Level Of Care Research Articles

Is Outpatient Supraglottoplasty Possible? Examination of Perioperative Comorbidities and Outcomes.

Supraglottoplasty (SGP) is necessary in approximately 10% to 15% of infants with congenital laryngomalacia (LM). Postoperative management strategies vary and this study examines outcomes and readmission rates. This is a retrospective chart review. A single tertiary care institution's patients undergoing SGP from 2012 to May 2022. Patients were assigned to 1 of 3 groups based on length of stay (LOS) including 0, 1, or 2+ days. Preoperative data included age, prevailing symptoms, and comorbidities at the time of surgery. Postoperative data included level of care, perioperative complications, readmission rates, and SGP failure. Descriptive statistics were used to evaluate differences between the 3 groups. Following SGP in 975 patients, 23.8% were discharged the same day (Group 0), 63.2% were observed overnight (Group 1), and 13.0% required 2+ days (Group 2). Four of the 616 patients in Group 1 were admitted to an intensive care unit (ICU) setting, and 11 patients in Group 2. The patients in Group 2 had a higher incidence of Pepcid use, previous intubation, cardiac anomalies, prior gastrostomy tube (G tube), subglottic stenosis, cyanosis, failure to thrive, and prematurity. The significant differences in the group admitted to the ICU were those admitted for airway, cerebral palsy, prior G tube, PSG, prior intubation, or cardiac anomaly (P = <.05). Readmission rates from Group 0 versus 1 were 1.3% and 2.9%, respectively, though this was not statistically significant. SGP is a safe procedure that can be performed in the outpatient setting in select patients.

Preoperative predictors of difficult early laparoscopic cholecystectomy among patients with acute calculous cholecystitis in Egypt

BackgroundEarly laparoscopic cholecystectomy (ELC) in the setting of acute calculous cholecystitis (ACC) requires to be performed by highly-skilled surgeons to avoid complications. The purpose of this study is to identify preoperative factors that would predict difficult ELC among patients with ACC prior to proceeding with surgery.MethodsWe retrospectively reviewed all patients who received ELC within 10 days from the onset of symptoms of ACC between August 1, 2018, and December 31, 2022. They were divided into 2 groups according to the difficulty of surgery.Results149 patients with ACC received ELC during the study period. ELC was considered difficult in 52 patients (35%). Five preoperative factors were identified as significant predictors of difficult ELC (DELC) on multivariate analysis: duration of acute attack ≥ 4 days from the onset of symptoms till surgery (OR 34.4, P < 0.001), ultrasound showing largest gallstone size > 20 mm (OR 20.2, P = 0.029), ultrasound showing gallstone impaction in Hartmann’s pouch (OR 7.2, P = 0.017), history of prior episode(s) of acute attack (OR 6.8, P = 0.048), and diabetes mellitus (OR 5.8, P = 0.046).ConclusionCareful preoperative assessment of patients with ACC is crucial among junior surgeons with limited surgical expertise prior to proceeding with ELC to identify those at risk of DELC to potentially reduce postoperative morbidity and mortality. If encountered, a management plan should be made, and surgery should proceed only upon confirming the availability of experienced surgeons in the field of biliary and laparoscopic surgery to supervise or assist in the procedure. Alternatively, such group of patients should rather be transferred to more advanced surgical centers which offer higher level of care to maintain patient safety and optimal surgical outcomes. More importantly, bail-out procedures should always be resorted to whenever DELC is encountered intraoperatively to prevent further surgical damage.

Telemedicine as a tool for bridging geographical inequity: insights in geospatial interactions from a study on chronic heart failure patients

IntroductionChronic heart failure patients experience large disparities in quality of and access to treatment, with rural populations receiving lower levels of care. Telemonitoring of patients is increasingly being used as an important tool for improving patient management and care and might reduce geographical inequities in healthcare.MethodsWe investigate the presence and magnitude of a geospatial interaction effect on the health benefit of a supplementary telemedicine intervention, by analyzing the relationship between distance to regular place of treatment and the benefit of telemedicine in a secondary analysis of data from a previously conducted RCT. We use change in EQ5D health status, SF-36 Physical component score and SF-36 Mental component score as the outcomes. In the unadjusted analysis, intervention group and distance group and the interaction term are included as the independent variables, in the adjusted analysis, multiple socioeconomic and health related variables are included to account for potential confounders.ResultsWe find evidence of a significant interaction between the effects of telemedicine and long distance to treatment for change in EQ5D health status (unadjusted: p = 0.016, adjusted p = 0.009) and unadjusted but not adjusted mental component score (unadjusted: p = 0.013, adjusted p = 0.0728), for the change in physical component score the interaction term was not significant (unadjusted: p = 0.118, adjusted p = 0.092).ConclusionIn our study we find that supplementary telemedicine is likely to reduce the health access inequities associated with geographical distance for chronic heart failure patients. However, our sample size was modest and further research is needed to confirm these findings.

Management and outcomes of acute appendicitis in children with congenital heart disease.

Congenital heart disease (CHD) care has evolved during the past decades. Advances in care have contributed to improved survival among CHD patients. Children with CHD are requiring interventions for non-CHD related medical issues that occur in the general pediatric population. A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004, to July 31, 2023. Discharges of patients with an admitting/principal diagnosis of appendicitis were evaluated and categorized as CHD or non-CHD. A total of 319,228 patients were identified with 1,25,858(39.4%) female, 1,38,966(43.5%) white, and median age of 11[IQR:8-14] years. 708(0.2%) had CHD with 85(12%) of them having a diagnosis consistent with single-ventricle CHD (SV-CHD). In univariate analysis, CHD patients were more likely to undergo conservative treatment (n = 172(24.2%)vs n = 59,358(18.6%)) and less likely to undergo laparoscopic appendectomy (n = 483(68.2%) vs n = 2,35,324(73.8%))(p < 0.001) compared to non-CHD. After adjustment, CHD patients had increased odds of undergoing open appendectomy compared to non-CHD. CHD patients were more likely to have an ICU admission (OR:8.36(95%CI 6.35-10.00),p < 0.001) and had a 77.6%(95%CI 40.89-123.93) increase in length of stay (LOS) (p < 0.001). CHD patients are more likely to have an open appendectomy than non-CHD patients. These findings suggest a distinctive pattern in the care of CHD patients compared to non-CHD. Overall, CHD patients had a more intense level of care with longer LOS and increased ICU admissions. Further work is needed to evaluate drivers of management decisions, the role of conservative treatment with antibiotics alone in the CHD population, and the potential impacts and safety of a laparoscopic approach.

Strategic Aeromedical Evacuations of the French Armed Forces in French Guiana From 2018 to 2020.

The French Armed Forces are deployed in French Guiana (FG) to protect national territory and ensure the security of strategically important sites. Military health support (MHS) provides medical support for missions in this tropical environment, which is hazardous and where confrontations are possible. MHS must organize tactical and strategic evacuations (Strat-AEs), so that an optimal level of care can be delivered. Overall, Strat-AE activity has been described previously but no specific data related to FG has been reported. The main objective of this study was to provide an overview of military Strat-AEs from FG. We conducted a retrospective cohort study from January 01, 2018 through 31 December, 2020. All patients who required a military Strat-AE were included, and we collected sociodemographic characteristics, medical information, service-related injuries and illnesses, and the reason for and conditions of evacuation. We analyzed 210 patients and 199 were included. Most were noncommissioned members (63.3%) and belonged to the Army (75.4%) and the Gendarmerie (15.6%). Injury or illness was duty-related in 66.2% of patients. The main cause for evacuation was nonbattle injury (63.3%), followed by illness (27.1%). Battle stress and injury accounted for 9.5%. The main reasons for evacuation were surgical conditions (58.3%), particularly orthopedic (47.2%). Medical (22.1%), psychiatric (18.6%), and dental (1.0%) disorders followed. Most patients were categorized by the flight surgeon as P3 (98.5%), the lowest level of priority, and D4 (82.9%), the lowest level of dependency. The escort used during evacuation was identical to that recommended by the requester in 83.5% of cases. The final destination was mainly a hospital (89.9%). The time lag between injury or onset of illness and the request for evacuation was significantly longer when local health resources were insufficient. The particularity of FG is a local health care system that provided initial care before the evacuation. To reduce the number of Strat-AEs in FG, the risk of nonbattle injury must be lessened and improvements must be made to the local health care system and to the partnership between civilian and military health services.

Psychological flexibility and celiac disease in adolescents: Understanding adherence and well-being for enhanced care. A rapid narrative review

Abstract Background Psychological flexibility (PF) has been approached as a mediator between health conditions and outcomes by promoting positive responses and healthier behavior repertoires. Purpose This rapid narrative review examines studies exploring the role of PF in influencing celiac disease outcomes among adolescents, with a particular focus on adherence to dietary management practices. Method Online databases were searched for studies exploring possible connections between PF, celiac manifestation, and management presented by adolescents. Selected articles have entered the analysis to highlight whether PF mediates or affects celiac-related outcomes in adolescents. Conclusions Adolescents demonstrate a greater capacity to organize their daily routines effectively while adhering to gluten-free diets. However, the emphasis on PF can significantly impact their social interactions. Although there is much research to be conducted on this possible connection, there are still primary assumptions that support the idea that PF can also be a factor in helping adolescents with celiac disease navigate the challenges of their illness and maintain a quality of life. Healthcare professionals can find value in incorporating elements from supporting therapies, health literacy programs, and health promotion strategies. Furthermore, insights from the review suggest the importance of standardizing interventions and measurements including counseling practices at the primary care level.

Utilizing laser therapy to manage oral potentially malignant disorders in older adults at the primary care level.

Oral lesions are a significant concern among older adults because they can progress to oral cancer if not diagnosed and treated promptly and effectively. Transportation to the hospital is a major barrier to oral healthcare for many older adults. The purpose of this editorial is to address the challenges of managing oral potentially malignant disorders in the older population, highlighting the barriers they face in accessing healthcare services, the potential use of laser therapy for management, and the direction of research in this area. Due to the limited access of the older to healthcare services, primary healthcare facilities within communities serve as their primary providers. Laser therapy is recommended for the management of oral potentially malignant disorders due to its favorable outcomes. This approach has been tested in several primary healthcare centers in Thailand. In our project, laser therapy was used to treat oral potentially malignant disorders in primary and secondary healthcare services. This includes photodynamic therapy for older patients with extensive lesions, as well as individuals with oral leukoplakia and erythroplakia who have declined curative surgery. It has also been used in cases of recalcitrant lichen planus to steroid or photobiomodulation therapy. This approach has been well accepted by both oral healthcare providers and patients. To expand access to these treatment options in such settings, it is critical to empower healthcare professionals, particularly dentists and dental nurses, to integrate laser techniques into geriatric care and oral cancer screening. Establishing a network foundation for orofacial laserology would also enhance the potential of such settings.

Analysis of budget expenditures of the Republic of Kazakhstan

This article provides a comprehensive analysis of the structure of the budget system and expenditures of the Republic of Kazakhstan (ROK), which are characterized by complexity and multilevel and reflect the amount of financial resources and the size of budget constraints at the levels of the budget system. The main focus is on the republican budget, which generates the country's revenues and finances national expenditures directed to such areas as defense, national security, foreign policy, as well as projects and assistance programs. The functioning of the budget system is regulated by regulatory legal acts (NPAs), including the Constitution of the Republic of Kazakhstan, the Budget Code of the Republic of Kazakhstan and other NPAs, which ensures transparent and effective management of public finances. The Ministry of Finance of the Republic of Kazakhstan plays a key role in the implementation of the state financial policy, coordinating work with other ministries and departments.The article presents the results of the analysis conducted by the author of this article of the execution of republican budgets for the period 2018-2022. It is shown that all three categories of budgets (republican, regional and local) demonstrate steady growth in spending, which can lead to increased public investment and expansion of government programs. Special attention is paid to the increased level of education and health care, which ensures the priority and higher level of efficiency of these sectors in comparison with other sectors of the economy of the Republic of Kazakhstan. Based on the analysis, a SWOT analysis was conducted, which revealed the strengths and weaknesses of the budget system of the Republic of Kazakhstan, as well as identified threats and opportunities to improve its condition.The article concludes with recommendations on ensuring the sustainability of the budget system and improving the efficiency of budget funds, including measures to increase transparency and efficiency of budget processes, optimize budget allocation, improve the effectiveness of social programs, reduce public debt, develop interdepartmental experience and use the state experience achieved in a number of sectors and territories.

Quality of Life of Vietnam People through Education and Health Index

The quality of life of the population is a measure of the sustainable development of the country, in which education and health care play an important role. In Vietnam, education and health care have made important strides in improving people's lives, helping to improve the level of education and public health care. The education system is expanding with many good improvement policies, while the health sector is also developing strongly through strengthening facilities and wider access to health services. However, there are still many challenges, quality disparities between regions and overload in hospitals... The article focuses on studying the current status of education, health care, and its impact on the quality of life of the population.

Knowledge about cardiovascular diseases in a first-level healthcare center in Lima, Peru.

Motivation for the study. In Peru, the knowledge level of patients about their cardiovascular health is unknown at the first level of care, which receives 85% of the population, and where primary disease prevention activities are carried out. Main findings. More than 70% of people had an inadequate level of knowledge about their own cardiovascular health. Implications. Our results highlight the need to improve the education of people on cardiovascular health issues at the first level of care, taking into account that these diseases are increasingly frequent in the population. This study aimed to determine the level of knowledge about cardiovascular diseases in people in a primary healthcare center (PHCC). A descriptive and cross-sectional study was carried out by surveying people who attended a PHCC in Lima, Peru. A score less than 6 was considered inadequate knowledge. A total of 400 people were surveyed, 66.3% were women and the mean age was 46.8 ± 16.2 years. The average score was 4.52 +/- 1.85. We found that 71% of those surveyed had an inadequate level of knowledge, regardless of age, gender or education level. Our findings show that the level of knowledge about risk factors and cardiovascular disease was inadequate in the primary care population. It is necessary to achieve proper specific education in cardiovascular risk factors in order to reduce the impact of these diseases.

Psoriasis: a disease beyond the skin.

Psoriasis is a chronic, immune-mediated inflammatory dermatosis with a multifactorial etiology, affecting approximately 3% of the Italian population. This condition not only imposes a substantial burden on physical health but also significantly diminishes the personal and social quality of life of affected individuals. This study aims to assess the critical role of integrated management approaches in psoriasis, focusing specifically on the role of primary care physicians in coordinating multidisciplinary care and addressing comorbidities. A comprehensive review of current therapeutic guidelines, classification systems, and available treatment strategies was conducted. This was supplemented with real-world clinical case studies. The study evaluated intervention approaches at both primary and secondary care levels, involving collaborations between general practitioners and specialists. Special emphasis was placed on the use of clinical assessment tools such as the Psoriasis Area and Severity Index (PASI) to categorize disease severity and guide therapeutic decisions. Our findings underscore the effectiveness of a multidisciplinary and personalized approach in managing psoriasis, particularly in moderate-to-severe cases. The pivotal role of primary care physicians in the early diagnosis, ongoing monitoring, and coordination of care pathways was highlighted, leading to significant improvements in comorbidity management. The clinical cases presented illustrate how tailored therapeutic regimens, supported by close collaboration between general practitioners and dermatologists, can result in the effective resolution of psoriatic lesions and markedly enhance patients’ quality of life. This study reinforces the necessity of a comprehensive, integrated, and multidisciplinary approach in the management of psoriasis, with primary care physicians serving as crucial intermediaries between community-based and specialist care. Depending on disease severity, treatment response, and recurrence patterns, primary care physicians play a central role in directing patients to appropriate secondary care services. The integration of specialist dermatological care with ongoing community-based monitoring optimizes clinical outcomes and mitigates the overall disease burden. We advocate for the establishment of clinical networks that facilitate seamless communication between different levels of care, ensuring holistic and targeted management of both psoriasis and its associated comorbidities. Keywords: Psoriasis, primary care physician, multidisciplinary care, integrated therapy, quality of life, comorbidities.

Contribution of Online Referral Systems to Health Services: Systematic Review

The online referral system (eReferral) is designed to improve waiting times and efficiency by standardizing information and online communication in the referral process. Online referral is the automation of the referral process in which appointments and other information regarding the outcome of a consultation are transferred between two or more healthcare providers. This study was designed to identify the implementation of online referrals at various levels of health care. This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of the 10 articles included in this review, 6 studies were conducted in the USA, 2 studies in Canada, and one each in the UK, and Saudi Arabia. The studies used a variety of designs, including Quasi-experimental (n=5), longitudinal (n=2), qualitative (n=1), and Research and Development (n=2). This study provides a clear picture of the use of an online referral system, starting from the work process, effectiveness, barriers, and development possibilities for a wider reach. This system is very helpful in easing the workload of specialist doctors and for patients who are referred users get the benefit of shorter waiting times/queues, making it possible to reduce medical costs further.

Symptom- and function-based trajectories of patients with dementia in hospital and community palliative care settings in the last two weeks of life: a retrospective cohort study

BackgroundThe prevalence of dementia is increasing worldwide and many people with the condition require some level of palliative care. However, the trajectories of function and symptom burden in palliative care services at the end of life remain unclear. This study aimed to describe and compare the longitudinal trajectories of function and symptom burden among patients with dementia between hospital versus palliative community care services in the last two weeks of life.MethodsA retrospective cohort study used data from the Australian Palliative Care Outcomes Collaboration. Patients with dementia who died between 1 January 2013 and 31 December 2020 from the Australian Palliative Care Outcomes Collaboration. Four validated clinical instruments were used to collect outcomes on each individual’s function and symptom distress and severity. Multilevel models were used to estimate the differences in clinical trajectories between hospital and community-based palliative care in the last two weeks of life.ResultsPatients with dementia tended to have low levels of distress for most symptoms but increasing levels of functional impairment. There were no or only marginally significant differences in the symptom trajectories between the community and hospital groups (OR ranged from 0.57 to 1.97). Although clinical trajectories of function were relatively similar between two groups, statistically higher functional indicators were observed for people when admitted to community palliative care services (OR = 0.42 and 2.27, respectively).ConclusionsOur findings suggest that community-based palliative care services can be as effective as hospital-based care for many patients with dementia nearing the end of life. With appropriate support for families, community-based care could serve as a viable alternative to hospital-based care for some patients in the final stages of dementia.

Factors Associated with Patient Activation in People with Heart Failure based on the Individual and Family Self-Management Theory: A Cross-sectional Study.

Patient activation (PA) is crucial for effective self-management of people with heart failure (HF). Clarifying factors associated with PA might be important to develop interventions to promote PA. This study aimed to explore Context factors associated with PA in people with HF. 268 patients were enrolled in a cross-sectional study (Median age=65 years). We surveyed variables based on Context factors of the Individual and Family Self-Management Theory (IFSMT), including demographic and disease factors, quality of chronic care, family function, and depression. Correlation analysis was conducted for data analysis, and path analysis was used to verify our hypothesis model about Context factors and PA. The median PA score was 51.10. Path analysis showed that age, educational level, living arrangement, device therapy, quality of chronic care, family function, and depression were directly or indirectly related to PA. The quality of chronic care mediated the associations between device therapy and educational level and PA. Age, educational level, living arrangement, and quality of chronic care affected family function and then affected activation. Depression mediated the relationships between the quality of chronic care, educational level, family function, and PA. This study increased the understanding of factors associated with PA in the HF population. When assessing PA in people with HF, those who are older, have a low educational level, living alone need more attention from healthcare professionals. Interventions focusing on improving the quality of chronic care, family function, and depression might help activate people to practice self-management.

Exploring parenting behaviors, stress, and closeness among foster parents

This mixed methods study with a triangulation design aimed to explore the impact of parenting styles and those that most make up parenting care among foster parents today. We assessed how foster parents individually view their management of childcare, perceived levels of support, and education opportunities surrounding foster care parenting practices or level of received preparedness. Furthermore, this study offered insight into if parental styles are associated with parental perceived stress level, and foster parent-foster child closeness. Preexisting secondary data from the Fostering Healthy Relationships study was utilized. This study contained national survey data and focus group transcriptions from licensed foster parents, which were collected during 2018–2019. Our current sample included quantitative data from 457 foster parent participants and qualitative data from 12 participants. Overall, the results indicated most parents who responded to the survey revealed having participated in authoritative parenting practices. Those with authoritative and authoritarian parenting practices had more stress, while authoritative reported more closeness with foster children.

Factors Affecting Delirium Care Core Competency Among Nurses: A Descriptive Correlational Study.

Nurses require optimal competency to deliver safe and high-quality care to patients with delirium. However, the factors influencing delirium care core competency remain unclear. This study aims to investigate the factors influencing core competency in delirium care among nurses. This study was conducted as a descriptive correlational study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A convenience sample of 202 Korean nurses from 15 hospitals completed a structured, web-based, self-administered questionnaire. The survey covered general characteristics, delirium care knowledge, moral sensitivity, barriers to delirium care, and core competency in delirium care. Multiple regression analysis identified the factors affecting core competency in delirium care. Results showed that barriers to delirium care, moral sensitivity, academic qualifications, and clinical ladder level were significant factors, accounting for 18.1% of the variance in delirium care core competency. To improve delirium care among nurses, using individual, team, and organizational approaches to address perceived barriers and moral sensitivity is crucial. Competency-based training programs and administrative support are crucial for enhancing the competency of nurses who are novices and those with associate degrees.

The Role of Educational Institution Administrators in Operating the Student Care and Assistance System at Vocational Colleges in Chonburi Province

Background and Aims: The objectives of this research are as follows: 1. to study and evaluate the operational level of the student care and assistance system. Students in vocational colleges in Chonburi Province 2. To compare the performance of the student care and assistance system in such colleges classified by status. and 3. to propose guidelines for operations related to the role of school administrators in developing student care and support systems for students in vocational colleges in Chonburi Province. Methodology: The sample group in this research consisted of administrators and teachers from vocational educational institutions in Chonburi province, totaling 269 people, using questionnaires as a tool for collecting data. which has a reliability value of the questionnaire at 0.97. For data analysis, basic statistics were used, including frequency, percentage, mean, and standard deviation. As for hypothesis testing, t-test statistics were used. Results: The finding found that (1) The opinion regarding the role of educational institution administrators in operating the student care and support system Students in vocational colleges in Chonburi Province Overall it is at a high level. (2) Level of opinions regarding the role of educational institution administrators in operating the student care and assistance system, classified by gender, found that overall there was no difference. When considering each aspect, it was found that the areas of student promotion and development were significantly different at the 0.05 level. While knowing each student individually student screening Preventing and solving student problems. And in the forwarding aspect, no differences were found. (3) Level of opinion regarding the role of educational institution administrators in operating the student care and assistance system, classified by status It was found that there was a statistically significant difference at the 0.05 level. Especially in the area of ​​student screening and in the area of ​​student promotion and development. which were significantly different at the 0.05 level, while no differences were found in other aspects. Conclusion: The study discovered that vocational college administrators in Chonburi Province are widely perceived to play an important role in student care and support. While gender had no overall impact on these opinions, there were differences in student promotion and development, and status had a significant influence on perceptions in areas such as student screening and development (p &lt; 0.05).

Development of a risk predication model for critical care needs in patients with intracerebral hemorrhage: a retrospective cohort.

It is very important to provide the correct nursing care for patients with intracerebral hemorrhage (ICH), but the level of critical care needs in patients with intracerebral hemorrhage is not clear. The purpose of this study is to establish a risk model based on the epidemiological and clinical characteristics of ICH patients, to help identify the critical care needs of ICH patients. The clinical data of ICH patients from January 2018 to September 2023 were analyzed retrospectively. The full cohort was used to derive the clinical prediction model and the model was internally validated with bootstrapping. Discrimination and calibration were assessed using the area under curve (AUC) and the Hosmer-Lemeshow tests, respectively. 611 patients with ICH were included for model development. 61.21% (374/611) ICH patients had received critical care interventions. The influencing factors included in the model were Glasgow Coma Scale (GCS) score, intraventricular hemorrhage, past blood pressure control, systolic blood pressure on admission and bleeding volume. The model's goodness-of-fit was evaluated, which yielded a high area under the curve (AUC) value of 0.943, indicating a good fit. For the purpose of model validation, a cohort of 260 patients with ICH was utilized. The model demonstrated a Youden's index of 0.750, with a sensitivity of 90.56% and a specificity of 78.22%. GCS, systolic blood pressure, intraventricular hemorrhage, bleeding volume and past blood pressure control are the main factors affecting the critical care needs of patients with ICH. This study has deduced a clinical predictive model with good discrimination and calibration to provide scoring criteria for clinical health care providers to accurately evaluate and identify the critical care needs of ICH patients, to improve the rational integration and allocation of medical resources.

Predictors of treatment outcome in higher levels of care among a large sample of adolescents with heterogeneous eating disorders

BackgroundDespite widespread use of higher levels of care in treating eating disorders in adolescents, research supporting the use of these treatments remains limited by small sample sizes and a predominant focus on anorexia nervosa. Further, existing data regarding predictors of outcome have yielded mixed findings. In the current study, we evaluated treatment outcomes and predictors of outcome among a large sample of adolescents with eating disorders presenting to inpatient, residential, partial hospitalization programs, and intensive outpatient programs across the United States.MethodsAdolescents (N = 1,971) completed self-report measures of eating disorder symptoms, depression, and anxiety at treatment admission, stepdown, and discharge. Using linear mixed effect models, we evaluated changes in symptoms over treatment separately among youth admitted to inpatient/residential treatment and those admitted to partial hospitalization/intensive outpatient programs, and used established metrics to gauge frequency of reliable (i.e., statistically reliable) and clinically significant change.ResultsResults suggested decreases in eating disorder symptoms, depression, and anxiety from intake to discharge. Around 50% of the sample reported reliable decreases in eating disorder symptoms at stepdown and discharge, with 30% of the sample reporting reliable reductions in depression and anxiety. Psychiatric comorbidity, primary diagnosis, age, and eating disorder symptoms at admission consistently predicted treatment-related change, although patterns in findings varied across symptoms.ConclusionsData from our sample are consistent with past work suggesting that adolescents enrolled in higher levels of care report clinical benefit; however, these effects are heterogenous, and a significant portion of individuals may not report reliable change in symptoms. Ultimately, ongoing work is required to better understand how and for whom higher levels of care may achieve their benefit and to identify the optimal approach for improving outcomes for adolescents with eating disorders.

Market concentration of the Brazilian hospital medical supplementary health system

BackgroundThe Brazilian supplementary health market has undergone transformations in recent years due to constant mergers and acquisitions of by large corporations, contributing to the increase in market concentration, especially in the poorest and least developed regions of the country. Thus, given the care it provides and its economic relevance, understanding the fundamentals of these movements, the likely consequences and trends for the health market are relevant, important, and strategic.ObjectiveTo understand the general and specific context of Brazilian supplementary health, its scenarios, and trends, with emphasis on the analysis of market concentration and recent mergers and acquisitions.MethodologyThe research is applied, descriptive and exploratory and uses secondary data from various sources, submitted to quantitative data analysis methods. The data are organized into three groups: historical and regulatory documents; industry data; and market.ResultsThe results show the growing concentration of the market promoted by large publicly traded corporations, the growing relevance of tech startups on the healthcare landscape, the predominant use of the relative valuation model, with implicit multiples for asset pricing and the prevalence of corporate health plans.ConclusionThe growing concentration of the system projects a market with fewer options and less competitiveness, since the growth of large operators is evident, in addition to the relevant increase in the number of complaints from users of the system, which signals the growing gap between the expectations of users and the levels of quality care offered. The study also highlights the predominance of corporate health plans, revealing the direct relationship between access to supplementary health services and employability rates. The analysis of M&A operations, in addition to the increase in market concentration, reveals the prevalence of the use of the relative valuation model and implicit multiples for the pricing of traded assets. This denotes the future expectation of wealth generation, at least equivalent to the historical series of the sector, on the part of investors, whose frustration may signal the decreasing attractiveness of resources and M&A operations in the sector in the coming years.