Hospital-based Model Research Articles

Progress on China' s national free antiretroviral therapy strategy in 2002-2014

To analyze the progress and characteristics of China' s "Free AIDS treatment strategy" since the implementation of the national "four free and one care" policy against AIDS 12 years ago. Retrospective cohort study and cross-sectional analysis had been conducted in this study. 368 449 cases that had received the ' free antiviral therapy' from 2002 to 2014 were selected from the National Treatment Database. Data from the baseline (initial time of ART, CD(4) cell count, and antiretroviral regimen) and from the follow-up program (dates and status of follow-up, CD(4) cell counts) were gathered and analysed by SAS 9.3. The number of cases that having received new treatment was increasing year by year, accounting for 75.4% of all the cases identified from 2010 to 2014. Constituent ratios of patients with baseline CD(4) cell count <200 cells/µl and clinical diagnosis of AIDS were decreasing from 81.0% in 2006 to 39.7 % in 2014. Status on drug optimization showed that: 3TC replaced DDI, EFV replaced NVP and TDF replaced D4T, making the utilization rates as 99.5%, 75.7%, and 60.6%, respectively, by 2014. Regions that were covered by the treatment accounted for 75.4% of all the counties/districts involved. The previous CDC-led AIDS treatment program and mode of management had been transferred to the hospital-based model. Proportion on the twice-CD(4)-testing model had been 75.2% since 2010, with the rate of virological detection increased from 70.8% in 2010 to 87.4% in 2014 and the virological unsuccessful testing rate decreased from 17.6% in 2010 to 11.8% in 2014. Among all the patients, the 1, 5 and 10 year survival rates appeared as 92.2%, 80.5% and 69.6%, respectively. For patients with baseline CD(4) cell counts as <50 cells/µl or >350 cells/µl, the corresponding survival rates showed as 81.6% , 69.9% , 60.9% and 97.9%, 89.8% , 81.0%, respectively. China' s HIV/AIDS free antiretroviral therapy program appeared as a national treatment cohort which involved large number of participants, with new patients joining in, annually. Criterion on drug optimization and treatment were consistently following the recommendation and guidelines set by WHO. Management program on treatment had gradually turned to hospital-based, with follow-up and laboratory testing programs guaranteed, ended up with satisfactory treatment effects.

Jacob Chose Hospice: A Critique of Invasive End-of-Life Care

Jacob Chose Hospice: A Critique of Invasive End-of-Life Care

We have to flap our wings or fall to the ground : the experiences of medical students on a longitudinal integrated clinical model

Background: In 2011, Stellenbosch University introduced a district hospital-based longitudinal integrated model for final-year students as part of its rural clinical school. The present study is an analysis of students’ experiences during the first 3 years of the programme. Methods: All 13 students who started the programme between 2011 and 2013 were interviewed. Thematic networks linking recurrent issues were developed and transcripts were analysed against this framework using ATLAS.ti. Results: Two major themes emerged. These were ‘preparation for being a doctor’ and ‘academic/exam preparation’. Students were overwhelmingly positive about the working atmosphere and their preparation for clinical practice and felt that their learning had been facilitated by the flexibility of the programme and the requirement to take responsibility. This contrasted with their academic (‘book’) learning, which was characterised by uncertainty about expectations, particularly regarding exams and parity with learning at the central teaching hospital. The flexibility of the integrated approach was seen as a problematic lack of structure when it came to academic learning. Negative academic emotions were compounded by some frustration about administrative issues early in the programme. Conclusions: The district hospital-based longitudinal integrated model has great potential as a teaching platform for final-year students; however, students remain concerned about academic learning. Potential strategies to reduce student anxiety include more opportunities for dialogue between rural students and specialist teaching platforms, clearly communicated expectations – both about what the students can expect from the programme and about what is expected from them – and administrative excellence.

A novel antidoping and medical care delivery model at the 2nd Summer Youth Olympic Games (2014), Nanjing China

BackgroundAntidoping and medical care delivery programmes are required at all large international multisport events.ObjectiveTo document and critique the novel antidoping and medical care delivery models implemented at the 2nd Summer...

A single nucleotide polymorphism in the promoter region of let-7 family is associated with lung cancer risk in Chinese.

Lung cancer is a complex polygenic disease and many genetic factors are involved in the development of the disease. As one of the most important and widely studied families of microRNA, let-7 appears to play an important role in initiation and progression of lung cancer. Any small changes in miRNA level or its target point can cause significant changes in gene function. In this study, we examined whether a single-nucleotide polymorphism in the promoter region of the let-7 family (rs10877887) is associated with the susceptibility to and prognosis of lung adenocarcinoma cancer. A hospital-based case-control research model was used in our study. The single-nucleotide polymorphism was genotyped in 69 lung cancer patients and 75 healthy controls by direct sequencing. The correlation between rs10877887 genotypes and the susceptibility to lung cancer was evaluated using an unconditional logistic regression model. Populations with the CT+CC genotype had a significantly increased AC risk compared to those with the TT genotype (CT+CC vs TT: P = 0.043, OR = 2.032, 95%CI = 1.018-4.054). Furthermore, the risk effect was greater in subgroups of females over 60 years old (CT+CC vs TT: OR = 6.857, 95%CI = 1.425-33.008, P = 0.012), and the C allele were confirmed to be a risk factor related to lung cancer in these females (P = 0.012). The single-nucleotide polymorphism rs10877887 in the promoter region of the let-7 family was found to be responsible for the susceptibility to lung adenocarcinoma cancer in Chinese individuals. This association was significantly stronger in females who were more than 60 years old.

Knowledge and Attitude of 851 Nursing Personnel toward Depression in General Hospitals of Korea.

Our study aimed to examine the knowledge and attitude of nursing personnel toward depression in general hospitals of Korea. A total of 851 nursing personnel enrolled at four university-affiliated general hospitals completed self-report questionnaires. Chi-square tests were used to compare the knowledge and attitude of registered or assistant nurses toward depression. In addition, binary logistic regression analysis was used to adjust for the following confounders: age-group and workplace. Registered and assistant nurses differed in their knowledge and attitude toward depression. The proportion of rational and/or correct responses were higher in registered nurses than assistant nurses for the following: constellation of depressive symptoms defined by DSM-IV (adjusted odds ratio [aOR], 3.876; P<0.001); suicide risk in depression recovery (aOR, 3.223; P=0.001) and psychological stress as a cause of depression (aOR, 4.370; P<0.001); the relationship between chronic physical disease and depression (aOR, 8.984; P<0.001); and other items. Our results suggest that in terms of the biological model of depression, the understanding of registered nurses is greater than that of assistant nurses. Moreover, specific psychiatric education programs for nursing personnel need to be developed in Korea. Our findings can contribute to the development of a general hospital-based model for early detection of depression in patients with chronic medical diseases.

The Partners HealthCare Settlement and the Future of Health Care Organizations

Abstract A recent settlement between Massachusetts and Partners HealthCare, along with successful antitrust actions by the Federal Trade Commission, may signal the beginning of the end of two decades of consolidation of health care providers. This consolidation has been associated with higher prices resulting from market power, justifying the antitrust actions. However, the appropriate remedy for the health sector is a unique challenge. The proposed settlement appears to lock into place the legacy of the hospital-based delivery model, rather than orchestrating a pathway to a new care delivery models. Clearly, we need a regulatory framework that will introduce innovative alternatives into the market, not enshrine the current costly paradigm.

Efficient national surveillance for health-care-associated infections

BackgroundThe detection of novel health-care-associated infections as early as possible is an important public health priority. However, no evidence base exists to guide the design of efficient and reliable surveillance systems. Here we address this issue in the context of a novel pathogen spreading primarily between hospitals through the movement of patients. MethodsUsing hospital admission data from the year 2007, we modelled the spread of a pathogen among a network of hospitals connected by patient movements using a hospital-based susceptible-infectious model. We compared the existing surveillance system in Scotland with a gold standard (a putative optimal selection algorithm) to determine its efficiency and to see whether it is beneficial to alter the number and choice of hospitals in which to concentrate surveillance effort. FindingsWe validated our model by demonstrating that it accurately predicted the risk of meticillin-resistant cases of Staphylococcus aureus bacteraemia in hospitals in Scotland in 2007. Furthermore, the model predicted that relying solely on the 29 (out of 182) sentinel hospitals that currently contribute most of the national surveillance effort results in an average detection time (time until first appearance of the pathogen in a hospital) of 117 days. This detection time could be reduced to 87 days by optimal selection of the same number of hospitals. Alternatively, the same detection time (117 days) can be achieved with just 22 optimally selected hospitals. Increasing the number of sentinel hospitals to 38 (teaching and general hospitals) reduced detection time by 43 days; a decrease to seven sentinel hospitals (all teaching hospitals) increased detection time substantially to 268 days. InterpretationOur results show that the present surveillance system used in Scotland is not optimal in detecting novel pathogens compared with a gold standard. However, efficiency gains are possible by better choice of sentinel hospitals, or by increasing the number of hospitals involved in surveillance. Similar studies could be used elsewhere to inform the design and implementation of efficient national, hospital-based surveillance systems that achieve rapid detection of novel health-care-associated infections for minimum effort. FundingThis research received funding from the European Union Seventh Framework Programme (FP7-HEALTH-2011-single-stage): Evolution and Transfer of Antibiotic Resistance (EvoTAR).

Innovative hospital-based care model puts pharmacists on the team

Abstract is an 85-year-old patient in the Indiana, PA, area who has chronic obstructive pulmonary disease (COPD). He was in and out of the hospital multiple times because of his chronic condition until 2013, when he became part of an innovative model of care that brings together a small group of health professionals, including a pharmacist, who are dedicated to improving transitions of care and reducing readmissions. Once enrolled in the Primary Care Resource Center (PCRC) model at Indiana Regional Medical Center in Indiana, PA, Gregory received personalized medication counseling from Laura Muchesko, PharmD, a PCRC pharmacist. got connected with Laura when I was in the hospital, said Gregory. We went over my whole medication list - and I've got a big list.

Hospital-based expert model for health technology procurement planning in hospitals.

Although in the last years technology innovation in healthcare brought big improvements in care level and patient quality of life, hospital complexity and management cost became higher. For this reason, necessity of planning for medical equipment procurement within hospitals is getting more and more important in order to sustainable provide appropriate technology for both routine activity and innovative procedures. In order to support hospital decision makers for technology procurement planning, an expert model was designed as reported in the following paper. It combines the most widely used approaches for technology evaluation by taking into consideration Health Technology Assessment (HTA) and Medical Equipment Replacement Model (MERM). The designing phases include a first definition of prioritization algorithms, then the weighting process through experts' interviews and a final step for the model validation that included both statistical testing and comparison with real decisions. In conclusion, the designed model was able to provide a semi-automated tool that through the use of multidisciplinary information is able to prioritize different requests of technology acquisition in hospitals. Validation outcomes improved the model accuracy and created different "user profiles" according to the specific needs of decision makers.

Lower Mortality in Persons Infected with HIV Receiving Antiretroviral Treatment in a Hospital-Based Model: An Observational Cohort Study

ABSTRACT: Aim: Although the National Free Antiretroviral Treatment Program (NFATP) is effectively administered through a community-based treatment model in China, there are some limitations in this model. No-one has reported the outcomes of highly active antiretroviral therapy as part of a hospital-based HIV treatment model in China. Methods: This study was a retrospective analysis of mortality and viral responses in HIV-positive patients taking highly active antiretroviral therapy regimens in a cohort registered in Ditan Hospital, Beijing, China, the largest infectious disease hospital in North China. Results: This study demonstrated low mortality (3.4% of patients died in a median follow-up of 19 months, with a mortality of 1.7 per 100 person-years) from 2005 to 2010 in Ditan Hospital. In an adjusted Cox proportional hazards regression analysis, CD4 cell counts less than 50 cells/μl (adjusted hazard ratio of 5.95 [95% CI: 1.3–28.2]) was the strongest risk factor for death, and switching regimens during treatment was associated with lower risk of death. The study also demonstrated 93.4% of patients were adequate viral suppression, 3% were definite virologic failure, 2% were probable virologic failure and 1.3% were indeterminate. In logistic regression analysis, the strongest risk factors for inadequate viral suppression or failure were single, divorced or widowed (adjusted odds ratio: 4.2; 95% CI: 1.2–14.9) and baseline alanine aminotransferase &gt;100 U/l (adjusted odds ratio: 6.2; 95% CI: 1.5–26.1). Conclusion: The hospital-based HIV treatment model appeared to be successful in improving patient survival and should be considered as an important alternative to the community-based treatment models commonly applied in China.

Alternative models of cardiac rehabilitation: A systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

A Hospital Nursing Research Enhancement Model

Evidence-based practice is fundamental to nursing, yet there are many reports in the literature of the difficulty associated with incorporating research activity that leads to evidence-based practice into daily practice. This study used a hospital-based research enhancement model (HREM) to plan, develop, and implement a research outreach ward-based seminar (ROWS) program and evaluate its effectiveness as a means for nurses to increase their knowledge and capacity in research and evidence-based practice. A survey was used to collect both quantitative and qualitative data for evaluation of the program. A total of 78 evaluations were returned after ROWS attendance. Three main themes from the survey were explored. These include accessibility of research, appreciation and application of research, and training in research. The results suggested that nurses are interested in participating in research activities, including projects, best practice forums, journal clubs, and seminars. The HREM can address some common barriers to an evidence-based practice culture and the application of evidence-based practice within nursing.

A Systematic Review of the Effectiveness of Hospital- and Ambulatory-Based Management of Multidrug-Resistant Tuberculosis

A systematic review of the literature was conducted on the effectiveness of MDR-TB management. A meta-analysis of treatment outcomes of patients treated in hospitals versus ambulatory-based models was performed in accordance with PRISMA guidelines. The pooled treatment success rate was 66.4% (95% confidence interval [CI] 61.4-71.1%), with no statistical difference between ambulatory (65.5%; 55.1-74.6%) and hospital-based models (66.7%; 61.0-72.0%). The pooled death rate was 10.4% (6.3-16.5%), the pooled treatment failure rate was 9.5% (7.3-12.4%), and the defaulter rate was 14.3% (10.5-19.1%). None of the differences between the two models were statistically significant for any of the outcomes considered. This work improves the quality of the evidence available supporting the World Health Organizations (WHO) recommendation that patients be treated using mainly ambulatory care, conditional on infection control measures in the home and clinic, clinical condition of the patient, availability of treatment support to facilitate adherence to treatment, and provisions for backup facility to manage patients who need inpatient treatment care.

G176 The National Cancer Survivorship Initiative: A National Approach to Improve the Quality of Aftercare For Survivors of Childhood Cancer

AimsThe National Cancer Survivorship Initiative [NCSI] (a partnership between the Department of Health, NHS Improvement, third sector organisations and user representatives) was established to improve the care provided for patients...

Estimation of the contribution of private providers in tuberculosis case notification and treatment outcome in Pakistan

To improve involvement of the private sector in the national tuberculosis (TB) programme in Pakistan various public-private mix projects were set up between 2004 and 2009. A retrospective analysis of data was made to study 6 different public-private mix models for TB control in Pakistan and estimate the contribution of the various private providers to TB case notification and treatment outcome. The number of TB cases notified through the private sector increased significantly from 77 cases in 2004 to 37,656 in 2009. Among the models, the nongovernmental organization model made the greatest contribution to case notification (58.3%), followed by the hospital-based model (18.9%). Treatment success was highest for the district-led model (94.1%) and lowest for the hospital-based model (74.2%). The private sector made an important contribution to the national data through the various public-private mix projects. Issues of sustainability and the lack of treatment supporters are discussed as reasons for lack of success of some projects.

Resident Education Versus Fellowship Training—Conflict or Synergy?

The fundamental mission of graduate medical education is to train young professionals to become future practitioners and academicians. Orthopaedic surgery training programs are primarily directed toward resident education. The subspecialty training of fellows, however, is arguably equally important. Thus, two constituencies that may compete for educational experience, attention, and resources are inherent to many training programs. We developed a survey to explore this issue prior to a symposium on this topic presented at the American Orthopaedic Association (AOA) meeting in June of 2009. Questions concerning the relationship between resident and fellowship education were distributed to orthopaedic residents in their fourth postgraduate year (PGY-4) of training who attended the Resident Leadership Forum at the 2009 AOA meeting. Responses were obtained from seventy-seven resident participants, a number that represents 12% of the total PGY-4 orthopaedic residents in 2009. The same survey was distributed to orthopaedic surgery department chairs, program directors, and fellowship directors across the United States. One hundred sixty-nine of this “faculty” group responded, a number that was 41.6% of the possible total. In the nineteenth century, surgeons generally were self-trained or learned by way of an apprenticeship1. No formal system was in place and few surgeons spent more than one or two years in a hospital setting. In 1889, with the founding of The Johns Hopkins Hospital, Dr. William Halsted transformed surgical training from its loosely organized structure to a university-sponsored, hospital-based model with graduated responsibility that culminated in a period of near autonomy. Formalization of the qualifications requisite of surgical subspecialties soon followed, largely to assure the public of a specialist’s preparation and skill2. The American Board of Orthopaedic Surgery (ABOS) was incorporated on February 4, 1934, and gave its first certification examination in 19353. Oversight of board certification implied the need for …

PSU9 Budget Impact of Autograft Harvest, Bone Graft Supplements and Orthobiologic Bone Graft Substitute in Foot and Ankle Fusion Procedures

No multicenter studies currently assess the incremental costs of autogenous bone graft harvest (autograft) in foot and ankle procedures. This study applied conservatively estimated incremental costs of autograft (with and without bone graft supplements/enhancers) using an interactive budgetary impact model comparing costs and cost offsets of an orthobiologic bone graft substitute (β-TCP with recombinant human platelet-derived growth factor-BB [rhPDGF-BB]) in foot and ankle fusion procedures. A Canadian hospital-based budget impact model was developed utilizing International Society of Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. Clinical and health economic literature, data from a 434-patient randomized control trial and data from a panel of ten experienced orthopaedic surgeons provided estimates of medical resource utilization and associated hospital costs. Model parameters were confirmed by six individuals representing 15 Canadian hospitals. Autograft carries incremental costs related to operating suite time (37.9 ± 17.0 minutes for an iliac crest donor site and 22.1 ± 21.6 minutes for local donor sites), recovery room time (25.0 ± 12.3 minutes for iliac and 3.5 ± 9.4 minutes for local), and donor site complications. Conservative base case incremental costs were $1,601(CAD) for iliac crest and $755 (CAD) for local sites. Complications at the harvest site contributed an additional base case cost of $414 for iliac crest and $182 for local sites. Use of an orthobiologic bone graft substitute had higher acquisition costs, but yielded per-case and annualized cost savings ($34 and $2,454, respectively, base case) by eliminating incremental costs, graft harvest complications, and patient pain reported for autograft harvest during clinical trial. The gold standard of harvesting autogenous bone graft as an adjunct to foot and ankle fusion surgery is associated with significant health care costs. The use of β-TCP with rhPDGF-BB eliminated variable, incremental hospital costs associated with bone graft harvesting and treating related complications.

Treatment dropout of patients in National Continuing Management and Intervention Program for Psychoses in Guangdong Province from 2006 to 2009: Implication for mental health service reform in China

AbstractIntroductionIn 2005, China commenced its mental health reform by establishing a national program to move from a hospital‐based service model to an integrated hospital and community treatment model for psychoses, adopting the key principles of and provisions for continuity of care, treatment accessibility and equitable mental health care. This paper reports the rate and associated factors of treatment dropout for patients with psychoses in the national program in Guangdong Province from 2006 to 2009.MethodsAdult patients with psychoses followed‐up in two demonstration sites in Guangdong Province were grouped as treatment dropout if they were lost to follow‐up for three consecutive months. Dropout rate was estimated, and associated factors were explored with multifactor binary logistic regression analysis.ResultsOf 1,386 patients followed up from 2006 to 2009, 73 patients (5.29%) dropped out (five deceased patients were excluded). Poor adherence to medication, having no medication, and having worse global clinical outcome contributed to increased risk of dropout by 12.765 (P = 0.0017), 7.400 (P = 0.0063) and 6.385 times (P = 0.0207), respectively. When course of illness increased by five years, the risk of dropout increased by 1.322 times (P = 0.0031).DiscussionTreatment dropout rate for patients with psychoses in Guangdong Province appears to be low. Implications for mental health service reform in China include assertive follow‐up for patients with history of poor adherence with treatment, free medications to poor patients to increase access to appropriate and affordable treatment, and active psychoeducation for patients with poor insight and their families.

Mental health system in China: history, recent service reform and future challenges

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.