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Against the background of the discussion about a comprehensive regional mental health care service, the essay discusses the possibility of a comprehensive, transparent and meaningful evaluation. Proposals for how structures, processes, and outcomes may be assessed are presented. We argue for collecting data that are transparent and actionable on all levels of care organisations. The suggested evaluation would be innovative, meaningful for individual patients, services, health care organisations and whole regions, and thus a way for a data-driven ongoing quality improvement., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G597).

Background: The analysis of interregional healthcare mobility represents one of the main criteria for evaluating Regional Healthcare Systems, both in terms of its economic-financial relevance and the quality and satisfaction of the services provided. The aim of the study is to analyze healthcare mobility and its associated cost in Italy in 2019 for all children ≤ 14 years of age., Methods: We collected data from the "Rapporto annuale sull'attività di ricovero ospedaliero - Dati SDO 2019" published by the Italian Ministry of Health. These data represent the tool for collecting information relating to all hospitalization services provided in accredited public and private hospitals present throughout the national territory. We collected data for all Italian regions and clustered them in two geographical areas: Center-North regions and South regions (including Sicily and Sardinia). We have analyzed the magnitude of the mobility of children among regions and in particular from the South to the Center-North and the relative cost of this interregional mobility., Results:  The hospitalization rate of children residing in the South regions was higher than  that of children residing in the Center-North regions (13.9% vs 12.3%). Children residing in the South were more frequently treated in other regions than those living in the Center-North (11.9% vs 6.9%). Even considering the high complexity hospitalizations, children living in the South more frequently underwent treatment in other regions (21.3% vs 10.5% of the Center-North). The cost of passive mobility amounts to € 103.9 million for the South regions (15.1% of the total hospitalizations' expenditure) and the 87.1% of this cost refers to the mobility to the hospitals of Center-North. The cost of healthcare migration from South regions to other South regions was much lower (12.9%, equal to € 13.4 million)., Conclusions: Healthcare mobility, while affecting all Italian regions, is particularly relevant in the South regions and indicates a lack of pediatric care, which should be strengthened by creating services that are currently not evenly distributed throughout the territory.

Background: Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina., Study Design: In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics., Results: The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative., Conclusions: Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative., (Published by Elsevier Inc.)

Purpose: Physician shortages and maldistribution, particularly within family medicine, have led many medical schools worldwide to create regional medical campuses (RMCs) for clerkship training. However, Canadian medical schools have developed a number of RMCs in which all years of training (i.e., a combined model that includes both preclerkship and clinical training) are provided geographically separate from the main campus. This study addresses the question: Are combined model RMC graduates more likely to enter postgraduate training in family medicine and rural-focused programs relative to main campus graduates?, Method: The authors used a quasi-experimental research design and analyzed 2006-2016 data from the Canadian Resident Matching Service (CaRMS). Graduating students (N = 26,525) from 16 Canadian medical schools who applied for the CaRMS match in their year of medical school graduation were eligible for inclusion. The proportions of graduates who matched to postgraduate training in (1) family medicine and (2) rural-focused programs were compared for combined model RMCs and main campuses., Results: Of RMC graduates, 48.4% matched to family medicine (95% confidence interval [CI] = 46.1-50.7) compared with 37.1% of main campus graduates (95% CI = 36.5-37.7; P < .001). Of RMC graduates, 23.9% matched to rural-focused training programs (95% CI = 21.8-25.9) compared with 10.4% of main campus graduates (95% CI = 10.0-10.8; P < .001). Subanalyses ruled out a variety of potentially confounding variables., Conclusions: Combined model RMCs, in which all years of training take place away from the medical school's main campus, are associated with greater proportions of medical students entering family medicine postgraduate training and rural-focused training programs. These findings should encourage policymakers, health services agencies, and medical schools to continue seeking complements to academic medical center-based medical education., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: Timeliness of cancer care is vital for improved survival and quality of life of patients. Service and care centralisation at larger-volume centres has been associated with improved outcomes. However, there is a lack of systematic data on the impact of tumour stream volume on timeliness of care., Aims: To investigate and compare timeliness of care for lung cancer, a high-volume (more commonly diagnosed) tumour stream, and oesophagogastric (OG) cancer, a low-volume (less commonly diagnosed) tumour stream, at a regional health service in Victoria, Australia., Methods: A retrospective cohort study comprising random samples of 75 people newly diagnosed with lung cancer (International Classification of Diseases and Related Health Problems-10 [ICD-10] diagnosis codes C34 in the Victorian Cancer Registry [VCR]) and 50 people newly diagnosed with OG cancer (ICD-10 diagnosis codes C15 or C16 in VCR) at one regional Victorian health service between 2016 and 2017. Binary logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between patient factors and suboptimal timeliness of care., Results: In comparison to OG cancer patients, lung cancer patients had reduced odds of suboptimal timeliness of care in reference to times outside OCP for referral to diagnosis (OR [95% CI] = 0.34 [0.14 to 0.83]) but increased odds of suboptimal timeliness for diagnosis to treatment (OR [95% CI] = 2.48 [1.01 to 6.09])., Conclusion: In the low-volume OG cancer stream, patients had longer wait times from referral to an MDM, where treatment decisions occur, but shorter time to commencement of first treatment. Conversely in the high-volume lung cancer group, there was delayed initiation of first treatment following presentation at MDM. There is need to explore ways to fast-track MDM presentation and commencement of therapy among people diagnosed with low-volume and high-volume cancers, respectively., (© 2020 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Importance: Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities., Objective: To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties., Design, Setting, and Participants: This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach., Exposure: Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization., Main Outcomes and Measures: Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality., Results: This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization., Conclusions and Relevance: Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.

Introduction: sickle cell trait is the heterozygous form of sickle-cell disease. Patients with sickle cell trait can synthesize normal hemoglobin A and hemoglobin S. This condition has no recognizable clinical signs; then subjects with sickle cell trait, ignoring their genetic status, can be found among blood donors. This can have severe impact on donors´ health status and on that of recipients, especially if these have sickle-cell trait. The purpose of our study is to determine the prevalence of sickle cell trait in blood donors., Methods: we conducted a 4-month descriptive prospective study (January-May 2017) at the Haute Matsiatra Regional Blood Transfusion Center (RBTC). All donors were screened by Emmel test and positive cases were confirmed by hemoglobin electrophoresis., Results: the study involved 427 donors, of whom 332 were men and 95 women (sex ratio 3.4). The average age of blood donors was 32.72, ranging from 18 to 64 years. Emmel test was positive in 5 donors (1.17%). These patients had the AS genotype confirmed by hemoglobin electrophoresis., Conclusion: the results of this study reveal the presence of sickle cell trait among blood donors at the CRTS. Most of them ignore their sickle cell status before blood donation. Quality and safety of blood and blood products are mandatory, hence the importance of screening among blood donors is a current relevant issue., Competing Interests: Les auteurs ne déclarent aucun conflit d´intérêts., (Copyright: Jocia Fenomanana et al.)

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Current literature favors a volume-outcome relationship in pulmonary lobectomy that prompted centralization of these operations abroad, in national, single-payer health care settings. This study examined the impact of regionalization on outcomes after lung cancer resection within a US integrated health care system., Methods: This study retrospectively reviewed major pulmonary resections (lobectomy, bilobectomy, pneumonectomy) for lung cancer that were performed before (2011 to 2013; n = 782) and after (2015 to 2017; n = 845) thoracic surgery regionalization during 2014., Results: Case migration from 16 regionwide sites to 5 designated centers was complete by 2016. Facility volume increased from 17.4 to 48.3 cases/y (P = .002), and surgeon volume increased from 12.5 to 19.9 cases/y (P = .001). The postregionalization era was characterized by increased video-assisted thoracoscopic surgery (86% from 57%; P < .001), as well as decreased intensive care unit use (-1.0 days; P < .001) and hospital length of stay (-3.0 days; P < .001). Postregionalization patients experienced fewer total (26.2% from 38.6%; P < .001) and major (9.6% from 13.6%; P = .01) complications. The association between regionalization and decreased length of stay and morbidity was independent of surgical approach and case volume in mixed multivariate models., Conclusions: After the successful implementation of thoracic surgery regionalization in our US health care network, pulmonary resection volume increased, and practice shifted to majority video-assisted thoracoscopic surgery and minimum intensive care unit utilization. Regionalization was independently associated with significant reductions in length of stay and morbidity., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. The work was funded by the Prince Mahidol Award Foundation, Thai Health Promotion Foundation, and International Decision Support Initiative. The Health Intervention and Technology Assessment Program (HITAP) is funded by the Thailand Research Fund (TRF) under a grant for senior research scholar (RTA5980011). HITAP’s International Unit is supported by the International Decision Support Initiative (iDSI) , which is funded by the Bill and Melinda Gates Foundation, the UK’s Department for International Development, and the Rockefeller Foundation. The findings, interpretations, and conclusions expressed in this article do not necessarily reflect the views of the funding agencies.

Aims: The Italian general practitioners (GPs) are not directly employed by the National Health Service but work as independent contractors. Their activity and their salary are managed at the national, regional, and local level. This paper analyses the Tuscany Region case study to investigate if primary care's target-setting styles are associated with different GP perceptions, by comparing nine different local agreements to a survey on 102 GPs. We propose a classification of the different target-setting (ideal typical) styles, ranging from "financial governance" (FG), mainly based on financial targets, to "clinical governance" (CG), that mainly relies on clinical and quality targets., Findings: Results show that GPs are more likely to have a more favourable attitude toward primary care managerial tools if they have certain characteristics, ie, quality measures. This suggest that target setting system might promote both the GPs' compliance to the targets set by the agreement and the involvement of the GPs in the LHA's governance processes too., Conclusions: The managerial tools could pave the way to overcome the classical "trade unionist" relationship between the regional and local authority and the GPs, working as a "trait d'union" between the two players., (© 2019 John Wiley & Sons, Ltd.)

Pancreatoduodenectomy (PD) is increasingly performed in high-volume centers, which may compromise waiting times. The aim of this study was to evaluate patient flow and outcome of PD within a regional oncology network of two high-volume centers. A post hoc analysis of a partially retrospective and prospective database was performed of all patients who underwent PD for pancreatic or periampullary neoplasms in both centers of the Gastrointestinal Oncology Center Amsterdam, a collaboration between an academic center and affiliated general teaching hospital, from 2010 to 2014. Outcomes included waiting time to surgery and postoperative morbidity and mortality. A total of 525 PDs were performed, 329 in the academic center (annual volume 66) and 196 in the teaching hospital (annual volume 39). Neoadjuvant treatment was more often used in the academic center, other baseline characteristics were similar. Overall time to surgery was 26 days, which was significantly less in the teaching hospital. The major postoperative morbidity rate was 38.3% (n = 201), and the 30- and 90-day mortality was 2.3% and 3.6%. A regional oncology network between an academic center and a general teaching hospital for PD can be an attractive option to safeguard waiting times in selected patients, without compromising outcome.

Background: On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move., Methods: Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis., Results: Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected., Conclusion: We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses., (© 2019 Royal Australasian College of Surgeons.)

Objective: To analyze the formation of spatial clusters of technical efficiency (TE) in the production of outpatient maternal health services in México for the period 2008 to 2015., Methods: We performed a longitudinal analysis of administrative and structural data related to the 243 Mexican health jurisdictions. We use window data envelopment analysis and spatial and econometric techniques. Structural correlates of each TE cluster obtained were identified estimating a pooled multinomial logit model., Results: We observed an increase in the overall TE, accompanied by a reduction in its standard deviation. Furthermore, we identified positive TE spatial dependence both globally and locally. Multiple regression analysis showed that the maximum-performance TE cluster was composed of health jurisdictions located in the North of México and characterized by social marginalization, a reduced indigenous population, and a low demand for maternal health services., Conclusions: The identification of TE clusters can provide elements to induce decision makers to innovative in ways of allocating resources and manage their utilization. In México as other low- and middle-income countries, it is key to develop targeting strategies to implement specific health services innovations putting to the population to be served at the front of the strategy. This implies testing new modalities to strengthen primary health services, the empowerment of community participation, the training and allocation of health personnel that could respond adequately to population's demand, and the active involvement of competent state and local authorities in the assessment of the results of these innovations., (© 2019 John Wiley & Sons, Ltd.)

Background: As citizens, patients and family members are participating in numerous and expanding roles in health system organizations, attention has turned to evaluating these efforts. The context-specific nature of engagement requires evaluation tools to be carefully designed for optimal use. We sought to address this need by assessing the appropriateness and feasibility of a generic tool across a range of health system organizations, engagement activities and patient groups., Methods: We used a mixed-methods implementation research design to study the implementation of an engagement evaluation tool in seven health system organizations in Ontario, Canada focusing on two key implementation outcome variables: appropriateness and feasibility. Data were collected through respondent feedback questions (binary and open-ended) at the end of the tool's three questionnaires as well as interviews and debriefing discussions with engagement professionals and patient partners from collaborating organizations., Results: The three questionnaires comprising the evaluation tool were collectively administered 29 times to 405 respondents yielding a 52% response rate (90% and 53% of respondents respectively assessed the survey's appropriateness and feasibility [quantitatively or qualitatively]). The questionnaires' basic properties were rated highly by all respondents. Concrete suggestions were provided for improving the appropriateness and feasibility of the questionnaires (or components within) for different engagement activity and organization types, and for enhancing the timing of implementation., Discussion and Conclusions: Our study findings offer guidance for health system organizations and evaluators to support the optimal use of engagement evaluation tools across a variety of health system settings, engagement activities and respondent groups., (© 2019 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Introduction: Oral anticancer drugs have disrupted hospital and community practices. A better coordination and patient support for medication and adverse events management by primary care providers (general practitioner, community pharmacist and liberal nurse) could improve the situation. The CHIMORAL study evaluated a model of coordination by territorial health networks., Methods: A here and elsewhere, prospective and multicentric study, comparing coordinated care with standard care. Primary outcome was the use of the hospital structure for adverse events within 6 months of initiating treatment., Results: In all, 283 patients were included. 92% had at least one adverse event, with a higher median number in the coordinated group (12.5 vs. 9.0, P=0.02). No difference in hospital use by arm (P=0.502). Increase in the use of community care for adverse events in the coordinated group (27% vs. 16%, P=0.009). No observed impact on progression rates, quality of life and treatment adherence. The overall survival rate at 6 months is numerically higher in the coordinated group (87% vs. 76%, P=0.064)., Discussion: This model does not show any difference on the primary endpoint. The lack of randomization, patient selection, power loss, and local initiatives to monitor these patients may have biased the analysis. A large number of uses of the healthcare system were observed. These results confirm the need for a dedicated care pathway for the patient with oral anticancer drugs., (Copyright © 2019 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Fluoroquinolones (FQs) are major antibiotics but their wide use in hospital and community settings has led to an increased bacterial resistance against this antibiotic class. We aimed to assess the efficiency of an antibiotic stewardship program targeting FQs in a local hospital, and its impact on bacterial resistance., Methods: This observational study was conducted in the local hospital of Morteau (Franche-Comté region, East of France). The hospital has 166 beds with health and medico-social sectors and a medical home affiliated with the facility. Local guidelines on empirical treatment regimens were released in 2007 aiming to reduce the use of FQs, especially for urinary tract infections. The following monitoring indicators were assessed: total consumption of antibiotics and of FQs (DDD/1,000 hospital patient-days), and resistance to nalidixic acid among Escherichia coli strains. Changes in the number of FQ packs sold in a community pharmacy were also recorded., Results: The FQ consumption decreased by 85.6% between 2006 and 2015 (from 41.1 to 5.9 DDD/1,000 patient-days). The resistance to nalidixic acid among E. coli strains substantially decreased after remaining steady until 2011 (-57.2% between 2007 and 2015). The number of norfloxacin packs sold in the assessed community pharmacy decreased by 88%., Conclusion: Setting up an antibiotic stewardship program in a local hospital can lead to a substantial reduction in FQ use and in E. coli resistance to FQs. It may also have a positive impact on community prescriptions., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: To examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period (April 2010 to March 2013) over two follow-up periods: to 2014/2015 and to 2015/2016., Design: Difference-in-differences analysis of emergency hospital admissions from English Hospital Episode Statistics., Setting: Local authorities in England classified as either pioneer or non-pioneer., Participants: Emergency admissions to all NHS hospitals in England with local authority determined by area of residence of the patient., Intervention: Wave 1 of the integrated care and support pioneer programme announced in November 2013., Primary Outcome Measure: Change in hospital emergency admissions., Results: The increase in the pioneer emergency admission rate from baseline to 2014/2015 was smaller at 1.93% and significantly different from that of the non-pioneers at 4.84% (p=0.0379). The increase in the pioneer emergency admission rate from baseline to 2015/2016 was again smaller than for the non-pioneers but the difference was not statistically significant (p=0.1879)., Conclusions: It is ambitious to expect unequivocal changes in a high level and indirect indicator of health and social care integration such as emergency hospital admissions to arise as a result of the changes in local health and social care provision across organisations brought about by the pioneers in their early years. We should treat any sign that the pioneers have had such an impact with caution. Nevertheless, there does seem to be an indication from the current analysis that there were some changes in hospital use associated with the first year of pioneer status that are worthy of further exploration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: The impact of deferring critically ill children in referral hospitals away from their designated pediatric critical care unit (PCCU) on patients and the healthcare system is unknown. We aimed to identify factors associated with deferrals and patient outcomes and to study the impact of a referral policy implemented to balance PCCU bed capacity with regional needs., Methods: We conducted a population-based retrospective cohort study of admissions to a PCCU following inter-facility transport from 2004 to 2016 in Ontario, Canada., Results: Of 10,639 inter-facility transfers, 24.8% (95% confidence interval [CI]: 23.5-26.1%) were deferred during pre-implementation and 16.0% (95% CI: 15.1-16.9%) during post-implementation of a referral policy. Several factors, including previous intensive care unit admissions, residence location, presenting hospital factors, patient co-morbidities, specific designated PCCUs and winter (versus summer) season, were associated with deferral status. Deferrals were not associated with increased mortality., Conclusions: Deferral from a designated PCCU does not confer an increased risk of death. Implementation of a referral policy was associated with a consistent referral pattern in 84% of transfers., (Copyright © 2019 Longwoods Publishing.)

The exploration and practice of the "1 + 10 + 1100000" model of local medical consortium includes three aspects: graded diagnosis and treatment, two-way referral, and dynamic flow; seamless connection between general practice and specialty to realize health management; and establishment of the "community health center-East Hospital-Tongji University" teaching platform., (© 2019 John Wiley & Sons, Ltd.)

Background: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls., Methods: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half., Results: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10 -4 ); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10 -3 ). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding., Conclusion: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Medicines regulatory harmonization has been recommended as one way to improve access to quality-assured medicines in low- and middle-income countries. The rationale is that by lowering barriers to entry more manufacturers will be enticed to enter the market, while the capacity at the national medicines regulatory authorities is strengthened. The African Medicines Regulatory Harmonization Initiative, agreed in 2009, is developing regional platforms with harmonized regulatory procedures for the registration of medicines. The first region to implement medicines regulatory harmonization was the East African Community (EAC). The harmonization was based on the existing EAC Free Trade Agreement, which officially launched the free movement of goods and services in 2010., Methods and Findings: In this study we conducted semi-structured interviews and performed document reviews. The main target group for our interviews was pharmaceutical companies. We interviewed 18 companies, including 64% of the total companies who had experienced the EAC joint product assessment procedure, and two EAC-based national medicines regulatory authorities. We found that generally pharmaceutical companies are supportive of the African-based MRH efforts and appreciative of the progress being achieved. However, many companies are now hesitant to use the joint product assessment procedure until efficiency improvements are made. Common frustrations were the length of time to receive the actual marketing authorization; unexpectedly higher quality standards than national procedures; and challenges in getting all EAC countries to recognize EAC approvals. Smaller, less attractive markets have not yet become more attractive from a corporate perspective, and there is no free trade of pharmaceuticals in the EAC region., Conclusions: Pharmaceutical companies agree that medicines regulatory harmonization is the way forward. However, regulatory medicines harmonization must actually result in quicker access to the harmonized markets for quality-assured medicines. At this time, improvements are required to the current EAC processes to meet the vision of harmonization., Competing Interests: The authors have declared that no competing interests exist.

The aim of this paper is to examine the approach taken to regionalization in Ontario, Canada, and its impact on health system performance as perceived by managers and clinicians. This is a qualitative study, with thematic analysis, based on interviews with 23 managers and clinicians working in primary healthcare and emergency care in two regions of Ontario. Our findings demonstrate that both sets of actors see regional structures as contributing significantly to improving their respective health system although they also identify areas that require improvement. Managers and clinicians agreed on propositions to focus on health determinants, major considerations specific to the local context (population, geography) and support for a three-level system with well-defined functions. However, they also expressed differing propositions about the political power of hospitals.

Background: Despite regionalization of perinatal care provides for the "in utero" transfer of high-risk pregnancies, there will always be a number of neonates who undergo acute inter-facility transport. The presence of a well-organized Neonatal Emergency Transport Service (NETS) can prevent and reduce risks of transportation, especially for very preterm infants, and is therefore mandatory for any program of regionalization of perinatal care. Italian National Health System is highly decentralized and Regions are autonomous to structure, plan and delivery their regional health services. Consequently, organization models and resources available vary widely and significant regional differences in access and quality of health services have been reported in the past years. A national survey was conducted in 2015 by the neonatal transport study group of the Italian Society of Neonatology with the aim to describe neonatal transfer practices and to assess the Neonatal Emergency Transport Services (NETS) status in the 20 Italian regions., Methods: A questionnaire regarding neonatal transfer practices and NETS activity for the previous year (2014) was sent to the 44 NETS operating in the 20 Italian regions. Demographic data were obtained from the Italian National Statistical Institute (ISTAT)., Results: The overall survey response rate was 100%. In 2014, only 12 (60%) of the 20 Italian regions were fully covered by NETS, 3 (15%) regions were partially covered, while neonatal transport was not available in 5 (25%) regions. Overall, in 2014, the 44 NETS operating in Italy transported a total of 6387 infants, including 522 (8.17%) having a gestational age < 28 weeks., Conclusions: The organization of NETS in Italy is devolved on a regional basis, resulting in a large heterogeneity of access and quality to services across the country. Where available, NETS are generally well-equipped and organized but limited volume of activities often cannot guarantee adequate levels of skills of personnel or an appropriate cost-efficiency ratio. The regions reported with lack of NETS have managed, or are trying, to fill the gap, but continuing efforts to reduce regional differences in the availability and quality of services are still needed.

The French health care system implemented several corporate management recipes such as diagnostic-related groups (DRGs), benchmarking, and activity-based management in a bid to restore fiscal discipline and to "reassert the center." The government also regrouped health policy decisions with the Regional Health Agencies and opted for a top-down line of command to ensure policy implementation. Though reforms emphasized evidenced-based policy and outputs measurement, outcomes were below expectations in many areas and led to a shift in values. Professional autonomy and patient engagement receded. This leads us to a critical evaluation of the French audit society., (© 2019 John Wiley & Sons, Ltd.)

The practice of functions of district health-care systems in Ethiopia is not clear. The aim of this study was to investigate the perspectives of administrators, health service providers, and health-care consumers regarding functions of district health-care systems as currently practiced. Grounded theory approach was applied using interviews and desk review of documents. This study was set up in Oromia National Regional State, Ethiopia. Inductive analysis of interviews was done. Interviews and document reviews were mirrored. Eleven functions of district health-care systems emerged in this study organized by level with relationships and commonality of few activities. The 11 functions of district health-care systems were creating capacity of health centers and health professionals for the provision of health care; creating access for the provision of health care; ensuring equitable access to health care; regulation of private health-care providers; disaster preparedness; monitoring risk factors and diseases in the district; provision of health promotive, preventive, and curative health care for communicable diseases and maternal health conditions; monitoring intermediate outcomes of care; developing capacity of health post and villagers toward demand creation for health care; provision of maternal and child health services; and helping health posts in reaching mothers and sick individuals., (© 2019 John Wiley & Sons, Ltd.)

The aim of the present case study is to illustrate the outcomes of a dedicated allied health (AH) research position within a large Queensland regional and rural health service. The secondary aim of the case study is to describe the enabling and hindering mechanisms to the success of the role. Semistructured interviews were conducted with the Executive Director of Allied Health and the current AH research fellow incumbent within the health service. A focus group was also undertaken with six stakeholders (e.g. clinicians, team leaders) who had engaged with the research position. Outcomes of the AH research fellow included clinical and service improvements, enhanced research culture and staff up-skilling, development of research infrastructure and the formation of strategic research collaborations. Despite being a sole position in a geographically expansive health service with constrained resources, key enabling mechanisms to the success of the role were identified, including strong advocacy and regular communication with the Executive. In conclusion, the case study highlights the potential value of an AH research position in building research capacity within a large non-metropolitan health service. Factors to facilitate ongoing success could include additional research and administrative funding, as well as increased use of technology and team-based research.

Introduction: The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea. There are limitations in measuring performance of such projects through analysis of health information system data alone due to data quality issues and a multitude of unmeasured factors that affect performance. A mixed methods study was undertaken to understand the contextual factors that affect health service performance., Methods: A performance assessment framework was developed including service delivery indicators derived from the National Health Information System. Prior to implementation, a baseline analysis of the indicators was undertaken. Subsequently, semi-structured interviews were conducted with health administrators, in which they were asked about factors they perceived to influence health facility performance. During the interviews, key informants were provided with health indicators for their province and asked to interpret the performance of facilities. Interviews were transcribed and inductive thematic analysis performed., Results: Performance indicators varied greatly within and between districts. Key informants cited a number of reasons for this variation. Health facilities accessible by road in urban areas, with competent and/or higher level staff and health services operated by churches or private companies, were cited as contributors to high performance. For high performing districts, key informants also discussed use of health information, planning and targeted strategies to improve performance. Inadequate numbers of staff, poorly skilled staff, funding delays and challenging geography were major contributors noted for poor performance., Conclusion: Analysis of quantitative indicators needs to be performed at health facility level in order to understand district level performance. Interpretation of performance through key informant interviews provided useful insight into previously undocumented contextual factors affecting health delivery performance. The sequential explanatory mixed methods design could be applied to evaluations of other health service delivery programs in similar contexts.

Nearly a decade has passed since Alberta folded nine regional health authorities and three government agencies into one province-wide health system: Alberta Health Services (AHS). Deemed a reckless experiment by some at the time, there is now mounting evidence province-wide integration of services across the healthcare continuum is an enabler of improved quality, safety, and financial sustainability. The article highlights specific examples of how AHS is strengthening partnerships, standardizing best practices, and driving innovation, making Alberta a national and international leader in areas such as stroke care and potentially inappropriate use of antipsychotics in long-term care. It also shows how province-wide integration is being leveraged to build workplace culture, enhance patient safety, and find operational efficiencies that result in cost savings and cost avoidance.

Background: In Finland, hospital districts (HD) are required by law to determine the level and availability of Emergency Medical Services (EMS) for each 1-km 2 sized area (cell) within their administrative area. The cells are currently categorised into five risk categories based on the predicted number of missions. Methodological defects and insufficient instructions have led to incomparability between EMS services. The aim of this study was to describe a new, nationwide method for categorising the cells, analyse EMS response time data and describe possible differences in mission profiles between the new risk category areas., Methods: National databases of EMS missions, population and buildings were combined with an existing nationwide 1-km 2 hexagon-shaped cell grid. The cells were categorised into four groups, based on the Finnish Environment Institute's (FEI) national definition of urban and rural areas, population and historical EMS mission density within each cell. The EMS mission profiles of the cell categories were compared using risk ratios with confidence intervals in 12 mission groups., Results: In total, 87.3% of the population lives and 87.5% of missions took place in core or other urban areas, which covered only 4.7% of the HDs' surface area. Trauma mission incidence per 1000 inhabitants was higher in core urban areas (42.2) than in other urban (24.2) or dispersed settlement areas (24.6). The results were similar for non-trauma missions (134.8, 93.2 and 92.2, respectively). Each cell category had a characteristic mission profile. High-energy trauma missions and cardiac problems were more common in rural and uninhabited cells, while violence, intoxication and non-specific problems dominated in urban areas., Conclusion: The proposed area categories and grid-based data collection appear to be a useful method for evaluating EMS demand and availability in different parts of the country for statistical purposes. Due to a similar rural/urban area definition, the method might also be usable for comparison between the Nordic countries.

Background: At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers., Methods: As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015., Results: Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations., Conclusions: A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

Objective: Compare state policies with standards outlined in the 2012 AAP Policy Statement on Levels of Neonatal Care., Study Design: Systematic, web-based review of publicly available policies on levels of care in all states in 2014. Infant risk information, equipment capabilities, and specialty staffing were abstracted from published rules, statutes, and regulations., Result: Twenty-two states had a policy on regionalized perinatal care. State policies vary in consistency with the AAP Policy, with 60% of states including standards consistent with Level I criteria, 48% Level II, 14% Level III, and one state with Level IV. Ventilation capability standards are highly consistent (66-100%), followed by imaging capability standards (50-90%). Policy language on specialty staffing (44-68%), and subspecialty staffing (39-50%) are moderately consistent., Conclusion: State policies vary in consistency, a potentially significant barrier to monitoring, regulation, uniform care provision and measurement, and reporting of national-level measures on risk-appropriate care.

Background: As inter-hospital alliances have become increasingly popular in the healthcare sector, it is important to understand the challenges and benefits that the interaction between representatives of different hospitals entail. A prominent example of inter-hospital alliances are certified 'trauma networks', which consist of 5-30 trauma departments in a given region. Trauma networks are designed to improve trauma care by providing a coordinated response to injury, and have developed across the USA and multiple European countries since the 1960s. Their members need to interact regularly, e.g. develop joint protocols for patient transfer, or discuss patient safety. Social capital is a concept focusing on the development and benefits of relations and interactions within a network. The aim of our study was to explore how social capital is generated and used in a regional German trauma network., Methods: In this qualitative study, we performed semi-standardized face-to-face interviews with 23 senior trauma surgeons (2013-14). They were the official representatives of 23 out of 26 member hospitals of the Trauma Network Eastern Bavaria. The interviews covered the structure and functioning of the network, climate and reciprocity within the network, the development of social identity, and different resources and benefits derived from the network (e.g. facilitation of interactions, advocacy, work satisfaction). Transcripts were coded using thematic content analysis., Results: According to the interviews, the studied trauma network became a group of surgeons with substantial bonding social capital. The surgeons perceived that the network's culture of interaction was flat, and they identified with the network due to a climate of mutual respect. They felt that the inclusive leadership helped establish a norm of reciprocity. Among the interviewed surgeons, the gain of technical information was seen as less important than the exchange of information on political aspects. The perceived resources derived from this social capital were smoother interactions, a higher medical credibility, and joint advocacy securing certain privileges., Conclusion: Apart from addressing quality of care, a trauma network may, by way of strengthening social capital among its members, serve as a valuable resource for the participating surgeons. Some member hospitals could exploit the social capital for strategic benefits.

Background: Consolidation is often considered by policymakers as a means to reduce service delivery costs and enhance accountability., Objective: The aim of this study was to estimate the potential cost savings that may be derived from consolidation of local health authorities (LHAs) with specific reference to the Italian setting., Methods: For our empirical analysis, we use data relating to the costs of the LHAs as reported in the 2012 LHAs' Income Statements published within the New Health Information System (NSIS) by the Ministry of Health. With respect to the previous literature on the consolidation of local health departments (LHDs), which is based on ex-post-assessments on what has been the impact of the consolidation of LHDs on health spending, we use an ex-ante-evaluation design and simulate the potential cost savings that may arise from the consolidation of LHAs., Results: Our results show the existence of economies of scale with reference to a particular subset of the production costs of LHAs, i.e. administrative costs together with the purchasing costs of goods (such as drugs and medical devices) as well as non-healthcare-related services., Conclusions: The research findings of our paper provide practical insight into the concerns and challenges of LHA consolidations and may have important implications for NHS organisation and for the containment of public healthcare expenditure.

Most health care organizations engage in formal and informal planning, yet their improvement initiatives may remain disjointed and reactive. Research on organizational decision-making has found that the "discovery" approach (seek and assess multiple options before selecting one) outperforms "idea imposition" (identify 1 option, then gather information to [dis]confirm it), yet is observed relatively infrequently. Might this imply that discovery frequently collapses before fruition? This qualitative study sought to better understand the planning-action disjunction, as observed in 1 organization, by comparing its planning processes against the discovery approach. It focused on a Canadian regional health system's recurrent, unsuccessful attempts to improve patient flow. Through extensive document review supplemented by interviews with 62 managers, it identified all relevant regional plans/reports produced during a 15-year period and followed each recommendation forward in time to discover its fate. Each report presented a lengthy, unprioritized list of disparate recommendations, few of which progressed to full implementation. It appeared that decision-makers repeatedly embarked on a discovery approach, but rapidly allowed it to splinter into multiple idea-imposition approaches; numerous options were generated, but never evaluated against each other. Thus, the product of each planning process was not a coherent strategy but a list of disconnected actions., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: Health Policy Program (Program Polityki Zdrowotnej – PPZ) is a state policy tool for engaging local government units into the mechanism of granting provision of health services. Authors show areas in which self-governments most often took preventive health care actions and describe legislative changes in the Act on provision of health services., Objective: The aim of the article is to quantitative and qualitative statement of PPZ prepared in Poland in 2016 and 2017, as well as presenting changing legal situation in the scope of evaluation of these projects., Materials and Methods: Authors use descriptive method, presenting changes of legal status. The article includes data available in the Bulletin of Public Information by The Agency for Health Technology Assessment. 590 programs were analyzed (239 from 2016 and 351 from 2017)., Results: In 2016 – 67% of submitted programs were given a positive opinion and in 2017 – 71%. The most of positively evaluated PPZ submitted by local government units (53% in 2016; 47% in 2017) referred to prevention of infectious diseases by vaccines. On the basis of analyses conducted, significant differences were observed in the implementation of the PPZ in various regions of Poland., Conclusions: In the recent years a big improvement in the quality of planned self-government health programs is observed. It is suggested that due to the regulation defining the model of the health policy program and the model of the final report, this trend will continue.

Background: Health service planning that takes into account as far as possible the regional needs and regional discrepancies is a controversial health issue in Germany., Objectives: In a pilot scheme, we tested a planning process for regional healthcare services, based on the example of dementia care. The aim of this article is to present the strengths and limitations of this planning process., Materials and Methods: We developed an indicator set for dementia care based on routine regional data obtained from two German statutory health insurance companies. Additionally, primary data based on a questionnaire sent to all GPs in the area were evaluated. These data were expanded through the addition of official socio-demographic population data. Procedures and evaluation strategies, discussion of the results and the derivation of planning measures followed, in close agreement with a group of local experts., Results: Few epidemiological data on regional variations in health care planning are publicly available. Secondary data from statutory health insurance companies can be assessed to support the estimation of regional health care needs, but interpretation is difficult. The use of surveys to collect primary data, and the assessment of results by the local health board may facilitate interpretation and may contribute towards more valid statements regarding regional health planning., Conclusions: Despite the limited availability of data and the considerable efforts involved in data analysis, the project demonstrates how needs-based health service planning can be carried out in a small region, taking into account the increasing demands of the local health care providers and the special local features.

Objective The aim of the present study was to describe how one regional health service the Illawarra Shoalhaven Local Health District embedded health literacy principles into health systems over a 3-year period. Methods Using a case study approach, this article describes the development of key programs and the manner in which clinical incidents were used to create a health environment that allows consumers the right to equitably access quality health services and to participate in their own health care. Results The key outcomes demonstrating successful embedding of health literacy into health systems in this regional health service include the creation of a governance structure and web-based platform for developing and testing plain English consumer health information, a clearly defined process to engage with consumers, development of the health literacy ambassador training program and integrating health literacy into clinical quality improvement processes via a formal program with consumers to guide processes such as improvements to access and navigation around hospital sites. Conclusions The Illawarra Shoalhaven Local Health District has developed an evidence-based health literacy framework, guided by the core principles of universal precaution and organisational responsibility. Health literacy was also viewed as both an outcome and a process. The approach taken by the Illawarra Shoalhaven Local Health District to address poor health literacy in a coordinated way has been recognised by the Australian Commission on Safety and Quality in Health Care as an exemplar of a coordinated approach to embed health literacy into health systems. What is known about the topic? Poor health literacy is a significant national concern in Australia. The leadership, governance and consumer partnership culture of a health organisation can have considerable effects on an individual's ability to access, understand and apply the health-related information and services available to them. Currently, only 40% of consumers in Australia have the health literacy skills needed to understand everyday health information to effectively access and use health services. What does this paper add? Addressing health literacy in a coordinated way has the potential to increase safety and quality of care. This paper outlines the practical and sustainable actions the Illawarra Shoalhaven Local Health District took to partner with consumers to address health literacy and to improve the health experience and health outcomes of consumers. Embedding health literacy into public health services requires a coordinated whole-of-organisation approach; it requires the integration of leadership and governance, revision of consumer health information and revision of consumer and staff processes to effect change and support the delivery of health-literate healthcare services. What are the implications for practitioners? Embedding health literacy into health systems promotes equitable, safe and quality healthcare. Practitioners in a health-literate environment adopt consumer-centred communication and care strategies, provide information in a way that is easy to understand and follow and involve consumers and their families in decisions regarding and management of the consumer's care.

Perinatal regionalization, or risk-appropriate care, is an approach that classifies facilities based on capabilities to ensure women and infants receive care at a facility that aligns with their risk. The CDC designed the Levels of Care Assessment Tool (LOCATe) to assist jurisdictions working in risk-appropriate care in assessing a facility's level of maternal and neonatal care aligned with the most current American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) and American Academy of Pediatrics (AAP) guidelines. LOCATe produces standardized assessments for each hospital that participates and facilitates conversations among stakeholders in risk-appropriate care. This article describes how public health departments implement and use LOCATe in their jurisdictions.

Andrew Lover and colleagues discuss regional malaria initiatives, the strengths and challenges.

Study Objective: Emergency medical services (EMS) provides out-of-hospital care to patients with life-threatening conditions, but the long-term outcomes of EMS patients are unknown. We seek to determine the long-term mortality of EMS patients in Denmark., Methods: We analyzed linked EMS, hospital, and vital status data from 3 of 5 geographic regions in Denmark. We included events from July 1, 2011, to December 31, 2012. We classified EMS events according to primary dispatch category (unconsciousness/cardiac arrest, accidents/trauma, chest pain, dyspnea, neurologic symptoms, and other EMS patients). The primary outcome was 1-year mortality adjusted for age, sex, and Charlson comorbidity index., Results: Among 142,125 EMS events, primary dispatch categories were unconsciousness or cardiac arrest 5,563 (3.9%), accidents or trauma 40,784 (28.7%), chest pain 20,945 (14.7%), dyspnea 9,607 (6.8%), neurologic symptoms 17,804 (12.5%), and other EMS patients 47,422 (33.4%). One-year mortality rates were unconscious or cardiac arrest 54.7% (95% confidence interval [CI] 53.4% to 56.1%), accidents or trauma 7.8 (95% CI 7.5% to 8.1%), chest pain 8.5% (95% CI 8.1% to 9.0%), dyspnea 27.7% (95% CI 26.7% to 28.7%), neurologic symptoms 14.1% (95% CI 13.6% to 14.7%), and other EMS patients 11.1% (95% CI 10.8% to 11.4%). Compared with other EMS conditions, adjusted 1-year mortality was higher in unconsciousness or cardiac arrest (risk ratio [RR] 2.6; 95% CI 2.5 to 2.7), dyspnea (RR 1.5; 95% CI 1.4 to 1.5), and in neurologic symptoms (RR 1.1; 95% CI 1.0 to 1.1), but lower in chest pain (RR 0.6; 95% CI 0.6 to 0.7) and accidents or trauma (RR 0.8; 95% CI 0.8 to 0.8)., Conclusion: EMS patients with unconsciousness or cardiac arrest, dyspnea, and neurologic symptoms are at highest risk of long-term mortality. Our results suggest a potential for outcome improvement in these patients., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: This paper investigates back-transfer: the transfer of patients near the end of their acute hospitalization to a local community hospital for the completion of their medical care. We seek to describe factors contributing to back-transfer, with the goal of elucidating the current use of back-transfer and barriers to its more widespread adoption for rural healthcare regionalization., Study Design: Observational unmatched case-control., Methods: This was a retrospective study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Demographic, geographic, rurality, procedural, and disease information was compared among cases and control groups using univariate analysis and multivariable logistic regression., Results: Over the 9-year period, 172,544 back-transfer eligible patients were admitted to 1 of 5 large Iowa hospitals, of which 287 (0.2%) were back-transferred. Back-transferred patients were more likely than their non-back-transferred counterparts to be older, male, and white; to live in large rural areas; and to have public insurance. As inpatients, they had longer median lengths of stay (15 vs 5 days; P <.001), more medical comorbidities, and were more likely to have a cardiac catheterization procedure than the control group., Conclusions: Back-transfer is a very rare event. While demographic and medical differences between back-transferred patients and controls may partially explain the infrequency, other systematic barriers must exist to limit back-transfer. These barriers likely include legal, financial, logistical, and patient care concerns. Despite the rarity with which it is employed, back-transfer is a promising strategy that could better utilize health resources, especially in rural America.

Objective: Rapid sequence induction (RSI) provides prompt airway control during emergency evacuation of trauma patients. Physicians may be tasked to travel with paramedic ambulance crews to the scene of injury when RSI is more likely to be required. This study investigates whether there are any differences in the practice of prehospital RSI during emergency retrievals for trauma since the establishment of the regional Major Trauma Network (MTN) in March 2012., Methods: A retrospective observational study examined prehospital records for all trauma patients from September 2010 to January 2015 at a Major Trauma Centre in Birmingham, UK. Prehospital physician availability increased from 12 to 24 h after March 2012, and tasking became centralized. Data included demographics, mechanism of injury, crew personnel, and details of RSI. The periods before and after the establishment of the regional MTN were compared., Results: There were 5244 patients: 1432 (27.3%) before and 3812 (72.7%) after March 2012. Of the patients, 67.2% were male. The most common injuries were road traffic collisions (45.0%). Physicians were more likely to be present after (2345 missions, 61.5%) than before (529 missions, 36.9%) March 2012 (P<0.01). RSI was performed 434 (8.3%) times and was more likely during the latter than the former period [359 (9.4%) vs. 75 (5.2%), P<0.01]. Successful tracheal intubation was achieved in 99% of occasions., Conclusion: The establishment of regional MTNs enables centrally tasked, 24-h physician availability for emergency trauma patients. There has been an increase in physician presence on emergency missions and increased frequency of RSI for at-risk trauma patients at times when there may previously have been an unmet requirement.

Introduction: In France, 26 regional pediatric palliative care teams (ERRSPP) were created between 2008 and 2012. We conducted the first prospective French study to describe the main specifications of the initial contact with an ERRSPP and to analyze the responses given., Design and Methods: All the requests for interventions on the part of the ERRSPP were collected between September 2013 and September 2014. We prospectively completed a questionnaire on the patient's clinical and demographic data (age, sex, disease), details regarding the request (type of applicant, unit's specialty, request pattern), and the answers provided (interval between diagnosis and request, duration of care by ERRSPP, death, changes compared to the initial request). The diseases were classified within one of the six groups of palliative pediatric care diseases, based on the standards of the Canadian palliative care association., Results: We gathered 67 requests, 61 relating to patients. The median age at the request was 49.8 months (range: 2.3-145). The original pattern was multiple: multidisciplinary decision-making (42 %), coordination of care (34 %), symptom management (21 %), logistic support for home care (19 %), education (9 %) and case discussion (6 %). Requests concerning multidisciplinary decision-making were predominant within the neonatal period (61 %); coordination of care was significant for children and adolescents (78 % after 4 years of age). The study of the median time from diagnosis to request compared to the groups of diseases revealed a short time in group 5 (neonatology: 0.36 months) and a long time in group 4 (irreversible and nonscalable diseases: 54.6 months) (P<0.001). At the end of the study, the follow-up of 50.8 % of the patients by ERRSPP was still going on (median duration of care by the ERRSPP of Languedoc-Roussillon region [ERRSPP-LR], 3.4 months [range: 0.2-5.5]). No request was formulated by a general practitioner., Conclusion: This study shows the heterogeneity of the initial contact made with an ERRSPP, confirming its different assignments and the need for a multidisciplinary team. The ERRSPP's answer was expanded in half of the cases, attesting to the changing needs over time., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Aim: The present study investigated the association between the structure of catheter replacement services in home medical care settings and regional characteristics., Methods: An anonymous self-administered questionnaire was carried out from August to September 2013. Participants were physicians from 5338 clinics that provided medical care services at home, and nurses from 1619 home-visit nursing stations in Tokyo and three adjoining prefectures. The questionnaire covered catheter replacement (gastrostomy tubes, nasogastric tubes, tracheal cannulas) during home medical care, and the professions of those who replaced urethral catheters for male and female patients. Regions were divided into two groups (higher- and lower-density regions) based on the number of clinics, number of home-visit nursing stations and the ratio of the population aged ≥65 years. The rates of respondents that reported catheter replacement was usually executed, and those who reported catheters were replaced by "physicians in principle" were compared between the groups., Results: Responses were received from 842 clinics (16.3%) and 499 home-visit nursing stations (31.4%). In the higher-density regions, the rate of physicians who reported urethral catheters for male patients were replaced by "physicians in principle" was significantly higher than in the lower-density regions (P < 0.001). In the lower-density regions, the rate of nurses who reported urethral catheters for male patients were replaced by "nurses in principle" was significantly higher compared with the higher-density regions (P < 0.016)., Conclusions: In home medical care settings, urethral catheters for male patients are replaced by nurses in regions where physician resources are limited. Geriatr Gerontol Int 2017; 17: 628-636., (© 2016 Japan Geriatrics Society.)