Management Of Complex Cases Research Articles

Phenotypes, genotypes, and the management of paroxysmal movement disorders.

A growing number of genes have been associated with classic and newly described paroxysmal movement disorders. Paroxysmal movement disorders share common mechanisms and clinical features with other neurological paroxysmal phenomena including epilepsy and migraine.

Management of complex and redo cases of pelvic fracture urethral injuries

ObjectivesPelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. MethodsOur centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995–2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. ResultsOver two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. ConclusionThe definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

Lichen planus in children

Abstract: Lichen Planus (LP) is a chronic, inflammatory disease of the skin and mucous membranes. It is more frequently seen in the middle-aged and elderly population but can be present in children, although this is relatively rare. This paper describes the presentation and management of lichen planus in children, illustrated by seven cases seen within the Paediatric Dentistry Unit. Dentists should be aware of the condition and understand when referral to a specialist centre is required and the need for multidisciplinary management of complex cases.CPD/Clinical Relevance: Although oral lichen planus is rare in children, it is important that dentists are able to identify its clinical presentation and abnormal changes to the oral mucosa, as well as being aware of possible local and systemic causes of the condition so that reassurance and correct management pathways can be implemented in primary care practice.

Concordancia entre la complejidad observada desde diferentes niveles asistenciales en pacientes crónicos complejos, con enfermedad avanzada o al final de la vida mediante un modelo de abordaje de la complejidad

ObjectiveTo ascertain the probable validity of a comprehensive complexity care model in the management and referral of complex cases by studying the agreement between complexities observed from different levels of care in complex chronic patients, advanced chronic patients and at the end of life, using this model as a tool. MethodsSource: PADES database (demographic and descriptive data) and opinion of the participants. Participants: the 3 referring (participating) professionals of each case (Primary Health Care [APS], Palliative Care Support Team [PADES], Specialist [ESP]). Variables: age, sex, patient typology (oncological, non-oncological), evolutionary or prognostic classification (chronic complex patient [PCC, advanced [PCA], end of life [PFV]). Model application: 1) detected complexity: clinical, psychoemotional, socio-familial, spiritual, ethical, and related to death; 2) degree of detected complexity: the highest complexity level achieved in the evaluated areas and 3) PADES intervention proposal: low complexity: occasional attention, medium: shared caring; high complexity: intense attention). Complexity detected and intensity of PADES intervention in each case according to APS, PADES, ESP: agreement analysis. Study: transversal observational in 2 phases (prospective and retrospective). Statisticians: Cohen's kappa index and χ2 (kappa comparison). Analysis: IBM SPSS v. 23 and Epidat v. 4.2. ResultsThe study encompassed 500 patients —prospective phase 248 and retrospective 252—, 54.3% women and 64.8%≥80 years. A 26.8% oncological, and 51.8% PCC, 26.4% PCA and 21.8% PFV. Complexity detected: medium/high, with an average of 3 areas affected by case (mainly clinical, psychoemotional, socio-familial, ethical). Agreement in the intervention intensity PADES with APS and ESP: kappa indices are good or very good (>0.80) at a global level, with both APS (kappa 0.92, 95% confidence interval: 0.89-0.95) as with ESP (kappa 0.83, 95% confidence interval: 0.78-0.87). This high agreement even improves with APS in the retrospective phase and is also maintained and is homogeneous when analyzed according to the typology and the prognostic classification of the patient. Only with ESP are there differences between categories, with P<0,0001 for all kappa presented. ConclusionThe highest agreement among observers in relation to the degree of support teams’ intervention according to the level of detected complexity suggests that this explored complexity model is adequate for the management and referral of complex cases, irrespective of the clinical typology (oncological or otherwise) and the patient's prognosis.

Complex case management to support disadvantaged jobseekers in Hungary

The paper presents a project based on the complex case management model aimed at improving the labour market position of permanently unemployed clients. The aim of the case management is to improve the employee skills and capabilities of the clients in order to assist them in getting a job on the open labor market. The model builds on fast, action-oriented interventions, and the principle of the voluntary participation of clients. The process is time-limited, which the goal of reaching certain developmental objectives during a defined time period. We present a case study as an example of this model.

Managing High-Cost Healthcare Users: The International Search for Effective Evidence-Supported Strategies.

High-cost healthcare users (HCUs) are a small proportion of the population who use a disproportionate amount of healthcare resources. Although the phenomenon occurs across the entire age spectrum, older adults represent the majority of HCUs. HCUs have drawn increasing attention internationally from clinicians, health policy-makers, and government administrators. Many experts have suggested that the short- and long-term sustainability of the healthcare system is threatened unless current approaches to the care and healthcare costs of this population are modified. Complex case management and care coordination models are being implemented internationally to address HCUs despite a lack of strong evidence to support their effectiveness in improving clinical outcomes or savings in costs of care. We review what is known about HCUs and the available evidence for the effectiveness of interventions designed to manage their high and costly healthcare use.

Evaluating the traditional day and night shift in an acute care surgery fellowship: Is the swing shift a better choice?

Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day. We reviewed 10 years (2007-2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant. During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays. Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration of swing shifts into the schedule. Daily trauma volume follows a temporal pattern which, when used correctly, can increase trainee exposure to complex and operative trauma cases. We encourage other centers to analyze their volume and adjust trainee schedules accordingly to maximize their educational experience. Therapeutic study, level IV.

Treatment Phasing: A Simplified Approach for Complex Case Management

Treatment Phasing: A Simplified Approach for Complex Case Management

Tracheoesophageal fistula in sibilings - A rare occurence

Introduction Esophageal atresia is one of the most common congenital malformations occurring in 1 in every 2000-4000 live births. Previously considered to be a fatal condition, it has now become an eminently treatable condition with survival limited only by the presence or absence of major cardiac malformations. For the majority of families, the condition is unique to one child which in itself is challenging. It is extremely rare to affect more than one sibling in any family. The risk of recurrence is 0.5-2% and rises to 20% if another sibling is affected. Case description We report on two siblings, born two years apart with Type C TOF who were treated at King Hamad University Hospital, Bahrain. The first sibling was born with a short gap esophageal atresia with a distal fistula and repaired shortly after birth in another institution. The second sibling was born with a more challenging long gap esophageal atresia also with a distal fistula. The fistula was ligated on the second day of life and a gastrostomy tube put in place for feeding; repair of the atresia took place 2 months later. Both patients underwent serial dilatations to overcome strictures but are both tolerating oral diets. The third sibling in the family was unaffected with TOF or any VACTREL association. Conclusion The etiology of TOF is multifactorial with genetic, environmental and unknown components. There were no known environmental factors which could have contributed to this rare occurrence, but the only factor of significance is consanguinity of the parents who are first cousins. On the other hand, genetic factors are responsible for 12% of cases, these are classified as Chromosomal mutations, Syndromic or Isolated. These siblings do not fall into any of the mentioned categories and it is therefore speculated that this occurrence is due to a sporadic mutation. Take-home message Esophageal atresia with or without fistula is a fairly common condition encountered by paediatric surgeons on a daily basis. Despite increased experience and advancements in management of complex cases, the etiology remains a mystery. Future research should focus on more in-depth genetic studies on the impact of co-sanguinity on sibling TOFs.

Barriers in Case Managers' Roles: A Qualitative Systematic Review.

The challenges faced by case managers when implementing case management have received little focus. Several qualitative studies have been published that may be able to shed light on those challenges. This study is a systematic review of qualitative literature to identify barriers case managers have when implementing case management. Five electronic bibliographic databases were systematically searched, and 10 qualitative studies were identified for inclusion in the review which were published from 2007 to 2016. Through thematic synthesis of findings, five themes were identified as barriers to case management implementation: unclear scope of practice, diverse and complex case management activities, insufficient training, poor collaboration with other health-care providers, and client relationship challenges. This review study suggested that standardized evidence-based practical protocols and certification programs may help overcome case managers' barriers and improve case management practices. Health policymakers, case management associations, and health-care management researchers should develop educational and practical supports for case managers.

Metabolic clinic for individuals with HIV/AIDS: a commitment and vision to the future of HIV services.

One of the biggest current challenges in managing an ageing cohort living with the HIV is handling dyslipidaemia, diabetes, metabolic syndrome and nonalcoholic fatty liver disease. Combination antiretroviral therapy decrease mortality and morbidity in HIV patients, but lead to increase in insulin resistance, dyslipidaemia, abnormalities of fat distribution and high risk of cardiovascular disease. Therefore, a metabolic clinic was established for individuals living with HIV in the Milton Keynes University Hospital NHS Foundation Trust. The clinic meets considerable demands by service users and hence has the potential to be popular. This review focuses on the importance of the development of a metabolic clinic for the purpose of audit, research, teaching and exchange of knowledge between HIV specialists and the metabolic team in the management of complex cases. Therefore, the metabolic clinic should be an integral part of HIV services especially as the cohort of the 'older' HIV population increases.

Management of high velocity and high-energy blast Injuries to the maxillofacial region at Nasserr Institute

Management of gunshot injuries to the face remains a cornerstone of the specialty of oral and maxillofacial surgery. Since the events of January 2011, the number of firearm related injuries has increased in Egypt, which was not the case since October 1973; this represented a challenge to both residents and experienced surgeons, owing to the complex nature of these injuries. The major types of gunshot injuries are blasts, either low order or high order explosives, high velocity and low velocity injuries. The severity of the injury depends on velocity, type of bullet and distance, resulting wounds could be penetrating, perforating or avulsive. The timing, sequence and prioritization of treatment remains the main areas of concern in the management of such complex cases. The following is the experience of the Maxillofacial Department at Nasser Institute in management of high velocity and high-energy blast Injuries to the maxillofacial region.18 cases of Maxillofacial gunshot injuries were admitted to Nasserr institute between January 2011 and October 2012 which was a time of street disturbances in Egypt, only nine patients met the criteria of selection suffering from high velocity injuries were included. Upon arrival, all patients underwent a primary survey and extensive clinical and radiographic examination, accordingly a treatment plan was set for each patient and surgical intervention there after according to the protocol we present. Based on our results and treatment outcome for all patients, we conclude that triaging gunshot injuries to a prepared trauma center, following a well-tailored protocol and the use of computer aided surgical simulation is an integral part to perfect the functional and esthetic outcome and treatment.

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Starfield and colleagues have suggested four overarching attributes of good primary care: “first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere.” As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

Surgical management of complex residual masses following systemic chemotherapy for metastatic testicular germ cell tumours

Post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) represents the treatment of choice in patients with residual masses following chemotherapy for metastatic germ cell tumours. Involvement of major retroperitoneal vessels or thoracic/lumbar spine is rare and challenging but needs complete resection for curative intent. We report on our experience in the management of such complex cases. A total of 185 patients underwent PC-RPLND and we identified 25 (13.5%) patients who needed complex adjunctive vascular (n = 16, 8.6%), skeletal (n = 5, 2.7%) and pancreaticoduodenal (n = 4, 2.2%) surgeries. We performed a retrospective analysis of treatment-associated complications according to the Clavien-Dindo classification. Progression-free, cancer-specific and overall survival was calculated. All patients were of intermediate/poor prognosis according to IGCCCG. Median tumour diameter at time of surgery was 18.6 (9.0-35) cm. Sixteen (8.6%) underwent vascular surgery including aortic resection and replacement, complete or partial resection of the inferior vena cava with thrombectomy, and resection and replacement of the iliac vessels. In five patients, 1-2 metastatic lumbar vertebral bodies were resected, stabilized and replaced. Four patients underwent en-bloc resection of a suprahilar mass with pancreas and duodenum. Pathohistology revealed vital cancer in five patients; teratoma and malignant somatic transformation was identified in 12 and 6 patients, respectively. Complications occurred more often in the group of complex RPLND (41.7 versus 7.2%, P = 0.02) with the majority representing grade I-IIa. After a median follow-up of 28.5 months, four patients developed recurrent disease and one patient died of the disease. Few patients with advanced GCT need complex vascular, skeletal or intestinal surgery in an interdisciplinary setting with good functional and oncological outcome. Due to the complexity, treatment should be performed at specialized centres.

The virtual fracture clinic: Reducing unnecessary review of clavicle fractures

IntroductionWe re-designed the outpatient management of trauma at our institution to eliminate appointments if there would be no change in management or information provision. All cases referred by the Emergency Department (ED) were reviewed at a Virtual Fracture Clinic (VFC) by an orthopaedic consultant and telephoned afterwards by a senior nurse. If face-to-face review was required, it was arranged at a specialist shoulder clinic. AimsThe primary aim of this study was to evaluate the proportion of clavicle fractures that could be discharged without physical review. The secondary aim was to assess the patient reported functional outcome and satisfaction among patients who were discharged without further review. Patients and methodsA retrospective review was performed of patients who attended the ED with a clavicle fracture between October 2011 and September 2012. 138 patients were included. The number of patients who were discharged without a physical review was analysed. All radiographs were classified according to the Robinson classification. We recorded the number of undisplaced/minimally-displaced fractures that were discharged virtually. The number of patients with a displaced midshaft fracture who were seen at a specialist clinic was also recorded. A questionnaire was sent to all patients at one year post-injury to evaluate their outcome (QuickDASH and EQ-5D) and satisfaction with the new service. Results62/138 (45%) were directly discharged from the VFC. The majority of virtual discharges occurred in the undisplaced fracture types (84% versus 13%, RR 6.4, 95% CI 3.5–11.5). 78% patients responded to the questionnaires. 91% of patients were satisfied with their recovery from the injury. 86.4% patients were satisfied with the information provided regarding their treatment. In the virtually discharged group the mean EQ-5D VAS was 78.1 (EQ5D range 0.06–1, SD 0.248). The mean Quick DASH score was 16.1(SD 25.2). ConclusionsVirtual discharge of undisplaced clavicle fractures is appropriate and results in acceptable clinical outcomes and patient satisfaction. This redesigned process has significant benefits for patients as there were far fewer hospital visits by avoiding unnecessary appointments. The orthopaedic service also benefited by having more time available for the management of complex cases.

OA14.03 Integrating Therapies into a Specialist Lung Cancer Nursing Team: An Evaluation

A diagnosis of advanced lung cancer inevitably results in deterioration in both health and functional status. This threatens a person’s independence and dignity and can be a burden to their family and carers. The lung cancer nursing team at Oxford identified a lack of timely therapy provision for their patient group and sought to improve this, concluding that having an occupational therapist (OT) in the team would significantly expand/diversify the service that could be offered to patients. Lung cancer therapy goals were identified as a) working with patients and carers to anticipate functional need rather than waiting for a crisis to occur b) providing a rapid, flexible and responsive service to those with existing needs and c) working in a keyworker role outside of traditional therapy expertise supporting patients at diagnosis, making treatment decisions and providing information. Funding was obtained from Macmillan Cancer Support for a three year project looking at delivering a new model of care. An Advanced Therapist Practitioner (ATP) with an OT background was recruited and embedded into the nursing team full time. Referrals were received from all members of the lung cancer MDT, the inpatient team, primary and palliative care. Interventions included home assessment, outpatient clinic review, breathlessness and anxiety management, provision of aids, support, education and advice. Data was gathered from a one year period when there were 305 new lung cancer diagnoses. 165 (54%) patients had identified therapy needs. A further 40 (13%) patients were seen by the ATP as part of her generic keyworker role. 205 referrals resulted in a total of 1005 interventions averaging 5 per person. Interventions were allocated to three levels ranging from simple telephone calls and liaison to complex case management. Average time from referral to first contact with the patient was half a day. The value of the role was measured in three ways: User Feedback Event, Satisfaction Questionnaire and a Stakeholder Questionnaire. Outcomes were overwhelmingly positive. Lung cancer patients have high functional needs. An ATP can become an integral part of traditional specialist nursing teams, is able to work in a keyworker capacity and is well accepted and used by the lung cancer MDT. The ATP role provides a strong bridge between primary and secondary care environments and preserves independence and dignity for longer. Evidence from users and stakeholders demonstrated high levels of satisfaction and quality of care.

Multi-morbidity as a driver of high cost, high resource utilisation and future risk

Introduction : Key health policy imperatives within the National Health Service (NHS) in England over recent years have seen an increase in the use of risk stratification tools and case finding activities, particularly in relation to identifying individuals at risk of unplanned admission to hospital. A common belief is that those at risk of emergency admission are a homogenous group, generally elderly, frail, multi-morbid and have had a high degree of hospital use in the past. This work illustrates that this is not the case and that there is a need to do more than just use a risk stratification algorithm to identify high risk patients - there is a benefit in using integrated data sets and analytical techniques to gain greater insight into what drives risk and identifying the different types of individuals within the high risk category. Method : An exercise was undertaken within Slough Clinical Commissioning Group (CCG) in Berkshire to profile the whole population (c. 150,000 individuals). A data set combining primary and secondary care records that contained data relating to all diagnoses, degree of morbidity burden, risk of future adverse events (e.g. hospitalisation, high cost) and prior activity and cost was used. The analysis focused on relationships and correlations between variables such as age, multi-morbidity, frailty and presence of specific diseases and prior cost and future risk of adverse outcomes. Results : Results will be shared that have provided the CCG and GPs with a new understanding about the key drivers of cost and how the overlap between different at-risk groups is not as large as the CCG first thought. A key finding is that multi-morbidity rather than age is the key driver of prior cost and future risk. The analysis has also revealed new insights for the CCG including: - Multi-morbidity is the norm – it is more common for people to have multiple chronic conditions than to have just one. - Multi-morbidity is not distributed evenly across a population - case-mix varies quite significantly between GP practices. - Multi-morbidity occurs in the whole of the adult population, not just in the elderly. - Multi-morbidity rather than individual diseases such as diabetes or COPD significantly increase future risk. Discussion : There has been a focus within the NHS on preventing unplanned admissions to hospital and the principle use of risk stratification tools and case finding techniques has been to identify people at risk of this adverse outcome. However, the analysis undertaken in Slough CCG raises a number of interesting issues which include: - 40% of high cost patients do not have an emergency admission. - High cost individuals occur across all of the adult population not just in the elderly. - Frail elderly patients only represent a small proportion of those who are going to be high cost or are at risk on an emergency admission. - People with certain diseases are more expensive to treat than others but cost and risk increase significantly in people with certain co-morbidity combinations. As a result of this, Slough CCG and GPs have begun to focus on patients with multi-morbidity and to think about the management of the totality of patients’ morbidity burden rather than managing individual diseases. They are also using this new intelligence to commissioning new services where there are gaps in provision. One example is a GP led service proactively managing 550 patients with certain disease combinations through a 6-month programme of care. Each patient will have an initial review by their GP and then a series of regular consultations aimed at managing them in a holistic way. Input and support will come from community based services, hospital based specialists and from the voluntary sector. This “Complex Case Management Service” is improving quality and reducing hospital use. Conclusion : Slough CCG will continue to focus on reducing emergency admissions, managing individual diseases and supporting the frail elderly as these will remain key national policy imperatives. However, as a result of this population profiling exercise they have a better appreciation of multi-morbidity as a key driver of cost and are now using this as a locus for their thinking, how services are provided and the case finding techniques to identify cohorts of people who may be amenable to particular care programmes.

Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria

ObjectiveTo determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. Material and methodA cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. ResultsThe prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5) ConclusionsThe prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management.

Vulnerable pregnant women in antenatal practice: Caregiver's perception of workload, associated burden and agreement with objective caseload, and the influence of a structured organisation of antenatal risk management

Introductionpregnancy care for vulnerable women is often perceived as a burden by caregivers as vulnerable clients require complex case management, additional time, and more often show adverse perinatal outcomes. Vulnerable clients bring about additional work strain for the caregiver, especially when the workload is high. We define client vulnerability as coexistence of psychopathology, psychosocial problems or substance use, together with features of deprivation. We investigated, as part of a national programme, whether the subjective caregiver's perception of workload and the objective registry-based caseload of vulnerable clients are in agreement, and whether a structured organisation of antenatal risk management reduces the burden associated with the perceived workload, in particular if the objective caseload is high. Methodswe combined three data sources: (1) at the unit level (i.e. midwifery practice, obstetric unit) interview data from caregivers, from which we derived a) the (subjective) caregiver's perception of workload, b) the associated burden and c) organisational structure of antenatal risk management, (2) at the unit level perinatal registry data, from which we derived a) unit characteristics and b) (objective) unit specific caseload, and (3) at the individual client level survey data collected during the first antenatal visit, from which the prevalence of vulnerable clients was derived. The study area was the South-West Netherlands (2.5 million inhabitants), containing areas with varying degrees of urbanisation and deprivation. Findingssixteen units had complete data on all measures. Generally, subjective workload and objective caseload were only weakly related, the relation being modified by the organisation of antenatal risk management. If the organisational structure of antenatal risk management was low, the experienced burden was high, even if the objective caseload was low. Highly structured antenatal risk management was associated with a medium to low burden. Discussionour observational study suggests that even a high caseload can be dealt with by structured antenatal risk management. A change from the current individual case-finding policies towards a more universal screen-like approach may thus benefit both the client and the caregiver.

Medicare Expenditures of Individuals with Alzheimer's Disease and Related Dementias or Mild Cognitive Impairment Before and After Diagnosis.

To characterize Medicare expenditure and usage trends in individuals with a coded diagnosis of Alzheimer's disease and related dementia (ADRD) or mild cognitive impairment (MCI) during the periods leading up to and after diagnosis. Retrospective observational cohort study. Five percent sample of the 2009 to 2013 Medicare claims files. Individuals newly diagnosed with ADRD (n = 25,916) or MCI (n = 2,784), each with a propensity-score matched control subject. Medicare expenditures and usage during the 24 months before and after a new diagnosis of ADRD or MCI. Medicare expenditures were 42% higher in participants with ADRD ($10,622 vs $15,091, P < .001) and 41% higher in those with MCI ($9,728 vs $13,691, P < .001) during the year before diagnosis than in matched controls. Medicare expenditures of participants with ADRD increased to $27,126 for the first 12 months immediately after diagnosis and decreased to $17,257 during the 12 months after that. For participants with MCI, average Medicare expenditures were $20,386 for the 12 months after diagnosis and $14,286 for the 12 months after that. Use of inpatient care, postacute skilled nursing facility care, and home health care increased substantially after diagnosis of ADRD or MCI. Participants with ADRD and MCI incurred significantly higher Medicare expenditures than matched controls, even before they received a formal diagnosis. Medicare expenditures of individuals with ADRD and MCI may start to increase at least 12 months before their diagnosis, peak during the first few months immediately after diagnosis, and decrease afterward but remain at a higher level than before diagnosis. These findings highlight the importance of early diagnosis and indicate the need for complex case management to coordinate care transitions for individuals with ADRD and MCI.