and ordinal) were used to analyze the data.ResultsFamily caregivers with a higher education and those who were the patient's partner were significantly associated with a higher level of preparedness for caregiving, while gender and age were not significant. Higher preparedness was significantly associated with higher competence and self-efficacy and lower symptoms of depression, even after the model was adjusted for education, relationship to the patient, gender, and age but not for anxiety or caregiver burden. Higher levels of preparedness were also significantly associated with better general health.Significance of resultsA higher level of preparedness for caregiving prior to allo-HSCT was associated with better family caregiver outcomes. Assessing family caregivers prior to allo-HSCT to identify those with insufficient preparedness might enable the provision of individually tailored psycho-educational support to help them cope with their caregiving role and prevent potential negative consequences.

Pro re nata (PRN, as-needed) medication is commonly used in forensic psychiatric inpatient care, but little is known about the participation of patients in its prescription and administration. This...

INTRODUCTION Antimicrobial Stewardship programs promote appropriate antimicrobial use through different avenues, including education. Advanced Practice Providers (APPs) provide inpatient care in a wide-range of settings. Little is known about the educational needs of APPs at academic medical centers or the effect of educational interventions directed at inpatient APPs on clinical care. Our study looked at the effect of an educational intervention on antimicrobial prescribing by APPs for asymptomatic bacteriuria (ASB) and candiduria (ASC). We also conducted a needs assessment on the opportunities and barriers to continuing medical education. METHODS The educational intervention consisted of in-person interactive learning accompanied by an online video. Pre-intervention and postintervention surveys included an educational needs assessment and knowledge acquisition assessment. A retrospective chart review of adult inpatients admitted to the APP services with bacteriuria or candiduria during the 3 months pre-intervention and postintervention was performed. RESULTS Our needs assessment revealed several barriers to APP-focused education including no protected time for learning, and curricula predominantly directed at the Graduate Medical Education level. Engaged APPs had improved knowledge scores, but the proportion of treated ASB or ASC episodes did not differ between the pre-intervention and postintervention. DISCUSSION Although our educational intervention did not change prescribing patterns, the intervention increased knowledge around ASB and ASC. The potential hierarchical structure of interprofessional care teams may be a barrier to changing antimicrobial prescribing. Our study identified the possibility of a hidden curriculum at academic medical centers that does not prioritize APP educational needs.

There are limited data on the impact of COVID-19 in children with a kidney transplant (KT). We conducted a prospective cohort study through the Improving Renal Outcomes Collaborative (IROC) to collect clinical outcome data about COVID-19 in pediatric KT patients. Twenty-two IROC centers that care for 2732 patients submitted testing and outcomes data for 281 patients tested for SARS-CoV-2 by PCR. Testing indications included symptoms and/or potential exposures to COVID-19 (N = 134, 47.7%) and/or testing per hospital policy (N = 154, 54.8%). Overall, 24 (8.5%) patients tested positive, of which 15 (63%) were symptomatic. Of the COVID-19-positive patients, 16 were managed as outpatients, six received non-ICU inpatient care and two were admitted to the ICU. There were no episodes of respiratory failure, allograft loss, or death associated with COVID-19. To estimate incidence, subanalysis was performed for 13 centers that care for 1686 patients that submitted all negative and positive COVID-19 results. Of the 229 tested patients at these 13 centers, 10 (5 asymptomatic) patients tested positive, yielding an overall incidence of 0.6% and an incidence among tested patients of 4.4%. Pediatric KT patients in the United States had a low estimated incidence of COVID-19 disease and excellent short-term outcomes.

Background Hospital-at-home (HaH) provides acute healthcare in patients’ homes as an alternative to traditional hospital inpatient care. HaH has been shown to improve clinical outcomes, increase patient satisfaction, and reduce hospitalization costs. Despite its effectiveness, the uptake of HaH remains slow and little is known about factors that impact the quality and transferability of HaH. This review aimed to qualitatively synthesize existing literature to examine the perspectives of stakeholders to identify areas of improvement in this model of care. Methodology Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from inception date until 3 February 2021. The included studies were assessed for quality using the Critical Appraisal Skills Program tool. This review was registered on the International Prospective Register of Systematic Reviews. The meta-synthesis was completed according to Sandelowski and Barroso’s guidelines. Results Sixteen articles met the inclusion criteria. The overarching synthesized theme was “the intricacies of developing HaH,” and the four main themes were (1) factors influencing patient selection, (2) advantages of HaH, (3) challenges of HaH, and (4) enablers for HaH development. Conclusion Overall, high levels of satisfaction were expressed by various stakeholders. Continuity of care remains an important factor for patient-centeredness in HaH. Caregivers should be involved in the decision-making process and supported throughout the HaH duration to prevent caregiver burnout. Collaboration and coordination among healthcare professionals are vital and can be strengthened through training and technological advancements of remote patient monitoring. Institutional and organizational support for stakeholders may make HaH a viable solution to modern healthcare challenges. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07065-0.

BACKGROUND: The coronavirus disease (COVID)-19 pandemic leads to significant changes in the healthcare system and undermining best practices for maintaining a diabetic limb. A large number of patients with diabetic foot are left without timely medical care and are at increased risk of complications, hospitalization, lower limb amputation, and death. A new paradigm must be adopted for the transition from inpatient care to community-based care. The introduction of a pandemic remote management for patients with diabetic foot ulcer includes an assessment of the risk of complications through telemedicine and further stratification of patients according to the developed algorithm. METHODS: A literature review was performed for articles related to telemedicine. We used PubMed, Google Scholar, Cochrane Library, and Ovid MEDLINE to search published articles. We used the following keywords: “Telemedicine,” “diabetes mellitus,” “COVID-19,” “diabetic foot ulcer,” and “remote monitoring.” RESULTS: Implementation of the proposed pandemic care includes telemedicine for remote monitoring and treatment of patients with diabetic foot ulcers, as well as an algorithm for determining the risk of diabetic ulcer infection and patient management tactics according to the identified risk. CONCLUSION: The management of patients with diabetic foot ulcers during a pandemic includes the following goals – to reduce the burden on the health-care system, maintain the safety and functionality of diabetic foot at home, and reduce the risk of COVID-19 in patients with diabetic foot ulcers. © 2021 Mariya V. Dmitriyeva, Saken K. Kozhakhmetov, Dulat K. Turebayev, Saltanat N. Urazova, Talgat M. Omarov, Nurbek S. Igissinov, Medet T. Toleubayev.

Purpose The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of emerging evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors. Method This prospective study compared costs and clinical outcomes of internal medicine patients admitted to a RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service. Results Baseline characteristics of 5,448 patients on the 2 services (3,250 on a RS and 2,198 on an NRS) were similar. On a RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services. Conclusions These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision-making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.

Aims Patients with severe behavioral and psychological symptoms of dementia (BPSD) are often admitted to mental hospitals, while, inpatient care could also lead to prolonged hospital stay. The present study aims to survey clinical profiles of patients who required inpatient treatment for BPSD, and then establish the criteria for introducing inpatient treatment through assessment by certified psychiatrists. Methods We performed a prospective survey about clinical characteristics of people with dementia who required treatment of BPSD at 12 mental medical institutions. All patients were assessed by certified psychiatrists to determine the optimal treatment settings: outpatient or inpatient. The multivariate logistic regression analysis was performed to specify factors contributed to the judgement of clinicians. Subsequently, the receiver operating characteristic curve analysis was conducted to explore a score derived from the Neuropsychiatric Inventory to divide patients into outpatient or inpatient groups. Results The present study included 386 patients, of which 242 were admitted to mental hospitals. BPSD were classified into four domains, and aggressive BPSD was significantly associated with assessment for inpatient treatment; the adjusted odds ratio was approximately 2 regardless of dementia severity. Furthermore, the composite score of agitation, irritability and aberrant behavior showed the highest area under the curve value (=0.706), which differentiated inpatients from outpatients with a sensitivity of 76% and a specificity of 54%. Conclusions Aggressive BPSD was the risk factor for inpatient treatment. The composite score of the Neuropsychiatric Inventory subdomain-related aggressive BPSD could be a screening tool to introduce inpatient treatment for BPSD. Geriatr Gerontol Int 2021; 21: 825-829.

The aim of the study was to estimate the economic damage by COPD, including direct medical and non-medical costs and indirect costs associated with premature deaths of working-age individuals.Materials and methods. First, estimation of the economic COPD burden in Astrakhan region (AR) was carried out using the clinical and economic analysis of the "cost of illness" (COI). Direct medical costs of inpatient, outpatient, ambulance and emergency medical care, as well as direct non-medical costs associated with the disability benefits payments, were taken into account. Indirect costs were defined as economic losses from undelivered products due to premature deaths of working-age individuals.Results. From 2015 to 2019, the economic COPD burden in AR amounted to 757.11 million rubles in total, which is equivalent to 0.03% of the gross regional product covering a five-year period of the study. Direct medical and non-medical costs totaled 178.02 million rubles. In the structure of direct medical expenses, expenses for inpatient, as well as ambulance and emergency medical care during the study period, increased by 92.5% and 45.5%, respectively. While the costs for the outpatient care decreased by 31.9%, the increase in direct non-medical costs associated with the disability benefits payments, increased by 5.1% (2019). Indirect losses amounted to 579.09 million rubles.Conclusion. The structure of the main damage is dominated by indirect losses in the economy associated with premature deaths of working-age individuals. In the structure of direct medical costs, inpatient care costs prevailed. These studies indicate the need to continue an advanced analysis of the economic burden of COPD, as well as to optimize the treatment and prevention of the exacerbations development of this disease.

Lung transplantation is an important option for patients with end-stage lung disease. Many of these patients deteriorate rapidly and require inpatient care at the time of the transplant evaluation. Research Question: How does the setting of lung transplant evaluation relate to perioperative outcomes, short-term postoperative outcomes, and healthcare costs accrued after transplant? Design: We reviewed the records of patients who underwent primary, bilateral lung transplantation at our center between January 1, 2014 and May 31, 2016. Patient evaluation setting was categorized as inpatient, outpatient, or combined. Demographics, clinical characteristics, and cost of care were assessed. Results: The study included 207 patients: 40 (19.3%) evaluated as inpatients, 146 (70.5%) as outpatients, and 21 (10.1%) as combined. Inpatients had the highest mean lung allocation scores (71.2 vs 49.7 [combined] and 40.8 [outpatient]; P < 0.001), lowest functional status at listing ( P < 0.001), highest number of blood products used during surgery ( P < 0.001), highest incidence of re-exploration for bleeding ( P = 0.006), and longest posttransplant hospital stays (median, 35 vs 15 days [combined] and 12 days [outpatient]; P < 0.001). One-year survival trended lower for inpatients (log-rank, P = 0.056). Inpatient evaluations had the highest total, variable, and fixed costs of posttransplant care ( P < 0.001). Conclusion: Inpatient lung transplant evaluation was associated with longer hospital stays, higher perioperative morbidity, and lower 1-year survival. Partial or complete inpatient evaluation was associated with a higher cost of care posttransplant.

The aim of this systematic review was to compare relevant health economic consequences of the CT-based robotic-arm-assisted system versus conventional Uni-compartmental Knee Arthroplasty (UKA). In November 2020, A PRISMA systematic review was conducted using four databases (Pubmed, Scopus, Cochrane and Google Scholar) to identify all comparative studies reporting health economic assessments, such as robotic system costs, consumable costs, surgical revision rate, operating time, length of stay, and inpatient care costs. A total of nine comparative studies published between 2014 and 2020 were included in this systematic review. There was a moderate risk of bias as assessed using the ROBINS-I Tool. The CT-based robotic-arm-assisted system seemed to be associated with a lower risk of revision, decreased analgesia requirements during hospitalization, a shorter length of stay, and lower inpatient care costs compared to a conventional technique. CT-based robotic-arm-assisted system for UKA appears to be an economically viable solution with a positive health economic impact as it tends to decrease revision rate compared to conventional UKA, improve post-operative rehabilitation and analgesia management. Post-operative inpatient care costs seem lower with the robotic-assisted system but depend on institutional case volume and differ among health systems. More studies are needed to confirm cost-effectiveness of CT-based robotic-arm-assisted system based on different health systems. Systematic review, Level IV

Introduction: Pediatric hospital care is becoming increasingly regionalized, with fewer facilities providing inpatient care for common conditions such as asthma. That trend has major implications for emergency medical services (EMS) medical care and operations because EMS historically transports patients to the closest facility. This study describes EMS transport patterns of pediatric asthma patients in greater depth, including an analysis of facility bypass rates and the association of bypass with demographics and clinical outcomes. Methods: This was a retrospective study of pediatric asthma patients ages 2-18 years transported by Lee County, FL EMS between March 1, 2018 – December 31, 2019. A priori, we defined bypass as greater than five minutes extra transport time. We performed geospatial analysis and mapping of EMS pediatric asthma encounters. We used the Pediatric Destination Tree (PDTree) project’s tiered approach to characterize receiving hospital facility pediatric capability. We analyzed incidence and characteristics of bypass, and bypass and non-bypass patient characteristics including demographics, emergency department (ED) clinical outcomes, and socioeconomic disadvantage (SED). Results: From the study period, there were a total of 262 encounters meeting inclusion criteria, 254 (96.9%) of which could be geocoded to EMS incident and destination locations. Most encounters (72.8%) bypassed at least one facility, and the average number of facilities bypassed per encounter was 1.52. For all 185 bypass encounters, there was a median additional travel time of 13.5 minutes (interquartile range 7.5 – 17.5). Using the PDTree’s classification of pediatric capability of destination facilities, 172 of the 185 bypasses (93%) went to a Level I facility. Bypass incidence varied significantly by age, but not by minority status, asthma severity, or by the area deprivation index of the patient’s home address. Overall, the highest concentrations of EMS incidents tended to occur in areas of greater SED. With regard to ED outcomes, ED length of stay did not vary between bypass and non-bypass patients (P = 0.54), and neither did hospitalization (P = 0.80). Conclusion: We found high rates of bypass for pediatric EMS encounters for asthma exacerbations, and that bypass frequency was significantly higher in younger age groups. With national trends pointing toward increasing pediatric healthcare regionalization, bypass has significant implications for EMS operations.

Purpose To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic. Methods Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests. Results The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults—most of which were tracheostomy-related—greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55–92%), whereas there was a dramatic decrease in the proportion of less frequent consults. Conclusion The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis. Supplementary Information The online version contains supplementary material available at 10.1007/s00405-021-06963-7.

OBJECTIVE To assess whether day-case major otologic ear surgery is a safe and feasible alternative to inpatient surgery, while maintaining equal complication rates, and to identify causes of admission after day-case surgery. DATA SOURCES PubMed, Embase, and Cochrane. REVIEW METHODS A systematic search was conducted. Studies reporting original data on the effect of day-case ear surgery on admission rate, patient satisfaction, and/or postoperative complications were included. Risk of bias of the selected articles was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. RESULTS A total of 1,734 unique studies were retrieved of which 35 articles discussing 34 studies were eligible for data extraction. The admission rates ranged from 0% to 88% following day-case endaural surgery, 0% to 13% following day-case stapes surgery, 0% to 82% following day-case mastoid surgery, and 0% to 15% following day-case cochlear implant surgery. Patient and parent satisfaction regarding day-case surgery ranged from 67% to 99%. Five studies comparing day-case and inpatient otologic surgery showed no difference in hearing outcome, postoperative complications, or patient satisfaction. CONCLUSION The highest pooled admission rate was seen following day-case mastoid surgery. Studies comparing day-case and inpatient care suggest hearing results and postoperative complication rates in day-case otologic surgery are similar to inpatient otologic surgery in both children and adults. Therefore, day-case major otologic surgery seems to be a safe and feasible alternative to inpatient surgery for both children and adults.

The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.