Organization Of Health Care System Research Articles

Impact of a multi site collaborative regional quality improvement project, ‘Safe Care, Saving Lives’ on neonatal outcomes in teaching and non-teaching hospitals in Andhra Pradesh and Telangana, India

Introduction: There is a high burden of neonatal mortality and morbidity in India with wide variations. Many complex issues, including the organization of health care systems, may play a role in health outcomes. ‘Safe Care, Saving Lives’ (SCSL) is a collaborative initiative of ACCESS Health International, Aarogyasri Healthcare Trust (state-wide health insurance program), and state governments of Andhra Pradesh and Telangana. Goal: The primary goal of SCSL is to implement a series of Potentially Better Practices (PBPs) across several (public teaching, public non-teaching, and private) hospitals to improve neonatal outcomes. Methods: SCSL Program: SCSL adopted the Institute of Healthcare improvement’s (IHI) Model for …

Stroke care during the COVID-19 pandemic: experience from three large European countries.

In order to cope with the exponentially increasing number of patients infected with SARS‐CoV‐2, European countries made enormous efforts to reorganize medical assistance and several diseases, including stroke, were particularly impacted. We report the experience of stroke neurologists from three European countries (Italy, France and Germany) that faced the pandemic at diverse time points and with different approaches, depending on their resources and healthcare system organization. Pre‐hospital and in‐hospital acute stroke pathways were reorganized to prioritize COVID‐19 management and, in severely affected regions of Italy and France, stroke care was centralized to a limited number of centers, whereas the remaining stroke units were dedicated to patients with COVID‐19. Access to acute stroke diagnostics and time‐dependent therapies was limited or delayed because of reduced capacities of emergency services due to the burden of patients with COVID‐19. A marked reduction in the number of patients presenting with transient ischaemic attack and stroke was noted in the emergency departments of all three countries. Although we only have preliminary data, these conditions may have affected stroke outcome. These indirect effects of the COVID‐19 pandemic could negate the efforts of stroke neurologists over the last few years to improve outcome and reduce mortality of stroke patients. Although the SARS‐CoV‐2 infection rate is slowing down in Europe, the effects of ending lockdown in the next months are unpredictable. It is important for the European and world stroke community to share what has been learned so far to be plan strategies to ensure stroke care in the future and upcoming challenging times.

A tale of two countries: how decentralized organization and long-term investment build resilient healthcare systems.

Healthcare systems are faced with unique challenges during the ongoing Covid-19 pandemic. This viewpoint compares the response to the Covid-19 pandemic in the UK and in Germany. Despite being two large European countries of comparable size with good healthcare systems and similar patterns of exposure to Covid-19, Covid-19 related deaths in the UK currently far outnumber those in Germany. This has several reasons, but two explanations stick out: 1. lower long-term investment into healthcare in the UK rendered the NHS more vulnerable to Covid-19; 2. the existence of a well-governed decentralised and partially redundant organisation of healthcare increased resilience in Germany’ s healthcare systems, enhancing the ability to adapt in response to unexpected challenges to healthcare. The response to the current pandemic also illustrates the power and the necessity to learn from each other through transparent communication of successes and mistakes.

Retrospective Analysis of Factors Associated with Long-Stay Hospitalizations in an Acute Psychiatric Ward.

PurposeTo evaluate the longest hospitalizations in an acute psychiatric ward [Service of Psychiatric Diagnosis and Treatment (SPDT)] and the related demographic, clinical and organizational variables to understand the factors that contribute to long-stay (LOS) phenomenon. The term “long stay” indicates clinical, social and organizational problems responsible for delayed discharges. In psychiatry, clinical severity, social dysfunction and/or health-care system organization appear relevant factors in prolonging stays.Patients and MethodsWe divided all the SPDT hospitalizations from 1 January 2010 to 31 December 2015 into two groups based on the 97.5th percentile of duration: ≤36 day (n=3254) and >36 day (n=81) stays, in order to compare the two groups for the selected variables. Comparisons were made using Pearson’s chi-square for categorical data and t-test for continuous variables, the correlation between the LOS, as a dependent variable, and the selected variables was analyzed in stepwise multiple linear regression and in multiple logistic regression models.ResultsThe longest hospitalizations were significantly related to the diagnosis of “schizophrenia and other psychosis” (Pearson Chi2=17.24; p=0.045), the presence of moderate and severe aggressiveness (Pearson chi2=29; p=0.000), compulsory treatment (Pearson Chi2=8.05; p=0.005), parenteral or other route administration of psycho-pharmacotherapy (Pearson Chi2=12.91; p=0.007), poli-therapy (Pearson Chi2=6.40; p=0.041), complex psychiatric activities (Pearson Chi2=12.26; p=0.002) and rehabilitative programs (Pearson Chi2=37.05; p=0.000) during the hospitalization and at discharge (Pearson Chi2=29.89; p=0.000). Many demographic and clinical variables were statistically significantly correlated to the LOS at our multiple linear and logistic regression model.ConclusionIn our sample, clinical illness severity and need for complex therapeutic and rehabilitative treatments were associated with prolonged psychiatric hospitalizations. Understanding this phenomenon can have not only economic but also clinical, ethical and social relevance.

People\u2013centred care versus clinic\u2013based DOT for continuation phase TB treatment in Armenia: a cluster randomized trial

BackgroundWHO’s directly observed therapy (DOT) strategy for tuberculosis (TB) treatment depends upon a well–organized healthcare system. This study sought to evaluate the effectiveness of self-administered drug intake supported by a family member versus in-clinic DOT.MethodsThis open–label, nationally-representative stratified cluster randomized controlled non–inferiority trial with two parallel equal arms involved drug–susceptible pulmonary TB patients in the continuation treatment phase. We randomly assigned outpatient–TB–centres (52 clusters) to intervention and control arms. The intervention included an educational/counseling session to enhance treatment adherence; weekly visits to outpatient–TB–centres to receive medication, and daily SMS medication reminders and phone calls to track adherence and record side effects. Controls followed clinical DOT at Outpatient–TB–centres. Both groups participated in baseline and 4–5 months follow–up surveys. The trial’s non–inferiority comparisons include: treatment success as the clinical (primary) outcome and medication adherence (self–reported), knowledge, depressive symptoms, stigma, quality of life, and social support as non–clinical (secondary) outcomes.ResultsPer–protocol analysis showed that the intervention (n = 187) and control (n = 198) arms achieved successful treatment outcome of 92.0 and 92.9%, respectively, indicating that the treatment success in the intervention group was non–inferior to DOT. Knowledge, depression, stigma, quality of life, and social support also showed non–inferiority, demonstrating substantial improvement over time for knowledge (change in the intervention = 1.05: 95%CL (0.49, 1.60); change in the control = 1.09: 95%CL (0.56, 1.64)), depression score (change in the intervention = − 3.56: 95%CL (− 4.99, − 2.13); change in the control = − 1.88: 95% CL (− 3.26, − 0.49)) and quality of life (change in the intervention = 5.01: 95%CL (− 0.64, 10.66); change in the control = 7.29: 95%CL (1.77, 12.81)). The intervention resulted in improved treatment adherence.ConclusionsThis socially empowering alternative strategy might be a preferable alternative to DOT available to patients in Armenia and in other countries. Further research evaluating cost effectiveness of the intervention and generalizability of the results is warranted.Trial registrationClinicaltrials.gov: NCT02082340, March 10, 2014.

Will applications on smartphones allow a generalization of telemedicine?

BackgroundTelemedicine is one of the healthcare sectors that has developed the most in recent years. Currently, telemedicine is mostly used for patients who have difficulty attending medical consultations because of where they live (teleconsultation) or for specialist referrals when no specialist of a given discipline is locally available (telexpertise). However, the use of specific equipment (with dedicated cameras, screens, and computers) and the need for institutional infrastructure made the deployment and use of these systems expensive and rigid. Although many telemedicine systems have been tested, most have not generally gone beyond local projects.Our hypothesis is that the use of smartphones will allow health care providers to overcome some of the limitations that we have exposed, thus allowing the generalization of telemedicine.Main bodyThis paper addresses the problem of telemedicine applications, the market of which is growing fast. Their development may completely transform the organization of healthcare systems, change the way patients are managed and revolutionize prevention. This new organization should facilitate the lives of both patients and doctors.In this paper, we examine why telemedicine has failed for years to take its rightful place in many European healthcare systems although there was a real need. By developing the example of France, this article analyses the reasons most commonly put forth: the administrative and legal difficulties, and the lack of funding. We argue that the real reason telemedicine struggled to find its place was because the technology was not close enough to the patient.ConclusionFinally, we explain how the development of smartphones and their current ubiquitousness should allow the generalization of telemedicine in France and on a global scale.

Russian Arctic: The Logic and Paradoxes of Changes

The paper contemplates massive transformation processes in the Russian Arctic zone, identified by the authors as the “re-development” of the Arctic, which integrate resource-intensive but necessary exploitation of the huge “Soviet legacy” and construction of the novel industrial and social facilities and infrastructure. The key role of Russian Arctic “re-development” as the most appropriate model at the country and regional levels is substantiated. The success of the Arctic development will depend to a decisive extent on the advanced revision of the basic provisions of the current state of industrial, energy, transport, demographic, etc policies. The paradoxes of the demographic situation in the Russian Arctic are considered and the directions of the organization of health care system in this macro-region are introduced taking into account: (a) specificity of the urbanized and rural areas in the Western and Eastern (beyond the Urals) parts of the Russian Arctic; (b) specific needs for medical service provided to miners and metal workers, servicemen, sailors and shift workers as well as communities of the indigenous peoples of the Russian North. Peculiarities of interaction between the state policy and that of the big corporations in the Arctic are disclosed including those concerning climatic risks mitigation. Given this perspective the public policy measures to regulate greenhouse gas emissions proposed by the Ministry of economic development of the Russian Federation are critically assessed. In conclusion, the consistency of recent changes in the development policy in the Russian Arctic that should result in organization of a special Federal ministry for the Arctic is substantiated.

Медичний стандарт як історична компонента на шляху до клінічного аудиту

Aim - the search, analysis and systematization of historical facts concerning the formation and evo-lution of the world medical standartization; severance of its certain long-standing models for the optimization of settling and introduction of the existing, and future analogs, particularly, in the clinical audit format. Material and Methods. In order to study the medical standard as a historical component the fol-lowing methods were used: bibliographic, historical, analytical and methods of systematization and comparison. Results and Discussion. As a result of the conducted research the main historical events in the world development of the medical standartization starting from 1500 up till nowadays were col-lected. In order to study the evolution of the medical standartization, the analysis of the normative documents that have regulated the process of standartization, especially the Doctor's statute(s) in Russia, Minimal standard of the medical equipment and works of the American college of surgeons, was carried out. The scientific works that initiated the introduction of the clinical audit in the Health Care system in Ukraine, Turkey, the USA and Great Britain were throroughly analyzed. Conclusions. The improvement of quality as to rendering the medical aid is a job priority in the health care systems in many countries. For that reason, the search for its optimization was and is still retrieved for many centuries. The territorial formation of medical standartization is associated with England, Russia and the USA, but the occurrence of clinical audit is connected with Ukraine, Turkey, the USA and Great Britain. The foundations of the medical standardization was lauched in 1500 year, while the clinical audit - in 1854 year. The medical standartization is a reflection of the history of development of the organization of health care system, that's why the expertness (knowl-edge) of historical stages concerning the setting and the introduction of medical standartization may give a new impulse in its improvement and development under present-day conditions of reforma-tion in the medical sphere in Ukraine. The earlier beginning of implementation of the medical stan-dartization in the health care system in different countries makes it possible to actualize its introduc-tion into the clinical audit format, that, in its turn, allows to improve the quality of rendering the medical aid. Key words: medical standartization, clinical audit, quality of medical aid

Medication Errors in Hospitals Training: A Practical Approach to Pharmacy Practice

A critical review of quality indicators defined by NABH(National Accreditaion Board for Hospitals and Healthcare Providers) of pharmacies of three leading hospital in Indore gave an insight to reasons and solution to occurrence the medication error and hindrances to effective pharmacy practice. A change in staffing and regular updating the staff brought a positive change for the concern. This approach can be useful across the organized health care system.

Acute Chest Syndrome in Children with Sickle Cell Disease in Italy: Results of a National Survey from the Italian Association of Pediatric Hematology Oncology (AIEOP)

Background: Acute Chest Syndrome (ACS) is the second cause of hospitalization in Sickle Cell Disease (SCD), burdened by significant morbidity and mortality. The guidelines regarding management of ACS are sometimes difficult to follow in the real world and the prevention and treatment strategies of ACS are often applied in an uneven manner in the various settings (community care, regional hospitals, reference university centers). Moreover, epidemiology, clinical phenotype and outcomes as well as risk factors could vary in different populations according to ethnicity, genotype or health care system organization. Aims and Methods: A retrospective multicenter observational study was conducted to investigate the epidemiology of ACS and to the evaluate the diagnostic and therapeutic pathways of ACS in children with SCD (age 0-18 years) in the 2013-2018 period, after the publication of the Italian Association of Pediatric Hematology Oncology (AIEOP) Guidelines for the Management of SCD in Childhood in Italy in 2012. Results: 126 children were recruited and 122 included in the analysis, with 208 evaluable episodes of ACS (range: 1-6 episodes /patient) from 11 AIEOP Centers. 73 M, 49 F. Mean age was 10.9 years. 85% patients were of African origin, 92% were HbSS/SB°; mean age at diagnosis of SCD of the entire cohort was 25,3 months (range 0-16,8). 44.2% of patients had more than one episode of ACS during the study period; 37% had had a previous episode before 2013. 58% had comorbidities, mostly respiratory (asthma or allergy). 75% of the patients underwent disease modifying treatment during study period (73% hydroxyurea, 2% chronic transfusion). The seasonality of ACS episodes was important in our country: 75% of episodes occured between October and March. 95% of ACS episodes were secondary to a Vaso-Occlusive Crisis. 76% of the admissions occurred in SCD reference centers, 24% in regional hospitals, but 30% later required transfer to reference centers for worsening of clinical conditions or need of exchange transfusion. The mean length of hospitalization was 9.6 days (range 1-46); one patient died of pneumococcal sepsis; 6 episodes required transfer to the Intensive Care Unit, mechanical ventilation was required in one episode. A good adherence to the AIEOP Guidelines was documented for some aspects: 99% of the patients were hospitalized, 98% performed chest X-ray for the diagnosis of ACS and in 99% antibiotic therapy was started. Others aspects were less satisfactory and in need of improvement: incentive spirometry was only performed in 19% of admissions; oxygen therapy was performed only in 75% of patients even if SatO2 was<95%; transfer to reference centers was not always timely. During 75% of ACS episodes a simple red cell transfusion was required for Hb>8g/dl, while in 16% an exchange transfusion was performed for severe respiratory distress (of these 71% were performed in patients transfered from regional hospitals); 38% required inhaled bronchodilators, 6% steroids. A preliminay evaluation of risk factors for recurrent ACS showed that in our cohort allergy to inhaled allergens (p 0.02) and enuresis (p 0.01) were associated with increased prevalence of recurrent ACS; patients with asthma/wheezing also presented more recurrent ACS compared to patients wihout them (23% vs 13%) but this data did not reach statistical significance. Conclusion: This study represents the first analysis in Italy of ACS, which is confirmed as a frequent event in our cohort, with a significant proportion of patients who experience recurrent ACS. Steps need to be undertaken to improve management of ACS and adherence to the AIEOP guidelines at a national level: stimulate the application of early preventive measures that are still under-utilized, increase the appropriateness of multidisciplinary specialist approach (transfusion specialist, acute care physicians, pneumologists, hematologists) strengthen the dissemination of information through training events for all the Hospitals of the network. Disclosures Colombatti: AddMedica: Consultancy; Global Blood Therapeutics: Consultancy; Novartis: Consultancy.

ACCESS TO CARE ROUNDS: A UNIQUE FORUM FOSTERING HEALTH SYSTEM AND SOCIAL SERVICE PARTNERSHIPS FOR OLDER VETERANS

Colorado Veteran Community Partnership (VCP) aims to connect Rocky Mountain Regional VA Medical Center front-line teams with diverse community partners to create integrated networks of support for older Veterans with complex needs and their family members and caregivers. To accomplish this goal, VCP launched Access to Care Rounds in January 2018 to build bridges between the healthcare system and community-based organizations. Each Access to Care Rounds features a cross-sector panel that discusses specific efforts to link a medically-complex, older Veteran to resources. This model was developed with stakeholder input and has highlighted topics related to chronic pain management, suicide prevention, homelessness, adult protective services, transportation, home-based primary care, hospice care, and firearm safety. Each Access to Care Rounds focuses on connecting VCP members, sharing expertise and resources, and highlights lessons learned related to care coordination, communication, and key processes that others can adopt/adapt to better serve older Veterans. On average, 30 individuals attend each session. Access to Care Rounds draw diverse audiences representing social services, mental health and other healthcare specialties. The latter include Social Workers (47%), Physicians (11%), Psychologists (8%), Registered Nurses (6%), and students/trainees (6%). Participants receive a description of the Veteran situation; the names, credentials, organizational affiliations and roles/expertise of each panelist; and, a resource list relevant to the constellation of issues addressed to enhance access to information and resources. Over 38% of respondents to session evaluations reported intentions to change their professional practice as a result of what they learned during an Access to Care Rounds.

The effect of advertising activity on patients' choice of medical organization

The article presents theoretical propositions concerning placement and dissemination of information about medical organization and practical recommendations of the advertising campaign of medical services. The analysis of the advertising activities' influence on the patient choice of the medical organization out of top annual revenue medical institutions in Russia was carried out. In economically developed countries, the support of possibility of choosing particular medical organization and physician in economic theory and in practice of organization of health care system is targeted to improving medical care quality and health care efficiency. The process of expanding possibilities of choice is officially declared as one of the priorities of development of Russian health care. However, the influence of consumer choice of patient of medical organization while addressing for medical care is still to be an object of research study in Russia.

Navigating between technology and professionalism: key points for the future of clinical laboratories

In the last few decades, monumental changes have been made to the landscape of clinical laboratories. Laboratory medicine has always been influenced by a broad range of trends affecting technological development, the healthcare system organization, medical practice and patient empowerment. In the coming decade, disruptions will intersect, interact, and overlap with these trends, and with the existing set of laboratory practices; combinatorial innovation will make it of critical importance for leaders to prepare for a future with the understanding of possible collisions between linear trends and nonlinear external forces. The aim of the present paper is to discuss the future of clinical laboratories according to two different approaches: technological and professional. In particular, a description is given of a revised version of a ‘ten points’ manifesto for the future of laboratory professionals, with a focus on the main drivers and efforts made to demonstrate the added value and true role of laboratory medicine in modern health care systems. The main goal of this manifesto is to emphasize the centrality of the contribution of clinical laboratories and their professionals to improved health care.

Does Hub‐and‐Spoke organization of healthcare system promote workers' satisfaction?

AbstractThe healthcare services network is a recent organizational structure of healthcare services that are interdependent and organized as a network on the basis of the Hub‐and‐Spoke model. This questionnaire‐based study analyzed socio‐psychological well‐being of health workers both in terms of team‐related experience and individual satisfaction and engagement with one's work in a Hub‐and‐Spoke healthcare service in comparison to non‐network healthcare service. Workers from two different public healthcare services involved in the treatment of the same skeletal rare diseases participated in the Study. We expected that working under a Hub‐and‐Spoke healthcare service—involving teamwork and cooperation among different healthcare services within the units, as well as among workers belonging to different units—would lead to greater psychological team‐related and individual benefits. In line with predictions, the findings showed that under a Hub‐and‐Spoke healthcare service, health workers felt highly interdependent by their team fellows and developed shared cognitions (i.e., team mental models) about their integration and their tasks to a higher extent than non‐network ones. They were also individually more satisfied of their job and displayed higher work engagement than non‐network workers. Beneficial team‐related dynamics, such as perceived interdependence, were responsible for the differences between the Hub‐and‐Spoke workers and non‐network ones. The implications of the present findings were discussed in terms of promotion of health workers' satisfaction and well‐being.

Plastic diagnostics: The remaking of disease and evidence in personalized medicine

Politically authorized reports on personalized and precision medicine stress an urgent need for finer-grained disease categories and faster taxonomic revision, through integration of genomic and phenotypic data. Developing a data-driven taxonomy is, however, not as simple as it sounds. It is often assumed that an integrated data infrastructure is relatively easy to implement in countries that already have highly centralized and digitalized health care systems. Our analysis of initiatives associated with the Danish National Genome Center, recently launched to bring Denmark to the forefront of personalized medicine, tells a different story. Through a “meta-taxonomy” of taxonomic revisions, we discuss what a genomics-based disease taxonomy entails, epistemically as well as organizationally. Whereas policy reports promote a vision of seamless data integration and standardization, we highlight how the envisioned strategy imposes significant changes on the organization of health care systems. Our analysis shows how persistent tensions in medicine between variation and standardization, and between change and continuity, remain obstacles for the production as well as the evaluation of genomics-based taxonomies of difference. We identify inherent conflicts between the ideal of dynamic revision and existing regulatory functions of disease categories in, for example, the organization and management of health care systems. Moreover, we raise concerns about shifts in the regulatory regime of evidence standards, where clinical care increasingly becomes a vehicle for biomedical research.

Skin aging: the dermal perspective

The world population of adults aged 60 years or more is increasing globally, and this development can impact skin disease morbidity and mortality, as well as being reflected in the health care system organization. There is substantial evidence that the burden from a remarkable number of skin nonmalignant and malignant conditions is greater in the elderly. Dermatologic research and clinical education in dermatology should focus on both challenges and opportunities created by aging. Skin aging due to intrinsic and extrinsic factors can alter significantly epidermal and dermal structure and functions. Dermal aging can be linked to a great number of complications in routine dermatologic conditions, with slow healing as an example of a severe complication in the elderly. This may be attributed to aged dermal fibroblasts modifying the tissue microenvironment via a shift in their soluble factors and extracellular matrix repertoire. This senescence-associated secretory phenotype can explain the particular proclivity of aged skin to develop malignancies.

„Zdrowie na peryferiach”. Lecznictwo i opieka zdrowotna w praktyce codziennej pierwszych dwóch dekad PRL na przykładzie listów do władz

Prezentowany tekst podejmuje probe pokazania zakresu problemow zdrowotnych i organizacyjnych zglaszanych w skargach i listach obywateli PRL do wladz dotyczących opieki zdrowotnej. Czy w skargach dotyczących opieki szpitalnej, pisanych zarowno przez pacjentow, jak i lekarzy oraz personel medyczny (pomocniczy) przewijaly sie te same zjawiska? Czym roznily sie formulowane przez poszczegolne grupy problemy i na ile mialy one charakter uniwersalny lub wyjątkowy dla danego czasu? Co dostrzegane w analizowanych listach roznice lub podobienstwa mowily o systemie panstwowej sluzby zdrowia – to bazowe pytania badawcze stanowiące punkt wyjścia prowadzonych analiz. “Health in the peripheries”. Medical and health care in everyday practice of the first two decades of the Polish People’s Republic [– on the example of letter to the state authorities] Citizens’ letters addressed to the state authorities were not a phenomenon specific to Poland of those times as a similar phenomenon was present in other countries of post-war Central Eastern Europe. The thematic scope of the letters addressed by Polish citizens to the state authorities focused usually on situations and phenomena that caused the most bitter everyday frustration and concern. What was most often brought up in these letters were unmet fundamental needs of people – housing problems, supply shortages, lack of work, issues related to the security of possession, etc. The problems of health care, although not prevailing in general (throughout the whole period of People’s Poland), was constantly present in the files of the Bureau of Letters and Complaints. The problems of the state health system (both open and closed healthcare systems) which emerge from the letters reveal that, regardless the perspective of the author (patient, doctor, medical staff), the set of the most burning issues was the same for all. This was especially true for the first twenty years after the war experiencing the biggest organisational difficulties of the Polish healthcare system. An analysis of the problems accompanying the organisation of state healthcare system reveals that a number of phenomena and work pathologies present at that time in the medical care institutions were similar as those in other socialist workplaces.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County

BackgroundIn Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use.MethodsA population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services.ResultsThose 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12–44% for those in the lowest income groups. However, age and gender differences were observed with men 65–79 years (OR 1.75 CI: 1.51–2.03) and women 80+ years (OR 1.50, CI 1.19–1.87) in the lowest income groups having a higher odds of frequent ED use.ConclusionThis study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

The Use of Assessment of Chronic Illness Care Technology to Evaluate the Institutional Capacity for HIV/AIDS Management.

The effectiveness of antiretroviral therapy has rendered HIV infection a manageable chronic condition. Currently, the health systems face the challenge of adopting organizational healthcare models capable of ensuring the delivery of comprehensive care. The Chronic Care Model has been reported for its effectiveness, particularly in terms of delivery system design. In this study, the Assessment of Chronic Illness Care (ACIC) questionnaire, a soft technology widely used for other chronic conditions, was employed on a teaching hospital to evaluate healthcare provided to people living with HIV/AIDS. The ACIC technology is a self-explanatory instrument which diagnoses, among the six components of the Chronic Care Model Framework, areas for quality improvements, indicating at the same time, intervention strategies and achievements. These components are healthcare network organization, delivery system design, self-management support, decision support, clinical information systems, and community. From May to October 2014, the tool was applied to the multidisciplinary teamwork at the points of care identified, as well as to the hospital management board. Respondents broadly rated care as basic. A pronounced contrast was observed from evaluation by management board and health professional staff in some components like organization of healthcare and clinical information system. The self-management support and delivery system design were the components best evaluated by the multidisciplinary team. Combined with the array of services offered, the entry points available at the hospital can ensure healthcare comprehensiveness. However, some gaps were detected, precluding the delivery of an effective care. The ACIC was considered an adequate technology to provide knowledge of the gaps, to promote productive discussions and reflections within teams and to indicate actions to achieve improvements on healthcare for people living with HIV/AIDS.

Telessaúde como eixo organizacional dos sistemas universais de saúde do século XXI

Novos desafios epidemiológicos e demográficos demandam novas formas de organizar os sistemas de saúde. O presente ensaio propõe a telessaúde como ferramenta organizativa, capaz de suavizar o triângulo de ferro da atenção à saúde e de facilitar a busca pelo triple aim, pelo seu potencial de aumento do acesso e qualidade com redução de custo. A integração da telessaúde ao processo de referência e transição entre serviços assistenciais aumenta a resolutividade da Atenção Primária à Saúde (APS), favorece a coordenação do cuidado, promove adesão terapêutica, diminui reinternações e estimula a prevenção quaternária. Este ensaio propõe a telessaúde como metasserviço que confere densidade tecnológica à APS e permite que ela se torne coordenadora efetiva do cuidado, passando a organizar o fluxo de informações, pessoas e insumos. Frente às inovações propostas, é essencial avaliar o impacto de ações já existentes de telessaúde para viabilizar a sua aplicação como metasserviço de saúde.