Optimal Level Of Care Research Articles

Developing a decision support system for patients with severe infection conditions in pre-hospital care

ObjectiveTo develop and validate a pre-hospital decision support system (DSS) for the emergency medical services (EMS), enabling the identification and steering of patients with critical infectious conditions (i.e., severe respiratory tract infections, severe central nervous system (CNS) infections, and sepsis) to a specialized emergency department (ED) for infectious diseases. MethodsThe development process involved four consecutive steps. The first step was gathering data from the electronic patient care record system (ePCR) on patients transported by the EMS, in order to identify retrospectively appropriate patient categories for steering. The second step was to let a group of medical experts give advice and suggestions for further development of the DSS. The third and fourth steps were the evaluation and validation, respectively, of the whole pre-hospital DSS in a pilot study. ResultsA pre-hospital decision support tool (DST) was developed for three medical conditions: severe respiratory infection, severe CNS infection, and sepsis. The pilot study included 72 patients, of whom 60% were triaged to a highly specialized emergency department (ED-Spec) with an attending infectious disease physician (ID physician). The results demonstrated that the pre-hospital emergency nurses (PENs) adhered to the DST in 66 of 72 patient cases (91.6%). For those patients steered to the ED-Spec, the assessment made by PENs and the ID physician at the ED was concordant in 94% of cases. ConclusionsThe development of a specific DSS aiming to identify patients with three different severe infectious diseases appears to give accurate decision support to PENs when steering patients to the optimal level of care.

A Decision support system (DSS) for municipal nurses encountering health deterioration among older people.

BackgroundThis study is part of a larger project called ViSam and includes testing of a decision support system developed and adapted for older people on the basis of M (R) ETTS (Rapid Emergency Triage and Treatment System). The system is designed to allow municipal nurses to determine the optimal level of care for older people whose health has deteriorated. This new system will allow more structured assessment, the patient should receive optimal care and improved data transmission to the next caregiver.MethodsThis study has an explanatory approach, commencing with quantitative data collection phase followed by qualitative data arising from focus group discussions over the RNs professional experience using the Decision Support system. Focus group discussions were performed to complement the quantitative data to get a more holistic view of the decision support system.ResultsUsing elements of the decision support system (vital parameters for saturation, pain and affected general health) together with the nurses' decision showed that 94 % of the older persons referred to hospital were ultimately hospitalized. Nurses felt that they worked more systematically, communicated more effectively with others and felt more professional when using the decision support system.ConclusionsThe results of this study showed that, with the help of a decision support system, the correct patients are sent to the Emergency Department from municipal home care. Unnecessary referrals of older patients that might lead to poorer health, decreased well-being and confusion can thus be avoided. Using the decision support system means that healthcare co-workers (nurses, ambulance/emergency department/district doctor/SOS alarm) begin to communicate more optimally. There is increased understanding leading to the risk of misinterpretation being reduced and the relationship between healthcare co-workers is improved. However, the decision support system requires more extensive testing in order to enhance the evidence base relating to the vital parameters among older people and the use of the decision support system.

An Argument for Change in Tobacco Treatment Options Guided by the ASAM Criteria for Patient Placement.

Tobacco use is a major threat to public health in the United States, and the number one cause of preventable death. Although most smokers try to quit unaided, robust data indicate that pairing behavioral support to US Food Drug Administration-approved cessation medications significantly increase cessation rates. Those who do receive assistance in quitting usually receive very low intensity treatment, regardless of the severity of their dependence or their medical and environmental circumstances. This is in stark contrast to how other substance use disorders are treated, where there are varying levels of care depending on addiction severity and biopsychosocial circumstances. The American Society of Addiction Medicine (ASAM) developed a formal algorithm for assessing substance use disorders and determining the optimal level of care. The ASAM Patient Placement Criteria are regularly used to determine the appropriate level of care for all substance use disorders except tobacco. This paper will review key aspects of the ASAM dimensions of care and placement levels, with emphasis on how they apply to tobacco use and present case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment. We also present current barriers to reimbursing healthcare providers for these services. We conclude with a commentary and discussion regarding recommendations for improvements in tobacco dependence treatment care.

The Benighted Hand Mechanism

This paper designs a mechanism that generalizes Judge Learned Hand’s negligence liability tests from his classic opinions in T. J. HOOPER (1932) and CARROLL TOWING (1947). The “Benighted Hand” mechanism incentivizes truthful reporting of the agents’ private costs of bilateral caretaking when agents also face different effectiveness of care and shares of injury costs. In “The Problem of Social Cost” (1960), Ronald Coase noted that Judges may not have the requisite knowledge of the costs of caretaking to determine the optimal level of care, but he and much of the subsequent literature simply treat this problem as a source of exogenous transaction costs. The mechanism design framework treats costs of obtaining private information endogenously, by incentivizing strategic agents to truthfully reveal their private information. The resulting liability schedule is efficient, but not generally compensatory. It allocates the full costs of accidents (including the costs of precaution) equally among the parties.

Development of the Pre-hospital Emergency Care, The Registered Nurses' Role in the Ambulance Service- A Swedish Perspective

In order to increase the medical competence in the ambulance service the National Board of Health and Welfare in Sweden stated in the year 2000 that every ambulance should be manned by at least one Registered Nurse (RN), and the rule entered into force in 2005. Now, nearly ten years have passed, and a question arises: how has the ambulance service and pre-hospital care developed since RNs became part of the ambulance service? Therefore the aim of this study was to explore how the ambulance services have developed since RNs became a part of the pre-hospital emergency care provided by the ambulance service. An explorative descriptive design was used. Data collection was carried out by a focus group interview and through a review of medical guidelines written by the medical directors and used in the years 1999, 2006 and 2015. A content analysis was conducted based on the collected data. The results shows how the pre-hospital emergency care has developed since RNs started to work in the ambulance service. The main areas of development concerned assessment of patients’ illness and injury, medical treatment, and steering to an optimal level of care, together creating conditions for care based on the individual patient needs. These findings may indicate an increasing independence in decision making among pre-hospital personnel after the RNs become a part of the ambulance service.

Learning-by-doing in torts: Liability and information about accident technology

In the economic analysis of liability law, information about accident risk and how it can be influenced by precautions is commonly taken for granted. However, a profound understanding of the relationship between care and accident risk often requires learning-by-doing. In a two-period model, we examine the implications for the optimal level of care and behavior under strict liability and negligence, showing that liability law may not induce efficient incentives.

Absence of Positive Results for Flexible Assertive Community Treatment. What is the next Approach?

Aims were to review results of the five psychiatric studies on Flexible Assertive Community Treatment (FACT) published during 2007-2013, and to compare FACT with Resource-group Assertive Community Treatment (RACT) which specifically focuses on empowerment and rehabilitation of clients in the stable phase. During 2007 articles appeared in scientific journals arguing in favor of the need for the development of the treatment method Assertive Community Treatment (ACT). A particularly notable article was one that featured a Dutch version of ACT, namely FACT. The initiative received great sympathy given that clinical practice and research showed that both American and British versions of ACT were in need of new impulses to be able to maintain an optimal level of care. Seven years have passed since the Dutch model was international presented and five empirical studies about FACT have been published and therefore a first critical examination of FACT was conducted. The review indicated that the five empirical studies failed to show that FACT involves improvement of the clients in terms of symptoms, functioning, or well-being. The conclusions were that at present there is no evidence for FACT and that RACT with its small, flexible ACT teams, where the client him/herself is included and decides on the treatment goals, might be able to provide new impulses and a new vitality to the treatment mode of an assertive community treatment.

Matching patients with substance use disorder to optimal level of care with the ASAM Criteria software

Great variation in assessment across Norwegian addiction programs necessitated a solution for harmonization. The American Society of Addiction Medicine (ASAM) Criteria Software is a computer-assisted structured interview and clinical decision support program. Using validated tools (e.g. Addiction Severity Index; ASI), it measures biopsychosocial conditions to match patients to an optimal level of care (LOC). Methods: This prospective, 10-site, double-blind study assessed a convenience sample of eligible treatment-seekers with substance use disorders in central Norway at intake (n = 261) and three months after naturalistic LOC placement (n = 153) on: (1) retention, (2) severity on seven ASI Composite Subscale Scores (controlling for differential dropout and baseline values) and (3) readiness for step-down care. Results: Retention differed significantly across groups and was lowest with under-matching vs. matching/over-matching (45% vs. 62% vs. 70%, p = 0.024). Matched patients reported less month-3 vs. baseline alcohol (p < 0.05) and cannabis (p < 0.05) use vs. no significant reductions with under-matching. ASI Composite Scores fell with matching on six of seven scales, two of seven with under-matching and three of seven with over-matching. Percent of patients per group ready to step-down to lower LOC was: 46% under-matched, 61% matched and 17% over-matched. Conclusions: Although more research is needed. The ASAM Criteria Software demonstrates predictive validity using all three prospectively planned measures.

Liability Standards with an Uncertain Outcome at Trial

We model a negligence standard where the defendant’s level of care is viewed with error by the judicial system. All cases are assumed to settle prior to trial, but the negotiated outcome reflects the expected outcome at trial. The policymaker may or may not be able to induce the optimal level of care on the part of the defendant. The optimal negligence standard bears no necessary relationship to the optimal level of care. As the standard of care rises to infinity, the outcome under the negligence standard approaches the outcome under strict liability. The level of care which may be achieved under the negligence standard is (asymptotically) at least as high as under strict liability and may be higher. Consequently, the level of social welfare under an optimally chosen negligence standard is at least as high as under strict liability and may possibly be higher. It should be noted, however, that if the defendant is made liable for the plaintiff’s pretrial legal costs, strict liability will induce the defendant to choose the optimal level of care.

Predictive and convergent validity of the ASAM criteria software in Norway

The ASAM Criteria Software from the American Society of Addiction Medicine is a new computer-assisted structured interview and clinical decision support program that implements validated tools such as the Addiction Severity Index (ASI), and measures biopsychosocial conditions to match patients to an optimal level of care (LOC). The study methods involved a prospective, double-blind, multi-site, naturalistic study of substance use disordered treatment seekers. We analyzed: (1) discrepancies in ASAM Criteria LOC recommendations versus Treatment-as-Usual (TAU), (2) the software's ability to clinically distinguish between patients with different LOC (convergent validity) and (3) predictive validity. Results indicated that the discrepancies in TAU LOC recommendations versus the Software were in line with previous research. Baseline comparisons using ASI Composite Subscale scores (CSs) showed better agreement with the ASAM LOC recommendations versus TAU. Finally, the ASAM recommendations were associated with better outcomes three months later for the matched versus mis-matched groups. These results confirmed the Software's convergent validity as well as predictive validity. These outcomes are promising and suggest that programs should avoid both under- and over-matching patients. Future, both national and international studies, should include the full complement of LOC specified in the ASAM Criteria, properly characterized, with larger samples.

Mental health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity.

Mental health promotion needs to be studied more deeply within the context of primary care, because persons with multiple chronic conditions are at risk of developing poor mental health. In order to make progress in the understanding of mental health promotion, the aim of this study was to describe the experiences of health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity – what these seniors believe is important for achieving a dialogue that may promote their mental health. Seven interviews with six women and one man, aged 83–96 years, were analyzed using qualitative content analysis. The results were summarized into nine subcategories and three categories. The underlying meaning of the text was formulated into an overarching theme that embraced every category, “perceived and well-managed as a unique individual”. These seniors with multimorbidity missed someone to talk to about their mental health, and needed partners that were accessible for health dialogues that could promote mental health. The participants missed friends and relatives to talk to and they (crucially) lacked health care or social service providers for health-promoting dialogues that may promote mental health. An optimal level of care can be achieved through involvement, continuity, and by providing a health-promoting dialogue based on seniors’ needs and wishes, with the remembrance that general health promotion also may promote mental health. Implications for clinical practice and further research are discussed.

Addressing Standards of Care in Resource-Limited Settings

: The choice between "best-known" standards of care (SOC) or "best available" standards as the control arm in a clinical trial is a fundamental dilemma in clinical research in resource-limited settings (RLS). When the health system is delivering less than an optimal level of care, using highest standard of care in a clinical trial may produce results that cannot be implemented or sustained locally. On the other hand, using interventions that are more feasible in the local setting may involve suboptimal care, and clinical outcomes may be affected. The need for improved standards in health systems in RLS, and the difficulty in securing them, has led many researchers advocate for policy changes at the national or international level to improve clinical care more systemically. SOC decisions in a clinical trial affect the level of benefit provided to study participants and the policy implications of the trial findings. SOC choices should provide high-quality care to help advance the health care system in host countries participating in the trial, but balancing the scientific and ethical objectives of SOC choices is difficult, and there is no single formula for selecting the appropriate SOC. Despite the challenges, well-designed and conducted clinical trials can and should make significant contributions to health systems in RLS.

Revisiting Perceptions of Quality of Hospice Care

Hospice services provided in the final months of life are delivered through complex interpersonal relationships between caregivers, patients, and families. Often, service value and quality are defined by these interpersonal interactions. This understanding provides hospice leaders with an enormous opportunity to create processes that provide the optimal level of care during the last months of life. The authors argue that the ultimate referral is attained when a family member observes the care of a loved one, and the family member conveys a desire to receive the same quality of services their loved one received at that facility. The point of this article is to provide evidence that supports the methods to ultimately enhance the patient's and family's experience and increase the potential for the ultimate referral.

Calcific Uremic Arteriolopathy

Calcific uremic arteriolopathy is a little understood diagnosis of increasing prevalence seen predominantly in patients with chronic kidney disease, particularly those who are approaching end-stage renal disease, who are undergoing renal dialysis, and who have secondary hyperparathyroidism. Calcific uremic arteriolopathy affects women more frequently than men, at a ratio of 3:1, and the median age at diagnosis is 48 years. A clear understanding of the pathogenesis and definitive plans of care are lacking. Nurses should be familiar with the clinical picture of calcific uremic arteriolopathy. Early recognition is important to develop optimal treatment plans and to limit progression of this rare but often fatal disease. Nurses have a pivotal role in maintaining the patient’s comfort and dignity, while setting realistic goals of care. Calcific uremic arteriolopathy remains a rare and complex clinical condition that requires a multidisciplinary health care team approach to provide the optimal level of care. Nurses have an essential role in the care of patients with the diagnosis of calcific uremic arteriolopathy.

Position paper of the Italian Association for the Study of the Liver (AISF): The multidisciplinary clinical approach to hepatocellular carcinoma

Patients with hepatocellular carcinoma should be managed with a multidisciplinary approach framed in a network where all the diagnostic techniques and therapeutic resources are available in order to provide the optimal level of care. Given this assumption, the Coordinating Committee of the Italian Association for the Study of the Liver nominated a panel of experts to elaborate practical recommendations for the multidisciplinary management of hepatocellular carcinoma aiming to provide: (1) homogeneous and efficacious diagnostic and staging work-up, and (2) the best treatment choice tailored to patient status and tumour stage at diagnosis. The 2010 updated American Association for the Study of Liver Disease Guidelines for hepatocellular carcinoma were selected as the reference document. For each management issue, the American Association for the Study of Liver Disease recommendations were briefly summarised and discussed, according to both the scientific evidence published after their release and the clinical expertise of the Italian centres taking care of these patients. The Italian Association for the Study of the Liver expert panel recommendations are finally reported.

Calcific Uremic Arteriolopathy

Calcific uremic arteriolopathy is a little understood diagnosis of increasing prevalence seen predominantly in patients with chronic kidney disease, particularly those who are approaching end-stage renal disease, who are undergoing renal dialysis, and who have secondary hyperparathyroidism. Calcific uremic arteriolopathy affects women more frequently than men, at a ratio of 3:1, and the median age at diagnosis is 48 years. A clear understanding of the pathogenesis and definitive plans of care are lacking. Nurses should be familiar with the clinical picture of calcific uremic arteriolopathy. Early recognition is important to develop optimal treatment plans and to limit progression of this rare but often fatal disease. Nurses have a pivotal role in maintaining the patient's comfort and dignity, while setting realistic goals of care. Calcific uremic arteriolopathy remains a rare and complex clinical condition that requires a multidisciplinary health care team approach to provide the optimal level of care. Nurses have an essential role in the care of patients with the diagnosis of calcific uremic arteriolopathy.

Social Wealth and Optimal Care

When accidents result in noncompensable losses, a monetary payment is not enough to compensate the victim. We study the characteristics of optimal levels of care and distribution of risk under these circumstances and show that care depends on the aggregate wealth of society but does not depend on wealth distribution. We then examine whether ordinary liability rules, regulation, insurance, taxes and subsidies can be used to implement the first-best outcome (in terms of both care and risk). Finally, our results are discussed in the light of fairness considerations (second best) and in the special case of accidents between individuals and a firm.

Results of a National Survey on Over-The-Counter Medicines, Part 1: Pharmacist Opinion on Current Scheduling Status

> OTC medicines make up an important part of the community pharmacy world. As with most aspects of practice, however, hurdles exist that prevent an optimal level of care. To gauge pharmacist agreement on the scheduling status of various OTC medicines. Pharmacists across Canada were surveyed by mail. Of the 5037 surveys mailed, 2403 were returned, with 2305 being usable for analysis (response rate of 49.4%). Across 25 agents, pharmacists tended to support existing control for pharmacies (such as Nix crème rinse and minoxidil topical solution) and returning control to pharmacies for unscheduled agents (such as ranitidine 75 mg tablets and nicotine patches). Pharmacists generally favour tighter control of OTC agents, especially those that are unscheduled. This hopefully reflects pharmacist desire to ensure their proper selection and use.

Validation of the Harmless Acute Pancreatitis Score in Predicting Nonsevere Course of Acute Pancreatitis

Background: The Harmless Acute Pancreatitis Score (HAPS) is a scoring algorithm to identify patients with nonsevere acute pancreatitis. The aim of this study was to evaluate the reproducibility of HAPS outside its original study setting. Method: Baseline information of all hospitalized patients with acute pancreatitis at Karolinska University Hospital, Stockholm, Sweden, between 2004 and 2009 was collected. The parameters constituting HAPS were signs of peritonitis, hematocrit and serum creatinine levels. Since hematocrit was not available in all patients, complete sample analysis was performed by replacing hematocrit with hemoglobin (strongly correlated with hematocrit; r = 0.86). Results: In total, 531 patients with a first-time or a recurrent attack of acute pancreatitis were included. Among 353 patients with complete information on parameters constituting HAPS, 79 patients were predicted to have a nonsevere course, of whom 1 patient developed severe acute pancreatitis. The specificity of HAPS in predicting a nonsevere course of acute pancreatitis was 96.3% (95% CI: 81.0–99.9) with a corresponding positive predictive value of 98.7% (95% CI: 93.1–100). Complete sample analysis replacing hematocrit with hemoglobin level predicted a nonsevere course in 182 patients, of whom 2 patients had severe acute pancreatitis (94.3% specificity and 98.9% positive predictive value). Conclusion: HAPS is a highly specific scoring algorithm that predicts a nonsevere course of acute pancreatitis. Therefore, HAPS might be an additional tool in the clinical assessment of acute pancreatitis where early screening is important to treat the patients at an optimal level of care.

Rivermead Mobility Index Can Be Used to Predict Length of Stay for Elderly Persons, 5 Days After Stroke Onset

Recovery after acute stroke is expected to continue for a long time but is most rapid during the first few days after onset. Because the cost of hospital care is rising constantly, there is increasing pressure from various administrative bodies to reduce the duration of hospital stay. To select the optimal level of care for elderly patients with stroke-related disability, it is important to be aware of adequate discharge destinations and to have reliable predictors for the length of institutional stay (LOS) (ie in hospital or nursing home). The purpose of the study was to find feasible prognostic indicators for the LOS, to be used 5 days after acute stroke, in persons 65 years and older. One hundred fifteen consecutive persons, 65 years and older, were assessed 5 days poststroke for the following: consciousness (Glasgow Coma Scale), language (aphasia/no aphasia), perceptual (Cancellation Tasks and Block Test), emotional (lability/no lability), energy and drive (Montgomery-Åsberg Depression Scale), mental (Mini-Mental State Examination), somatosensory (normal/impaired), and urinary (continent/incontinent) functions; mobility (Rivermead mobility index [RMI]); activities of daily living (Barthel Index); and side of hemiplegia or hemiparesis. In addition, previous living arrangements (alone vs with another person), stroke characteristics, and demographic information were documented. Length of institutional stay was recorded 5 days to 3 months poststroke onset. Multiple regression survival analyses showed that the factors with the greatest positive impact on short LOS, 5 days poststroke, were the following: no previous stroke; Glasgow Coma Scale ≥ 13 (mild brain injury); and RMI ≥ 4 points, corresponding to the ability to rise from a chair in less than 15 seconds and stand there for 15 seconds with or without an aid. In addition to medical appraisal, the RMI ≥ 4 points, a quickly performed test, can be used to predict short LOS for persons with stroke as early as 5 days after stroke onset.