Day Hospital Care Research Articles

Effectiveness and tolerability of long-acting intramuscular risperidone as adjuvant treatment in refractory borderline personality disorder

Dear Editor The lack of effective oral treatments for severely affected patients with borderline personality disorder (BPD) lead us to frequently use depot antipsychotic medication in our personality disorder unit. BPD is characterized by severe instability of interpersonal relationships, of self-image, and of affects resulting in marked impulsivity. The importance of the disorder is reflected in persistent functional impairment and in elevated suicide rates (Cheng et al. 1997; Paris 2005). There is no current consensus on the best treatment for BPD, and different combinations of oral medications are being prescribed by physicians (Paris 2011; Silk 2011). Furthermore low treatment compliance with oral medication is particularly described in these patients due to their characteristic personal instability which might significantly affect the efficiency of the drugs. For that reason, the possibility that lack of efficacy of oral treatments in refractory BPD patients might reflect the lack of compliance needs to be explored. In that sense, we designed a study to explore the benefits of using a depot IM medication, longacting intramuscular risperidone, in the treatment of BPD patients refractory to previous oral medication trials. A total of 49 BPD patients (30 women and 19 men) were included in the study. Inclusion criteria were the following: (1) 18–45 years of age; (2) diagnosis of borderline personality disorder (BPD) according to DSM IV criteria; (3) score equal or greater than 16 in the Zanarini Rating Scale for BPD; (4) “severely or very severely ill” as defined by a score 5 or greater in the CGI severity scale; and (5) refractory to a combination of oral medications commonly used for BPD treatment. Exclusion criteria were (1) current substance use dependence disorder; (2) life history of schizophrenia, schizophreniform disorder, bipolar disorder, or neurological disorders; (3) unstable medical disease or pregnancy; and (4) demonstrated intolerance to oral risperidone. The sample mean age was 27 years (SD±4.5) and the average duration of the disease was 7 years (SD±3.3). Patients were regularly treated in the day-care hospital due to severe behavioral dyscontrol causing markedly functional impairment. The study was approved by the Institutional Ethical Committee, and all patients signed informed consent. Treatment was started with an initial dose of 37.5 mg IM injection of LA risperidone repeated every 2 weeks, which could be raised to 50 mg as to clinical consideration. Patients were evaluated at months 1, 3, and 6 with clinical scales including the Zanarini Rating Scale for BPD, the Hamilton Anxiety Rating Scale, the Brief Psychiatry Rating Scale (BPRS), the Overt Aggression Scale (OAS), the Clinical Global Impression scale (CGI), and the Global Assessment of Functioning (GAF). Gradual significant improvement of severity ratings was observed from the first month and during the first 3 months of treatment (p<0.001), but no significant changes in the CGI scale were observed between the third and sixth J. L. Carrasco (*) :N. Palomares :M. D. Marsa Institute of Psychiatry and Mental Health, Hospital Clinico San Carlos, C/ Martin Lagos s/n, 28040 Madrid, Spain e-mail: jcarrasco.hcsc@salud.madrid.org

Hôpital de jour de dermatologie : entre circulaire frontière et réalité

Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

Differences in the use of health resources by Spanish and immigrant HIV-infected patients

HIV-immigrant use of health services and related cost has hardly been analysed. We compared resource utilisation patterns and direct health care costs between Spanish and immigrant HIV-infected patients. All HIV-infected adult patients treated during the years 2003-2005 (372 patients) in this hospital were included. We evaluated the number of out-patient, Emergency Room (ER) and Day-care Unit visits, and number and length of admissions. Direct costs were analysed. We compared all variables between immigrant and Spanish patients. Immigrants represented 12% (n=43) of the cohort. There were no differences in the number of out-patient, ER, and day-care hospital visits per patient between both groups. The number of hospital admissions per patient for any cause was higher in immigrant than in Spanish patients, 1.3 (4.4) versus 0.9 (2.7), P=.034. A high proportion of visits, both for the immigrant (45.1%) and Spanish patients (43.0%), took place in services other than Infectious Diseases. Mean unitary cost per patient per admission, out-patient visits and ER visits were similar between groups. Pharmacy costs per year was higher in Spanish patients than in immigrants (7351.8 versus 7153.9 euros [year 2005], P=.012). There were no differences in the total cost per patient per year between both groups. The global distribution of cost was very similar between both groups; almost 75% of the total cost was attributed to pharmacy in both groups. There are no significant differences in health resource utilisation and associated costs between immigrant and Spanish HIV patients.

Quel choix d’activités physiques et sportives dans une perspective d’apprentissage pour des jeunes ayant des troubles cognitifs ou des troubles psychiques ?

Social integration and/or inclusive education through sports of people with disabilities or of pupils with special education needs are at the same time encouraged by the law and often questioned, but only a few scientific studies have measured their impact. More precisely, the physical learning processes of children with cognitive disabilities or mental disorders are often confined to rehabilitation-type activities. And yet, these children can also acquire skills by practicing mainstream physical activities. A field experiment, conducted in a specialized institution (day-care hospital and medico-pedagogical day school) during 2 years with two groups of 59 youngsters eight to 15 (15 girls and 44 boys), shows the relevance of physical activities and associated social skills. The aim was to measure the impact of learning cycles in swimming, climbing and basketball on their physical and linguistic abilities and their relations to others. Results show that according to their internal logic features, some physical activities are more adapted to the emergence of new physical and social behaviours depending on the nature of the impairments. However, the positive changes observed tend to fade when these youngsters go back to their foster groups in the institution.

Economic burden of injuries in children: Cohort study based on administrative data in a northwestern Italian region

The aims of the present study were to identify which types of injuries are responsible for the major component of the health burden and to estimate the relative costs in a cohort of Italian children. All children (0-14 years) residing in the Piedmont region, who were hospitalized for an injury (ICD-9-CM codes 800-995, excluding late effects from injury and allergies) between 1 January 2003 and 31 December 2003, were considered. The cohort was linked by a unique identifier to: all the hospitalizations, all the day-hospital care, and all the prescribed medicines. Outcome was defined as the difference in health service use in the 12 months following the injury, and was compared to the year preceding the injury occurrence. Total number of hospital admissions for each individual, cumulative length of stay, day-hospital care, and prescribed medicines were calculated for the two periods. The cost of additional inpatient days and of additional outpatient care was calculated. The three most common injury categories were: intracranial injury (27.6%), fracture of upper limb (18.7%); and fracture of lower limb (9.07%); they were responsible for the major part of the additional inpatient days (55%) and outpatient care (70%). The additional expense for the National Health System during the year following an injury is approximately 1700 € for children aged 0-14. This is the first Italian study to attempt to quantify the injury economic burden in a cohort of children: the costs imposed on society by injuries, suggest how important it is to commit resources to injury prevention.

Unawareness of memory impairment and behavioral abnormalities in patients with Alzheimer's disease: relation to professional health care burden.

The present study investigates the impact of unawareness of deficit (anosognosia) in patients with Alzheimer's disease upon professional health care burden. Cross-sectional study with a consecutive clinical sample from an Alzheimer day-care hospital in France. 65 patients with probable AD, aged from 75 to 94 years old, consecutively admitted at the Alzheimer Day Hospital to complete a program of cognitive stimulation and psychosocial rehabilitation. Each patient was submitted to a standardized evaluation including clinical investigation, cerebral imagery, and neuropsychological assessment. Anosognosia of memory deficit and anosognosia of behavioral disturbances were measured as the "discrepancy scores" between patients' self-reports and family member ratings of patient memory performance and behavioral disturbances. Professional health care burden was assessed with the Professional Health Care Dementia Burden Index (PCDBI; maximal score: 12), designed for this study. Multiple linear regressions were used to examine the correlations between the PCDBI and the severity of anosognosia. The findings showed a significant positive correlation between the PCDBI and both anosognosia of memory impairment and behavioral abnormalities (both p at least less than 0.05). However, there was no significant correlation between the severity of the burden and the severity of cognitive decline or functional impairment (both p at least>0.05). Anosognosia in Alzheimer disease patients has a negative impact upon the professional caregivers' burden over and above the cognitive deficit and the functional impairments.

Recovery from Intracranial Hemorrhage Due to Leptospirosis

Intracranial hemorrhage is a rare and fatal presentation of leptospirosis. In this paper we present the case of a 51-year-old male farmer who lives in northern Iran. He came to our hospital with a severe headache. A paraclinical evaluation showed clear signs of thrombocytopenia, and a brain MRI revealed left temporoparietal hemorrhage. Our preliminary diagnosis was Leptospirosis, and after 26 days of hospital care the patient was discharged in good condition. This paper will educationally help physicians in better diagnosis and treatment of leptospirosis.

Équithérapie et autisme

Equine-assisted therapy is used beside therapies realised at the Child Psychiatry Center and included into individualised therapeutic program. The goals are to adapt therapeutic principles outside hospital and with pony as mediator in order to exercise adjustment and control systems: Communication and relationships with others, cognitive regulation (attention, mental representation, understanding causality, anticipation), motor regulation (tonus, body consciousness, postural adjustment, balance, coordination), emotional regulation (self-esteem, relaxation, pleasure, coping emotionally with problems, expressing and sharing emotions), adjusting to change. Varied activities with tranquil and easy-going ponies were realised in a calm secure environment by three therapists with experience in horseback riding for a group of four children. An individual plan targeting specific goals was worked out for each child. Results were evaluated with standardized tools (Behavior Function Inventory and Behavior Summarized Evaluation Scale) for six children with autistic spectrum treated at the day-care hospital, which participated to equine-assisted therapy. Improvements are obtained since the first session and concerns all developmental functions, especially communication, imitation, perceptual, emotional and motor adjustment. With his/her pony the child is stable, calms down, adjusts his/her interactions, is more aware of the effects of his/her actions, and optimal sensory integration can take place. So, equine-assisted therapy is an efficient remediation of the neurophysiologic functions involved in developing communication and social skills, and cognitivo-emotional regulation.

Insight in True Charles Bonnet Syndrome

Back to table of contents Previous article Next article LETTERFull AccessInsight in True Charles Bonnet SyndromeKurt Segers M.D.,Kurt Segers M.D.Search for more papers by this author,Published Online:1 Apr 2010https://doi.org/10.1176/jnp.2010.22.2.247.e1AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In a recent issue of your journal, Gupta et al. 1 described two patients who are said to suffer from true Charles Bonnet syndrome. 1 Although there is no universal consensus about the diagnostic criteria of Charles Bonnet syndrome, the prefix “true” suggests the most stringent criteria and, in particular, the presence of full insight into the hallucinatory nature of the images together with the absence of cognitive decline. 2 Interestingly, many patients seem to pass through an initial phase of deception before recognizing the unreality of these images. 3 However, the 60-year-old man reported by Gupta and colleagues has a 6-year history of abnormal behavior (washing his hands, trying to get rid of the bugs on his food and clothes) directly related to the lack of insight in the hallucinatory nature of the bugs he sees. Therefore I suggest not to use the term “true Charles Bonnet syndrome,” and maybe not even the term Charles Bonnet syndrome for his condition, especially since Charles Bonnet himself stressed in his original description of the syndrome the fact that the patient was healthy and had a normal judgment and memory. 4 It would be more adequate to use the descriptive term “complex visual hallucinations” rather than an eponym. Memory Clinic of the Neurology Department, Memory Clinic of the Geriatric Daycare Hospital, Brugmann University Hospital, Brussels, Belgium

Insight in True Charles Bonnet Syndrome

Back to table of contents Previous article Next article LETTERFull AccessInsight in True Charles Bonnet SyndromeKurt Segers M.D.,Kurt Segers M.D.Search for more papers by this author,Published Online:1 Apr 2010https://doi.org/10.1176/jnp.2010.22.2.247.e1AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In a recent issue of your journal, Gupta et al. 1 described two patients who are said to suffer from true Charles Bonnet syndrome. 1 Although there is no universal consensus about the diagnostic criteria of Charles Bonnet syndrome, the prefix “true” suggests the most stringent criteria and, in particular, the presence of full insight into the hallucinatory nature of the images together with the absence of cognitive decline. 2 Interestingly, many patients seem to pass through an initial phase of deception before recognizing the unreality of these images. 3 However, the 60-year-old man reported by Gupta and colleagues has a 6-year history of abnormal behavior (washing his hands, trying to get rid of the bugs on his food and clothes) directly related to the lack of insight in the hallucinatory nature of the bugs he sees. Therefore I suggest not to use the term “true Charles Bonnet syndrome,” and maybe not even the term Charles Bonnet syndrome for his condition, especially since Charles Bonnet himself stressed in his original description of the syndrome the fact that the patient was healthy and had a normal judgment and memory. 4 It would be more adequate to use the descriptive term “complex visual hallucinations” rather than an eponym. Memory Clinic of the Neurology Department, Memory Clinic of the Geriatric Daycare Hospital, Brugmann University Hospital, Brussels, Belgium

Appropriateness of admission and stay in obstetrics wards: a new tool assessing unnecessary days of hospital care

Introduction: The Appropriateness Evaluation Protocol (AEP) is a widely used assessment tool that identifies and measures the inappropriateness variables of hospital healthcare related to unjustified admission and/or length of stay, however it does not apply specifically to gynaecology or obstetrics wards. Objectives of the study: The main objectives of the present study were to develop a new tool for the evaluation of the appropriateness of admission and hospital stay in obstetric settings; as well as to analyze the main determinants of inappropriate admission and days of hospital stay within all the units of the Pediatric Hospital “Regina Margherita” and the Obstetrics and Gynaecology Teaching Hospital “S.Anna” in Turin. Methods: A multidisciplinary team of reviewers, composed of gynaecologists, paediatricians and obstetricians, was established and the appropriateness evaluation criteria, the operational handbook and the plan were all defined. Data were collected during the period between September and December 2005 and then put in an ad hoc database. Data analysis and evaluation were performed by univariate analysis (chisquare test) and multivariate analysis using a multiple logistic regression model. The level of significance was set at p&lt;0.05. Results: Out of 734 clinical records, 598 were considered for the study. The prevalence of inappropriateness of admission was 3.34%. The total number of examined days was 2888, 801 of which (27.74%) were considered to be inappropriate. The variables “place of residence” (÷²=6.272; p=0.0435) and “type of admission” (÷²=14.223; p&lt;0.001) were significantly associated with the inappropriateness of the admission. Between the 2nd and the 8th day of hospital stay the percentage of inappropriate days exponentially increased (up to 56%). With regards to the quality of the clinical records almost all of them were characterized by the presence of anamnesis, objective exams, discharge letters, clinical diary entries and the signature of the responsible healthcare professional. Objective examination was often incomplete or partially complete or absent. Conclusions: The proposed Obstetric AEP was demonstrated to be useful for the evaluation of the appropriateness of obstetric admissions and hospital stays, as well as the determinants for when these were inappropriate. This specific tool, in the future, could be used to monitor hospital usage and the allocation of resources related to this health care area

Daily practice management of myelodysplastic syndromes in France: data from 907 patients in a one-week cross-sectional study by the Groupe Francophone des Myelodysplasies

There is little published information on the everyday clinical management of myelodysplastic syndromes in real world practice. We conducted a cross-sectional study of all patients with myelodysplastic syndromes attending 74 French centers in a 1-week period for inpatient admission, day-hospital care or outpatient visits. Nine hundred and seven patients were included; 67.3% had lower-risk myelodysplastic syndromes (International Prognostic Scoring System: low or intermediate-1). Karyotype had been analyzed in 82.5% of the cases and was more often of intermediate or poor risk in patients under 65 years old compared with those who were older. Red blood cell transfusions accounted for as many as 31.4% of the admissions. Endogenous erythropoietin level was less than 500 IU/L in 88% of the patients tested. Erythroid stimulating agents had been or were being used in 36.8% of the lower risk patients, iron chelation in 31% of lower risk patients requiring red blood cell transfusions and lenalidomide in 41% of lower risk patients with del 5q. High-dose chemotherapy, hypomethylating agents, low dose cytarabine and allogeneic stem cell transplantation had been or were being used in 14.8%, 31.1%, 8.8% and 5.1%, respectively, of higher-risk patients. Karyotype is now assessed in most patients with myelodysplastic syndromes, and patients under 65 years old may have more aggressive disease. Apart from erythroid-stimulating agents and, in higher-risk myelodysplastic syndromes, hypomethylating agents, specific treatments are used in a minority of patients with myelodysplastic syndromes and red blood cell transfusions still represent the major reason for hospital admission.

The Burden of Hospital Readmissions for Patients with Sickle Cell Disease in California and North Carolina: 2004 to 2007.

Abstract 554 Introduction:Hospital readmissions are viewed within health services and policy circles as an indicator of poor quality care. Little is known about what patient characteristics may also contribute to readmissions among patients with sickle cell disease (SCD). We used hospital administrative data from two states to examine patient and hospital discharge-level characteristics associated with hospital readmissions in this patient population. Methods:The State Inpatient Databases (SID) provided by the Healthcare Cost and Utilization Project contain patient-level discharge data from 100% of hospitals in participating states. We used SID data from North Carolina and California for the years 2004 through 2007 to examine patient and discharge-level characteristics associated with hospital readmissions among patients with SCD. We identified SCD patients in the dataset using the following ICD9 codes: 28241-28242, and 28260-28269. Encrypted patient identifiers were availabel for the majority of patients in the dataset. For each individual SCD patient in the dataset, we defined an index admission as the patient's first admission in the dataset during the study period. We defined a readmission as any subsequent non-elective admission appearing in the dataset occurring within 1-month of any prior admission. We used ICD9 codes and Clinical Classification Software codes to identify comorbidities associated with SCD: vaso-occlusive crisis, pulmonary hypertension, cerebrovascular accidents, leg ulcers, gall bladder disease, retinopathies, avascular necrosis, chronic renal failure, acute chest syndrome, blood infections, and pneumonia. We also identified patients with diagnostic codes of HIV or other viral infections. We used discharge disposition codes provided in the dataset to identify patients who discharged themselves against medical advice (AMA). We used oneway ANOVAs, t-tests, chi-square tests, and multiple linear and logistic regressions to examine the association of patient-level and discharge-level characteristics with readmission history. A generalized estimating equation was used to account for within-patient clustering as appropriate. Results:We identified 9966 SCD patients who together accounted for 38363 hospital discharges during the study period. Sixty-five percent of the discharges were from California. Thirty-five percent of the discharges were identified as readmissions given our study definitions. The average length of stay for readmissions was 1.4 days longer than that of other hospitalizations (6.7 vs. 5.3, p < 0.001). Readmissions remained 0.76 days longer on average than other hospitalizations after adjustment for patient age, sex, insurance type, and sickle-related comorbidities (p < 0.001). The average billed charges for readmissions (unadjusted) were $4427 higher than that of other hospitalizations (p < 0.001). After adjustment for age, sex, and sickle-comorbidities, readmissions remained $1923 more expensive than other hospitalizations. The addition of length of stay to the model reversed the readmission effect on average charges. In a patient-level analysis, only 24% of the 9966 individuals in the dataset ever had a readmission during the study period. Nevertheless, this 24% of patients accounted for 71% of the total discharges, 76% of the total days of care, and 74% of the billed charges observed during the study period. In adjusted models, ever experiencing a readmission during the study period was significantly associated with a patient being female, being younger, leaving the hospital AMA, and ever experiencing vaso-occlusive crisis, pulmonary hypertension, cerebrovascular accidents, leg ulcers, gall bladder disease, retinopathies, avascular necrosis, chronic renal failure, acute chest syndrome, blood infections, pneumonia, or a viral infection (non-HIV) during the study period. Conclusions:A relatively small percentage of SCD patients, who appear to have more severe illness, are responsible for an overwhelming majority of hospital readmissions, which in turn are associated with significantly increased days of hospital care and total charges. The development of interventions to reduce readmissions among the small percentage of patients who disproportionately account for these costly admissions may be an effective and equitable focus of policy efforts to reduce the readmission rate for patients with SCD. Disclosures:No relevant conflicts of interest to declare.

Erlöszuordnung von Zusatzentgelten in der Intensivmedizin

In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs.

Avoidable Portion of Tobacco-Attributable Acute Care Hospital Days and Its Cost Due to Implementation of Different Intervention Strategies in Canada

The impact of four effective population-based interventions, focusing on individual behavioural change and aimed at reducing tobacco-attributable morbidity, was assessed by modeling with respect to effects on reducing prevalence rates of cigarette smoking, population-attributable fractions, reductions of disease-specific morbidity and its cost for Canada. Results revealed that an implementation of a combination of four tobacco policy interventions would result in a savings of 33,307 acute care hospital days, which translates to a cost savings of about $37 million per year in Canada. Assuming 40% coverage rate for all individually based interventions, the two most effective interventions, in terms of avoidable burden due to morbidity, would be nicotine replacement therapy and physicians’ advice, followed by individual behavioural counselling and increasing taxes by 10%. Although a sizable reduction in the number of hospital days and accumulated costs could be achieved, overall these interventions would reduce less than 3% of all tobacco-attributable costs in Canada.

Health Care Use in Patients With Chronic Intestinal Dysmotility Before and After Introducing a Specialized Day-Care Unit

Patients with chronic intestinal dysmotility (CID) have a lifelong disease, and no curative treatment is available. Interventions are needed to improve the care and support of the patients. The aim of this study was to measure health-care consumption in adult patients with CID before and after the introduction of a specialized day-care unit. Retrospective analysis was made of medical and nursing records from 3 different health-care delivery systems: period I, traditional care (1987-1996); period II, outpatient clinic (1997-1999); and period III, specialized day-care unit (2000-2002). There were 54 patients (44 women) with a median age of 47 years (range, 22-80 years). The need for admissions to hospital care decreased from 80% to 35% of the patients after the introduction of the specialized day-care unit (P < .002). Also, the mean number of days in hospital care per patient and year was reduced from 39.4 to 3.3 days. The number of outpatient visits remained unaltered. The average cost per patient-year decreased from $32,698 during traditional health-care services to $9,681 after introducing the specialized day-care unit (P < .002). Irrespective of the form of care delivery, the majority of patients (67%-77%) needed daily treatment with analgesics, and 81%-84% needed nutritional support on a regular basis. Individually tailored care at a specialized day-care unit leads to substantially decreased needs for hospital stays and lower costs in patients with CID.

Length of stay and associated costs of obesity related hospital admissions in Ireland.

BackgroundObesity is the cause of other chronic diseases, psychological problems, obesity shortens the lifespan and puts strain on health systems. The risk associated with childhood obesity in particular, which will accelerate the development of adult morbidity and mortality, has been identified as an emerging public health problem.MethodsTo estimate the length of stay and associated hospital costs for obesity related illnesses a cost of illness study was set up. All discharges from all acute hospitals in the Republic of Ireland from 1997 to 2004 with a principal or secondary diagnostic code for obesity for all children from 6 to 18 years of age and for adults were collected.A discharge frequency was calculated by dividing obesity related discharges by the total number of diagnoses (principal and secondary) for each year. The hospital costs related to obesity was calculated based on the total number of days care.ResultsThe discharge frequency of obesity related conditions increased from 1.14 in 1997 to 1.49 in 2004 for adults and from 0.81 to 1.37 for children. The relative length of stay (number of days in care for obesity related conditions per 1000 days of hospital care given) increased from 1.47 in 1997 to 4.16 in 2004 for children and from 3.68 in 1997 to 6.74 in 2004 for adults.Based on the 2001 figures for cost per inpatient bed day, the annual hospital cost was calculated to be 4.4 Euromillion in 1997, increasing to 13.3 Euromillion in 2004. At a 20% variable hospital cost the cost ranges from 0.9 Euromillion in 1997 to 2.7 Euromillion in 2004; a 200% increase.ConclusionThe annual increase in the proportion of hospital discharges related to obesity is alarming. This increase is related to a significant increase in economic costs. This paper emphasises the need for action at an early stage of life. Health promotion and primary prevention of obesity should be high on the political agenda.

Organização de um serviço de assistência ao paciente com diabetes melito tipo 1

This article will provide the necessary information to establish a childhood and adolescence management center that would promote the integration and coordination of interdisciplinary members as healthcare teams. It will also show how Instituto da Criança com Diabetes from Rio Grande do Sul (ICD) was built, structured and how it works. The aim of this program is to decrease the frequency of hospitalization in acute cases, to decrease chronic complications and to qualify human resources. So far 1315 outpatients and day-care hospital patients, mostly type 1 diabetes, have been seeing free of charge in Public Health Service (PHS), in a partnership with Grupo Hospitalar Conceição (GHC) and the Ministry of Health. Among other activities an educational program (consisting of 45-minute daily classes) is given to the patient and his family. From 2004 to 2007 it could be seen a decrease from 7,5% to 2,7% in the diabetes related hospitalization concerning these patients. Clinical guidelines followed by the interdisciplinary ICD team will also be presented in this essay.

Day hospital versus inpatient management of uncomplicated vaso‐occlusive crises in children with sickle cell disease

Day hospital (DH) management for patients with sickle cell disease (SCD) experiencing uncomplicated vaso-occlusive pain crises has been utilized as an alternative care delivery system to inpatient hospitalization. The objective of this study was to determine whether DH management results in shorter length of stay compared to inpatient care. We conducted a retrospective cohort study with 35 DH admissions and 35 inpatient admissions for children with SCD presenting with uncomplicated vaso-occlusive crises (VOCs). A DH admission was defined as a minimum of two consecutive days of aggressive pain management as an outpatient, including intravenous hydration and analgesics, supported by home treatment over night with oral analgesic and anti-inflammatory agents. We gathered data on demographics, pain scores, length of stay, admission charges, and needs for persistent care. DH care resulted in a 39% reduction of the average length of stay compared to inpatient admissions. Multivariate linear regression demonstrated that the location of patient care for VOCs was a significant predictor of length of stay (P < 0.0006) after controlling for patient characteristics, severity of illness, and disease history. We conclude that a dedicated DH facility has the potential to provide efficient and timely management of uncomplicated VOCs through reduction of length of stay. This delivery care system may be particularly relevant for children who are significantly impacted by inpatient hospitalization.

Smoking-attributable morbidity: acute care hospital diagnoses and days of treatment in Canada, 2002

BackgroundSmoking is one of the most important risk factors for burden of disease. Our objective was to estimate the number of hospital diagnoses and days of treatment attributable to smoking for Canada, 2002.MethodsDistribution of exposure was taken from a major national survey of Canada, the Canadian Community Health Survey. For chronic diseases, risk relations were taken from the published literature and combined with exposure to calculate age- and sex-specific smoking-attributable fractions (SAFs). For fire deaths, SAFs were taken directly from available statistics. Information on morbidity, with cause of illness coded according to the International Classification of Diseases version 10, was obtained from the Canadian Institute for Health Information.ResultsFor Canada in 2002, 339,179 of all hospital diagnoses were estimated to be attributable to smoking and 2,210,155 acute care hospital days. Ischaemic heart disease was the largest single category in terms of hospital days accounting for 21 percent, followed by lung cancer at 9 percent. Smoking-attributable acute care hospital days cost over $2.5 billion in Canada in 2002.ConclusionSince the last major project produced estimates of this type, the rate of hospital days per 100,000 population has decreased by 33.8 percent. Several possible factors may have contributed to the decline in the rate of smoking-attributable hospital days: a drop in smoking prevalence, a decline in overall hospital days, and a shift in distribution of disease categories. Smoking remains a significant health, social, and economic burden in Canada.