Resource Use Outcomes Research Articles

PP063 [Lung » Airway disease and related issues]: PATIENT CHARACTERISTICS, RESOURCE USE, AND CLINICAL OUTCOMES OF STATUS ASTHMATICUS IN TWO DIFFERENT MODELS OF PICU CARE

PP063 [Lung » Airway disease and related issues]: PATIENT CHARACTERISTICS, RESOURCE USE, AND CLINICAL OUTCOMES OF STATUS ASTHMATICUS IN TWO DIFFERENT MODELS OF PICU CARE

Impact of relational continuity of primary care in aged care: a systematic review

BackgroundGreater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes.MethodsSystematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions.ResultsHeterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335).ConclusionGreater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed.Review registrationCRD42021215698.

Fostering interspeciality learning in cancer survivorship care: Learning suite results.

e23003 Background: As survivorship provision declines within cancer centres, primary care providers are increasingly entrusted in the follow-up care of cancer survivors. Empowering specialists and primary care providers about survivorship through educational interventions is essential. Interspecialty education is poorly integrated into residency training, which may impede collaboration between different providers in practice. Interspecialty partnership can positively impact patient and resource-use outcomes. The aim of this study was to assess if a cancer survivorship learning suite (LS) impacts attitudes of family medicine, radiation oncology and medical oncology trainees towards interspecialty collaboration in Montreal, Canada. Methods: A survivorship (LS) developed by a Manitoba-based team under the sponsorship of a Canadian Partnership Against Cancer grant held by Cancer Care Ontario was delivered to 49 McGill University family medicine, radiation oncology, and medical oncology trainees. The LS comprised in-person delivery of a 3-hour case-based workshop, presented by a radiation oncologist and a family physician, both experienced in the field of survivorship. An adapted version of the Readiness for Interprofessional Learning Scale (RIPLS) was completed by participants before and after workshop delivery. Statistical analyses included non-parametric (Wilcoxon Signed rank tests) comparisons. Results: Response rate was 63.2%, and included family medicine (65%), radiation oncology (26%), and medical oncology (10%) trainees, respectively. Following the workshop, participants were significantly more likely to agree that interspecialty learning in residency “would help physicians become better team workers”, (Z = 2.7, p < 0.008, n = 31), and “improves relationships between physicians of different specialties in independent practice afterwards”, (Z = 2.6, p < 0.009, n = 31). Participants were also significantly more likely to agree that “shared interspecialty learning < would > increase < their > ability to understand clinical problems”, (Z = 2.8, p < 0.005, n = 31). Conclusions: While much literature has focused on interprofessional collaboration at different levels of education and practice, few studies have assessed interspecialty collaboration of physicians of different specialties. This survivorship LS demonstrated favorable changes in attitudes towards interspecialty learning.

Enabling conditions for an equitable and sustainable blue economy.

The future of the global ocean economy is currently envisioned as advancing towards a 'blue economy'-socially equitable, environmentally sustainable and economically viable ocean industries1,2. However, tensions exist within sustainable development approaches, arising from differing perspectives framed around natural capital or social equity. Here we show that there are stark differences in outlook on the capacity forestablishing a blue economy, and on its potential outcomes, when social conditions and governance capacity-not just resource availability-are considered, and we highlight limits to establishing multiple overlapping industries. This is reflected by an analysis using a fuzzy logic model to integrate indicators from multiple disciplines and toevaluate their current capacity to contribute to establishing equitable, sustainable and viable ocean sectors consistent with a blue economy approach. We find that the key differences in the capacity of regions to achieve a blue economy are not due to available natural resources, but include factors such as national stability, corruption and infrastructure, which can be improved through targeted investments and cross-scale cooperation. Knowledge gaps can be addressed by integrating historical natural and social science information on the drivers and outcomes of resource use and management, thus identifying equitable pathways to establishing or transforming ocean sectors1,3,4. Our results suggest that policymakers must engage researchers and stakeholders to promote evidence-based, collaborative planning that ensures that sectors are chosen carefully, thatlocal benefits are prioritized, and thatthe blue economy delivers on its social, environmental and economic goals.

The effect on work presenteeism of job retention vocational rehabilitation compared to a written self-help work advice pack for employed people with inflammatory arthritis: protocol for a multi-centre randomised controlled trial (the WORKWELL trial)

BackgroundWork problems are common in people with inflammatory arthritis. Up to 50% stop work within 10 years due to their condition and up to 67% report presenteeism (i.e. reduced work productivity), even amongst those with low disease activity. Job retention vocational rehabilitation (JRVR) may help prevent or postpone job loss and reduce presenteeism through work assessment, work-related rehabilitation and enabling job accommodations. This aims to create a better match between the person’s abilities and their job demands. The objectives of the Workwell trial are to test the overall effectiveness and cost-effectiveness of JRVR (WORKWELL) provided by additionally trained National Health Service (NHS) occupational therapists compared to a control group who receive self-help information both in addition to usual care.MethodsBased on the learning from a feasibility trial (the WORK-IA trial: ISRCTN76777720), the WORKWELL trial is a multi-centre, pragmatic, individually-randomised parallel group superiority trial, including economic evaluation, contextual factors analysis and process evaluation. Two hundred forty employed adults with rheumatoid arthritis, undifferentiated inflammatory arthritis or psoriatic arthritis (in secondary care), aged 18 years or older with work instability will be randomised to one of two groups: a self-help written work advice pack plus usual care (control intervention); or WORKWELL JRVR plus a self-help written work advice pack and usual care. WORKWELL will be delivered by occupational therapists provided with additional JRVR training from the research team. The primary outcome is presenteeism as measured using the Work Limitations Questionnaire-25. A comprehensive range of secondary outcomes of work, health, contextual factors and health resource use are included. Outcomes are measured at 6- and 12- months (with 12-months as the primary end-point). A multi-perspective within-trial cost-effectiveness analyses will also be conducted.DiscussionThis trial will contribute to the evidence base for provision of JRVR to people with inflammatory arthritis. If JRVR is found to be effective in enabling people to keep working, the findings will support decision-making about provision of JRVR by rheumatology teams, therapy services and healthcare commissioners, and providing evidence of the effectiveness of JRVR and the economic impact of its implementation.Trial registrationClinical Trials.Gov: NCT03942783. Registered 08/05/2019 (https://clinicaltrials.gov/ct2/show/NCT03942783); ISRCTN Registry: ISRCTN61762297. Registered:13/05/2019 (http://www.isrctn.com/ISRCTN61762297). Retrospectively registered.

Impact of Intrauterine Growth Restriction on Cardiac Surgical Outcomes and Resource Use

We sought to evaluate outcomes of congenital heart operations and resource use in patients with intrauterine growth restriction (IUGR). This was a retrospective matched case-control study of 41 consecutive patients with IUGR matched 1:2 with a comparison cohort of 82 contemporaneous patients without IUGR who underwent congenital heart operations during the interval from January 1, 2000 to January 1, 2012. Matching was based on the Risk Adjustment for Congenital Heart Surgery (RACHS)-1 risk category, diagnostic category, age at operation, and gestational age. Operative mortality (6 of 41 cases [14.6%] for the study group versus 5 of 82 cases [6.1%] for controls) and any major adverse event (14 of 41 cases [34.2%] for the study group versus 23 of 82 cases [28%] for controls) occurred in a higher percentage of study patients, with insignificant p values. Important differences in secondary outcomes included the following: mean total length of stay (56.3 days versus 28.0 days for controls; p < 0.0001), postoperative days of mechanical ventilation (25.8 days versus 5.4 days for controls; p = 0.002), postoperative cardiopulmonary arrest (7 of 41 cases [17.1%] versus 4 of 82 cases [4.9%] for controls; p = 0.03), and postoperative infection (13 of 41 cases [31.7%] versus 13 of 81 cases [16.1%] for controls; p = 0.04). The mean charge for the study group was considerably higher than that for the control group: $493,915 versus $175,144; p < 0.0001. IUGR is associated with a substantially increased length of hospital stay, postoperative morbidity, and resource use. These findings are relevant to risk stratification, prognosis, and potentially to contracting and reimbursement. IUGR merits further attention as an important risk factor in congenital heart operations.

Association of definition of acute kidney injury by cystatin C rise with biomarkers and clinical outcomes in children undergoing cardiac surgery.

Research has identified improved biomarkers of acute kidney injury (AKI). Cystatin C (CysC) is a better glomerular filtration rate marker than serum creatinine (SCr) and may improve AKI definition. To determine if defining clinical AKI by increases in CysC vs SCr alters associations with biomarkers and clinical outcomes. Three-center prospective cohort study of intensive care units in New Haven, Connecticut, Cincinnati, Ohio, and Montreal, Quebec, Canada. Participants were 287 patients 18 years or younger without preoperative AKI or end-stage renal disease who were undergoing cardiac surgery. The study dates were July 1, 2007, through December 31, 2009. For biomarker vs clinical AKI associations, the exposures were first postoperative (0-6 hours after surgery) urine interleukin 18, neutrophil gelatinase-associated lipocalin, kidney injury molecule 1, and liver fatty acid-binding protein. For clinical AKI outcome associations, the exposure was Kidney Disease: Improving Global Outcomes AKI definition (based on SCr or CysC). Clinical AKI, length of stay, and length of mechanical ventilation. We determined areas under the receiver operating characteristic curve and odds ratios for first postoperative biomarkers to predict AKI. The SCr-defined vs CysC-defined AKI incidence differed substantially (43.6% vs 20.6%). Percentage agreement was 71% (κ = 0.38); stage 2 or worse AKI percentage agreement was 95%. Interleukin 18 and kidney injury molecule 1 discriminated for CysC-defined AKI better than for SCr-defined AKI. For interleukin 18 and kidney injury molecule 1, the areas under the receiver operating characteristic curve were 0.74 and 0.65, respectively, for CysC-defined AKI, and 0.66 and 0.58, respectively, for SCr-defined AKI. Fifth (vs first) quintile concentrations of both biomarkers were more strongly associated with CysC-defined AKI. For interleukin 18 and kidney injury molecule 1, the odds ratios were 16.19 (95% CI, 3.55-73.93) and 6.93 (95% CI, 1.88-25.59), respectively, for CysC-defined AKI vs 6.60 (95% CI, 2.76-15.76) and 2.04 (95% CI, 0.94-4.38), respectively, for SCr-defined AKI. Neutrophil gelatinase-associated lipocalin and liver fatty acid-binding protein associations with both definitions were similar. The CysC definitions and SCr definitions were similarly associated with clinical outcomes of resource use. Compared with the SCr-based definition, the CysC-based definition is more strongly associated with urine interleukin 18 and kidney injury molecule 1 in children undergoing cardiac surgery. Consideration should be made for defining AKI based on CysC in clinical care and future studies.

Including Patient-Reported Outcomes and Patient-Reported Resource-Use Questionnaires in Studies

More efficient and better informed healthcare systems are expected to have improved knowledge of the impact of interventions on patient outcomes and resources used by patients and providers in specific health conditions. To describe trends related to putting patients at the center of healthcare decision making, regulatory trends and best practice recommendations for developing high-quality patient-reported outcomes (PROs), and strategic issues related to including PROs in studies. We summarize PRO concepts, definitions, and broadly-accepted scientific standards for developing, assessing, and interpreting PROs. Three conceptual models are presented as examples for assessing PROs in relation to other outcomes. We discuss different perspectives for stakeholders, including regulatory issues pertaining to formal guidance for PRO development and for use in trials. We provide examples of PROs used in studies for assessing health outcomes in oncology and resource-use outcomes in low back pain patients. Psychometric scientists working closely with multi-disciplinary teams and regulatory authorities have greatly improved the science of collecting, assessing, and understanding patient-reported outcomes in clinical trials. A simplified framework is presented for strategic considerations for including PROs in studies, such as the appropriate timing for PRO endpoints. Asking patients about their health status and/or use of resources improves our understanding of how interventions and care processes may impact their lives and their budgets. We provide examples from a back pain trial of patient-reported resource-use questionnaires for medicines taken and other services or products used by patients. Healthcare stakeholders are placing increased emphasis on resource use and the impact of interventions on patients, including effects associated with diagnostic tests. Patient-reported outcomes are being used in clinical practice and in clinical research, supported by formal best-practice guidelines. Radiology has a role as an engaged stakeholder in the design, conduct, and interpretation of patient-based evidence, and in its relevance to health policy implementation.

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Managing sheep and beef farm systems - where does pasture persistence fit in?

Pasture persistence is highly rated by sheep and beef farmers as an important factor determining wholefarm performance. Managing pastures to ensure the persistence of newly sown pasture species must be considered as a part of the decision making process of the whole farm. The farmer aims to optimise the outcomes of resource use over time, rather than maximise any single resource, and therefore grazing decisions must be considered in this context. Pasture renewal is a major event-driven disruption that replaces current pasture species with competitive species, creating a grass-legume complex that has a tendency to develop towards a community of plants that tolerate the local environmental stress. Pasture persistence can be improved through managing the impacts of and interactions between environmental stressors on the pasture. Interactions between pasture management options, such as grazing and fertiliser, and the major environmental stressors of soil moisture, temperature, soil fertility, grazing and pests are discussed. Keywords: ecology, environmental stressors, farm systems, grazing management, pasture persistence.

Clinical and resource-use outcomes of risperidone long-acting injection in recent and long-term diagnosed schizophrenia patients: results from a multinational electronic registry

ABSTRACTBackground: Non-adherence to pharmacological treatment leading to frequent relapses and rehospitalizations is a major issue of concern among schizophrenia patients, especially those who are recently diagnosed. Risperidone long-acting injection (RLAI) has been shown to be efficacious, improve compliance, and increase long-term retention rate on therapy.Objective: To determine clinical outcomes and hospitalizations before and after the initiation of RLAI among schizophrenia patients with recent (≤2 years) diagnosis relative to those who had long-term (> 2 years) diagnosis.Research design and methods: The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is an observational study of patients with schizophrenia who start treatment with RLAI. Data were recorded at baseline, retrospectively for the 12 months prior to baseline, and prospectively every 3 months for 24 months. Data on patients with a defined length of diagnosis were pooled from eight countries.Main outcome measures: Clinical Global Impression of Illness Severity (CGI-S), Global Assessment of Functioning (GAF) scores, and hospitalization data were key outcomes.Results: The magnitude of improvement in CGI-S scores was greater in the recent versus long-term diagnosis group [Δ −1.48 vs. Δ −0.95 (12 months); Δ −1.6 vs. Δ −1.09 (24 months)]. There were parallel improvements in GAF scores [Δ 19.4 vs. Δ 13.7 (12 months); Δ 22.3 vs. Δ 16.8 (24 months)]. The decline in the proportion of patients hospitalized from the retrospective to the prospective period was greater in the recent versus long-term diagnosis group (Δ −36.0 vs. Δ −19%, respectively) at 12 months. This was also true for the number of hospital stays (Δ −0.6 vs. Δ −0.3, respectively) and length of stay (days) (Δ −20.9 vs. Δ −6.9, respectively) at 12 months. Common adverse events in both groups included psychiatric, gastrointestinal, musculoskeletal and reproductive system and breast disorders.Conclusions: Treatment with RLAI is associated with improved outcomes in recently diagnosed and chronic patients. However, the magnitude of improvement was higher in recently diagnosed patients.

Forest property rights in the frame of public policies and societal change

Property rights over natural resources became a distinct area of inquiry in environmental economics and policy in the last decades, but their role has not yet been investigated thoroughly. Transition countries represent an excellent material of analysis of various policies and institutional developments concerning the regime of use and management of natural resources. The processes of societal transformation had deep impacts on the forestry sector, entailing land reforms and subsequent changes to its institutional and organisational framework. This paper presents an analysis of the reciprocal relationship between the evolving forest property rights and the conduct of policy and economic actors, in connection with their outcomes. The theoretical framework consists of institutional economics, whose core concept is that patterns of interaction between institutions and actors produce physical outcomes, assessable by criteria such as equity and efficiency. The study concentrated on three distinct periods and the applicable property regimes. Within this framework, the impacts of the characteristics of property regimes and the general framework of socio-economic conditions on the exercise of property rights were analysed. The analysis of the conduct of forest owners in relation to the institutional design was completed by the analysis of the other actors influential for land reforms. Romanian forestry sector, in evolution from the period shortly before World War II to present, represents the case of the study. Research data were collected by interviewing/questioning, participant observation and literature review. They were analysed through an integrated method of content analysis and a matrix analysis. An important conclusion is that not only the regime of forest property is determinant for the outcomes of resource use and management, but also the general settings in which they are embedded. Another essential point is that land reforms driven by either efficiency or equity rationales are not mere diversions of the benefit stream, but complex processes with serious implications for the status of the resource at stake.