Specialist Hospital Care Research Articles

Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: a retrospective service evaluation

BackgroundUK “Pathway” teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet “homelessness” is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless.MethodsRetrospective analysis of patients referred to “Pathway” homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected.ResultsA total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission.ConclusionsDisengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study.

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD. To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD. We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models. Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records. Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.

Association between parental hospital-treated somatic illnesses in childhood and later mental disorders among offspring up to early adulthood: An explorative study in the 1987 Finnish Birth Cohort.

Aims: Earlier studies on the associations between parental somatic illnesses and children's psychological wellbeing have focused on the most common somatic illnesses or on specific groups of illnesses. In this study, we aimed to systematically examine whether parental somatic illnesses, diagnosed during an offspring's childhood, are associated with later mental disorders of the offspring and, if so, identify which parental somatic illnesses in particular increase the likelihood for later mental disorders among the offspring. Methods: The 1987 Finnish Birth Cohort study yields longitudinal nationwide follow-up data that include a complete census of children born in a single year. Children have been followed over time through to the year 2012 using official registers maintained by the Finnish authorities. Parental diagnoses of specialised hospital inpatient care were identified from the Hospital Discharge Register after children's birth and followed up until the end of 1995. Children's psychiatric diagnoses from specialised hospital care were identified from the same register for the periods 1996/1998-2012. Logistic regression analyses were used to calculate sex-specific odds ratios for associations of mental disorders with maternal and paternal somatic illnesses using parental death, education, social assistance and psychiatric inpatient care as covariates. Results: Parental somatic illnesses during an offspring's childhood seem to increase the risk for later mental disorders. Several previously unreported somatic parental illnesses were found to be significantly associated with offspring's later mental health. Conclusions: Parental somatic illnesses should be considered as a significant adverse childhood life event, calling for preventive actions and child-centred support in adult healthcare.

Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care.

To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. Cross-sectional study. About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.

Costs And Effectiveness Of An Integrated Care Intervention For Muscle-Skeletal Diseases Transition From Primary Care To Specialized Hospital Care

Costs And Effectiveness Of An Integrated Care Intervention For Muscle-Skeletal Diseases Transition From Primary Care To Specialized Hospital Care

Quelle place pour une école dans un hôpital dans le cadre de soins associés au décrochage scolaire

BackgroundAlthough school dropout is not a psychiatric diagnosis, it is a frequent concern for child psychiatrists, and covers a variety of psychopathological situations. In addition, severe psychopathologies in adolescence also constitute a risk of school dropout, hence undermining the prognosis. Integrating care into the issue of dropping out of school seems like an interesting lead. Since 2008 we have reorganized the partnership between the specialized hospital care system and the detached school group in our hospital to meet these increasing demands. Here we propose to reevaluate the first 50 patients who benefited from this device, to assess their clinical situation at discharge (t1) and at 30 months (t2) and to explore the factors potentially associated with their reinsertion. MethodsSocio-demographic and clinical variables were retrospectively collected at t0 and t1. Regarding evaluation at t2, the data were obtained by telephone call. The retained criteria for reintegration at 30 months are: the resumption of schooling (classical, adapted, or medico-social type) or the existence of a professional activity. ResultsBetween 2008 and 2012, we received 52 subjects (36 boys, 69%) in the hospital's educational system in combination with consultation (n=20) or day hospitalization (n=32). They had miscellaneous psychopathological profiles. In total, 37 were pupils (71%) and the average period of school absence was 6.7 months. The average duration of care in the care plan was 4 months. At age 30 months, 34 subjects (65%) had school rehabilitation with significant overall clinical improvement (30% increase in EGF score). Only the existence of an educational measure at t0 and the clinical severity (CGI-S and EGF) at t1 was significantly associated with poor reinsertion at t2. ConclusionAdolescents at risk of dropping out of school have benefited from the system in terms of psychosocial adjustment and reintegration into school. Although psychopathological profiles were diverse, the only prognostic factor was the existence of a child protection measure.

Conditions for success in introducing telemedicine in diabetes foot care: a qualitative inquiry

BackgroundThe uptake of various telehealth technologies to deliver health care services at a distance is expanding; however more knowledge is needed to help understand vital components for success in using telehealth in different work settings. This study was part of a larger trial designed to investigate the effect of an interactive telemedicine platform. The platform consisted of a web based ulcer record linked to a mobile phone to provide care for people with diabetic foot ulcers in outpatient clinics in specialist hospital care in collaboration with primary health care. The aim of this qualitative study was to identify perceptions of health care professionals in different working settings with respect to facilitators to engagement and participation in the application of telemedicine.MethodsTen focus groups were conducted with health care professionals and leaders in Western Norway between January 2014 and June 2015 using Interpretive Description, an applied qualitative research strategy.ResultsFour key conditions for success in using telemedicine as a new technology in diabetes foot care were identified: technology and training that were user-friendly; having a telemedicine champion in the work setting; the support of committed and responsible leaders; and effective communication channels at the organizational level.ConclusionsSuccessful larger scale implementation of telemedicine must involve consideration of complex contextual and organizational factors associated with different work settings. This form of new care technology in diabetes foot care often involves health care professionals working across different settings with different management systems and organizational cultures. Therefore, attention to the distinct needs of each staff group seems an essential condition for effective implementation.

Accessibility Intra-centres Group of the Integrated Health Care Area of Left Barcelona

Introduction : In a city like Barcelona, due in part to the diversity of providers and organizations that offer services to the population, we discovered an ongoing lack of coordination and monitoring of the patient once he/she has entered the system. This environment justifies the creation of the Integrated Healthcare Areas (IHA), a project of the Health Consortium and healthcare providers in the territory, the main aim of which is to improve healthcare in Barcelona City. There are four IHAs, defined in the setting of inter-institutional conferences in December 2006, with the presence and consensus of leading authorities and health agents: North, Left, Right and Coast. Ours is the project of Left Barcelona, and our mission is to provide the population with comprehensive healthcare, within territorial Left Barcelona, through the effective coordination of the health service entities and their professionals. The Integrated Health Care Area of Left Barcelona (IHALB) is a wide territory in terms of population that includes almost 1/3 of the whole of Barcelona (4 districts and 19 Basic Health Units) and complex in terms of volume of providers involved (Hospitals, Primary Care, Paediatrics, Mental Health and Social Services). In 2013, the Accessibility Intra-centres Group was born, with the aim of: - Agreeing and standardizing circuits involving different levels of care and providers. - Analyzing and sharing the operation of the different units (admissions, citizen care, invoicing) of each entity which reveals the implications of our errors / malfunctions. - Sharing the information that each provider receives and the level of care in the territory. Often information is according to attendance levels. - Analyzing gaps in circuits and establishing methods of rapid problem-solving. - Identifying key parties in the care process to avoid unnecessary travelling for the citizen. Short description of practice change implemented : The working group is made up of professionals specializing in the field of customer care, both primary care and hospitals, in the aforementioned region. The area of activity is Left Barcelona with a population of 520.581 inhabitants The objectives of the group are: - To establish communication channels and coordination between the different units of admissions / Citizen care, of the different providers of IHALB. - To establish circuits which facilitate referrals without the intervention of the patient as a messenger, and to make the process of referrals less bureaucratic. - To display and share information received from CatSalut (Insurance of Public Services in Catalonia). Key findings : During almost two years of work, we obtained the following results and documents, which have had an impact on the entire population of reference: - Information to citizens from other regions when they are referred from primary care to the hospital: Production of a leaflet for citizens of other regions of Spain linked with the process of identification and invoicing between communities when they require scheduling of appointments in specialized hospital care. - Identification of key players in the process of referral and invoicing. - Management of rehabilitation requests initiated in the hospital without the necessity for a new visit at primary care level: establishing referral circuits from primary care. - Eliminating the figure of the ‘messenger patient’ with the use of ICT tools: information can be shared between professionals by way of various digital platforms. - Registering the group on the IHA website. - Registering the group on e-Catalonia. - Accessibility of groups at risk of social exclusion, or protected groups (children/pregnant women). Highlights : When the difficulties faced by all parties involved are pooled regarding information, processing, interpretation of data and the problems that our patients have in navigating our healthcare system, we realize that we all share the same difficulties and by tackling them together we get better results that benefit both the community and the centers. This results in an optimization of time and resources while contributing to reducing the bureaucracy of healthcare processes. The fact of establishing joint and agreed circuits means that we all speak the same language and that the information we give our clients is consistent and facilitative. Conclusion : At the group’s beginnings, and as a starting point, relationships between different providers were improved and circuits were made more effective. However, shortcomings were detected in communication and information. Two years later, we are focusing on more specific areas, improving the detection of problems and unifying criteria regarding the relationship between providers and citizens and also amongst ourselves. In AISBE we put the citizen at the core of what we do. We aim to avoid the bureaucracy of administrative activities that have little added value, the circuits and the care continuum in order to increase the quality of the citizen’s experience.

Neonatal Psychology: Theories and Practice

Não se aplica

Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda's National Referral Hospital.

To identify reasons for neonatal admission and death with the aim of determining areas needing improvement. A retrospective chart review was conducted on records for neonates admitted to Mulago National Referral Hospital Special Care Baby Unit (SCBU) from 1(st) November 2013 to 31(st) January 2014. Final diagnosis was generated after analyzing sequence of clinical course by 2 paediatricians. A total of 1192 neonates were admitted. Majority 83.3% were in-born. Main reasons for admissions were prematurity (37.7%) and low APGAR (27.9%).Overall mortality was 22.1% (Out-born 33.6%; in born 19.8%). Half (52%) of these deaths occurred in the first 24 hours of admission. Major contributors to mortality were prematurity with hypothermia and respiratory distress (33.7%) followed by birth asphyxia with HIE grade III (24.6%) and presumed sepsis (8.7%). Majority of stable at risk neonates 318/330 (i.e. low APGAR or prematurity without comorbidity) survived. Factors independently associated with death included gestational age <30 weeks (p 0.002), birth weight <1500g (p 0.007) and a 5 minute APGAR score of < 7 (p 0.001). Neither place of birth nor delayed and after hour admissions were independently associated with mortality. Mortality rate in SCBU is high. Prematurity and its complications were major contributors to mortality. The management of hypothermia and respiratory distress needs scaling up. A step down unit for monitoring stable at risk neonates is needed in order to decongest SCBU.

Prevalence and immediate outcome of candida colonized preterm neonates admitted to Special Care Unit of Mulago Hospital, Kampala Uganda.

Candida species is the third commonest cause of sepsis among neonates. Colonization by Candida is a predictor for candidemia among preterm neonates. To determine prevalence of early Candida colonization and early outcome among colonized preterm neonates admitted to Mulago hospital Special Care Unit. A prospective observational cohort was conducted between December 2008 and April 2009. Preterm neonates aged >72 hours and less than one week were screened for Candida colonization of the groin, oral pharynx and rectum using CHROMagar. Colonized neonates were followed up for 14 days. Blood cultures were done for those with signs of septicaemia. The Fisher's exact tests and logistic regression were conducted for factors associated with colonization and mortality among colonized neonates. P values of < 0.05 were considered significant and confidence interval of 95% was used. Candida colonization occurred in 50/213 (23.5%) neonates. Gestational age ≤ 30 weeks was the only factor independently associated with colonization (p = 0.005). Of the colonized 14/46 (30.4%) died and 13/46 (28.3%) developed mucocutaneous candidiasis. No candidemia was identified. Multiple site colonization was independently associated with mortality (p=0.035). The consequence of high colonization observed in this study needs to be further elucidated in Uganda.

Has socioeconomic equity increased in somatic specialist care: a register-based cohort study from Finland in 1995–2010

BackgroundEqual access to health care according to need is an important goal for health policy in Finland. Earlier research in Finland and elsewhere has mainly been cross-sectional, but the results have implied that the goal has not been fully realised in somatic specialist hospital care. This study examines trends in socioeconomic equity in use of somatic specialist hospital care.MethodsWe used register data on somatic specialist hospital admissions among 25–84 year-old persons in Finland in 1995–2010 with individually linked register-based socio-demographic information. We calculated age-standardised admission rates per 100,000 person years by income, examined risk ratios using Poisson regression models and computed concentration indices separately for men and women. Linear trends in the socioeconomic distribution of admissions and surgical procedures were estimated with linear regression models for annual concentration indices.ResultsOverall, use of somatic specialist hospital care decreased steadily throughout the study period. A stepwise inverse income pattern was found in hospitalisation risk and in non-surgical admissions: the lower the income group, the higher the risk. The relative admission risk was approximately two times higher in the lowest income group compared to the highest among both genders. Few differences were found in surgical admissions. Income group differences remained stable in hospitalisations and surgical admissions, but increased in non-surgical admissions during the study period. An inverse pattern of increasing operation rates with decreasing income was found in primary hip and knee replacement operations, and in lower limb amputations. A similar pattern emerged during the study period in coronary revascularisations. There were no differences were found in lumbar fusion or lumbar disc operations, prostatectomies or appendectomies. Income group differences in hysterectomies disappeared during the study period.ConclusionsWhile the results of the current study suggest that use of somatic specialist care declined in line with improving population health in 1995–2010, the increase of socioeconomic health differentials was only partly reflected in the distribution of somatic specialist hospital care. Further research is needed to evaluate the need to improve use and content of specialised hospital care among the low-income groups in order to improve equity in health care.

Specific social challenges for rare diseases: the French experience, 2005-2014

The first strategic Plan in the world with a comprehensive approach for rare diseases was implemented in France from 2005 to 2008, followed by a second Plan in 2011 [1]. The 1st Plan had one objective: ensuring equity in the access to diagnosis, treatment and provision of care. The Second Plan aims at improving patient’s and carers’ health and social care, as well as developing research and European and international cooperation. Among the major achievements of the 1st Plan was the designation and support of 131 National centres of expertise in University hospitals, coordinating networks of 500 centres of competence at regional level. One of the missions of those centres is the coordination with primary care, medical and social care. In the framework of the 1st Plan, pilot networks were created by two centres together with patient organisations and local professionals, and funded by the Regional Health Agencies of Pays de la Loire and Languedoc-Roussillon. It is now understood that the interface of centres of expertise with social services is essential, when taking care of severely disabling and rare diseases, to facilitate clinical research and clinical trials, prevent the burn-out of medical teams and the explosion of medical costs. Highly specialised hospital care is inefficient if patients do not access adapted schooling, employment, housing and social services at home. Without adapted support, they soon return to the hospital. Moreover, specialised social care is much cheaper than hospital care, and people have a better quality of life. Today the regrouping of existing centres of expertise, diagnosis and research laboratories, patient associations, social professionals and care networks is encouraged to share resources and tools and cover all rare diseases and patients with unclear diagnosis in the long term. Following a call for proposals in 2013, 20 to 25 disease networks are being identified and supported. Disease networks and clusters of centres of reference at regional level are encouraged to establish links with the local authorities in charge of the compensation of disabilities « Maisons Departementales des Personnes Handicapees (MDPH) », participate in workshops to improve the use of medical certificates, develop a common language and common evaluation tools. Following the creation of international codes for rare diseases, Orphanet is now assessing consequences of rare diseases on disabilities in daily life using WHO ICF-CY 2007, and developing disease specific fact sheets [2]. All rare diseases are not associated to rare disabilities [3]. However 65% of rare diseases are associated to multiple disabilities. People with complex dependency needs do not find adequate support in existing social services: they require pluridisciplinary evaluations, collaboration of different local services, existing centres of expertise and resource centres, and complex cases managers if available. Coordination and good will are not enough. Integration of all available health and social services is needed to support inclusive and continuous life trajectories.

PDB72 - The Cost of Specialized Hospital Care for Patients with Diabetic Foot Ulcers in Russia

PDB72 - The Cost of Specialized Hospital Care for Patients with Diabetic Foot Ulcers in Russia

Survival in systemic lupus erythematosus, 1995–2010. A prospective study in a Danish community

The objective of this paper is to investigate survival and causes of death in a Danish lupus population. Two hundred and fifteen SLE patients (94% Caucasians) were followed prospectively for up to 16 years. Thirty-eight patients died. Survival rate and causes of death were analysed. Overall standardized mortality ratio (SMR) was 2.2. Peak values were recorded for patients aged 20-29 (SMR 21.1). Cumulated survival rates at one, five, 10 and 15 years were 98.6%, 93.6%, 86.5% and 73.0%, respectively. The most common causes of death were cardiovascular events (32%), respiratory system disease (16%) and malignancies (13%). Deaths due to infections and active SLE were rare and predominated within the first seven years after diagnosis and before age 40, while cardiovascular deaths prevailed after 20 years' follow-up. This study shows that despite progress in lupus management, including direct access to specialized hospital care and increased use of hydroxychloroquine, mortality in lupus patients is still increased. Main causes of death were active disease and infections among the young and newly diagnosed, while cardiovascular deaths prevailed in longstanding disease.

Reducing neonatal mortality in India: critical role of access to emergency obstetric care.

BackgroundNeonatal mortality currently accounts for 41% of all global deaths among children below five years. Despite recording a 33% decline in neonatal deaths between 2000 and 2009, about 900,000 neonates died in India in 2009. The decline in neonatal mortality is slower than in the post-neonatal period, and neonatal mortality rates have increased as a proportion of under-five mortality rates. Neonatal mortality rates are higher among rural dwellers of India, who make up at least two-thirds of India's population. Identifying the factors influencing neonatal mortality will significantly improve child survival outcomes in India.MethodsOur analysis is based on household data from the nationally representative 2008 Indian District Level Household Survey (DLHS-3). We use probit regression techniques to analyse the links between neonatal mortality at the household level and households' access to health facilities. The probability of the child dying in the first month of birth is our dependent variable.ResultsWe found that 80% of neonatal deaths occurred within the first week of birth, and that the probability of neonatal mortality is significantly lower when the child's village is closer to the district hospital (DH), suggesting the critical importance of specialist hospital care in the prevention of newborn deaths. Neonatal deaths were lower in regions where emergency obstetric care was available at the District Hospitals. We also found that parental schooling and household wealth status improved neonatal survival outcomes.ConclusionsAddressing the main causes of neonatal deaths in India – preterm deliveries, asphyxia, and sepsis – requires adequacy of specialised workforce and facilities for delivery and neonatal intensive care and easy access by mothers and neonates. The slow decline in neonatal death rates reflects a limited attention to factors which contribute to neonatal deaths. The suboptimal quality and coverage of Emergency Obstetric Care facilities in India require urgent attention.

Evaluation of the frequency and obstetric risk factors associated with term neonatal admissions to special care units

Approximately 10-15% of term babies may require admission to neonatal special care units. This level of care is frequently an unexpected event for parents. To review the frequency and obstetric risk factors associated with the admission of term neonates to a tertiary hospital special care unit (SCN). All babies born ≥37-weeks gestation admitted to the SCN at King Edward Memorial Hospital between 2004 and 2006 were identified from the institutional maternity and neonatal databases. Maternal and obstetric factors were reviewed to identify potential predictors of admission to the SCN. During the study period, 1671 term neonates born to 1624 women were admitted to the SCN (14.4% of term deliveries). Neonatal intensive care unit admissions accounted for 10.6% of the term admissions. The most common reasons for SCN admission were respiratory complications (n=421, 25.2%), observation postresuscitation (n=402, 24.1%) and hypoglycaemia (n=152, 9.1%). Elective caesarean delivery was significantly associated with admission to the special care unit for respiratory complications compared with all other delivery modes (37 vs 23%, P<0.001), particularly if the birth occurred at <39-weeks gestation (38 vs 24%, P<0.001). In our population of women delivering at a tertiary maternity facility, approximately 1:8 term babies were admitted to the neonatal special care unit. Elective caesarean delivery was associated with a significant risk of admission for respiratory complications compared with other birth modes, especially when <39-weeks gestation.

Evidence-Based Community Stroke Rehabilitation

Survival after stroke initially can depend on the acute phase of specialist hospital care; however, the greatest impact on patient health and well-being is from the long-term consequences faced when stroke survivors leave the hospital. Optimal recovery requires the provision of coordinated specialist rehabilitation, not only in the early stages of returning home but also, usually, many months after the stroke. Delivery of stroke specialist care in the patient’s home is increasingly common, particularly as health services face the challenge of reducing costs and are moving care out of expensive hospitals. There is also evidence that rehabilitation in the home environment is more beneficial for patients.1,2 Cumulative research evidence reporting the benefits of a variety of rehabilitative interventions addressing the longer-term consequences of stroke has been summarized in excellent reviews on stroke rehabilitation.3–6 Complementing these are national guidelines from countries such as the United States, Australia, Canada, and the United Kingdom that provide comprehensive guidance on a wide range of treatments that clinicians should consider in the rehabilitation of stroke patients.7–10 These documents also deal with the general organization of services, from managing discharge from hospital to specialist rehabilitation services operating in the community and longer-term care. The purpose of this article is to combine information from research literature and guideline documents and to ask the question, what are the key issues when implementing evidence-based community services in practice? We focus on the need for specialist services for stroke patients once they leave the hospital and highlight tensions between the clinical desires to deliver tailored, complex interventions with the need for clear specifications for leaner services in a period of financial austerity. We identify some of the gaps in the research literature, particularly how to identify what the essential elements of …

¿Qué pacientes se benefician más de la atención geriátrica hospitalaria en opinión de los especialistas en Geriatría?

ObjectiveTo assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care. Material and methodsWe carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals. ResultsA total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents. ConclusionsCertain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.

Que nous apprend la cohorte SAFEs sur l’adaptation des filières de soins intra-hospitalières à la prise en charge des patients âgés ?

The ageing of the french population confronts our society with enormous challenges of which the adaptation and the organization of health and psychosocial cares to aged people. The SAFEs cohort analysis has led to better identify older inpatients that presented adverse outcomes during their hospitalization or after their hospital discharge. From the main results, a feature discussion concerning care models adaptation is proposed. This feature discussion highlights: the importance to rehabilitate functional disorders as soon as possible from the admission in the hospital environment; the negative impact playing by a fragmented and sometimes "over"-specialized hospital care system; the importance of the coordination in cares within and between hospital- and community-care models; the necessity for health care professionals to be better trained to geriatric medicine specificities. Therefore, with the double objective of both optimizing the use of the financial resources and to implement adapted and good quality cares, it is necessary to elaborate a real and concrete health policy specifically dedicated to co-morbid and disabled old adults. Such health policy will have to target the care networks as a whole and lead to specific and adequate financing assistances.