Range Of Health Care Services Research Articles

InCept – Patient’s Perception of Primary Health Care Provision with Respect to Access, Continuity and Coordination: International Qualitative Perspectives

Introduction: Health care systems across the world are confronted with three main challenges: an increasing burden of multimorbidity, an aging society and an unmet need for GPs (general practitioners). As the first point of contact, which provides a comprehensive range of health care services and coordinates the healthcare agencies, Primary Care (PC) can be a central part of the answer. In previous research which examined the quality of PC, patient satisfaction, especially in a qualitative manner, was studied the least. By comparing patient satisfaction in different health systems gleaned in an open-ended, qualitative manner, we aim to answer the question as to whether patients’ descriptions about their needs can be linked to specific health care structures.
 Methods: From December 2019 to April 2021, we contacted GPs from Brazil, Germany, Sweden, Switzerland, and the British Isle Jersey and asked them to recruit potential interview partners. Patients had to have a stroke and/or a myocardial infarction (MI) during the past year combined with an underlying chronic condition (diabetes and/or hypertension and/or obesity) to ascertain regular contact with the healthcare system. Minimum two patients per country were included.
 Patients were interviewed based on an identical semi-structured interview-guideline in their respective mother-tongue. Transcribed interviews were analysed according to qualitative content analysis in a mixed deductive - inductive way.
 Results: Overall 34 interviews were performed (Germany n=10, Sweden n=7, Switzerland n= 4, Brazil N=10, Jersey n=3). The derived category system consisted of 4 main categories (access, coordination, continuity, patient centeredness) and 10 subcategories.
 Patients’ perceptions of their care process in and after acute incidents can provide information about their preferences with care provision that can partially be related to specific structural components of care. Health care processes in general were considered as positive if a flow of information was accomplished in a non-technical, friendly and family involving way. Non-physician staff seem to create reassurance and provide the feeling of an available contact person. Longitudinal continuity in the context of trust, a sense of security, and a long-lasting doctor-patient relationship were perceived as positive. A shortage of resources following acute treatment such as heart sport groups, self-help groups and physiotherapy, as well as the limited provision of information and education about the event was criticized by patients. In the countries without formal gatekeeping (Germany, Switzerland, Jersey), communication between PC physicians and specialists, as well as informational continuity, seem to be perceived worse.
 Conclusion: This pilot study, in an international setting indicates, that patients’ experiences can provide important information about the relevance of defined care structures to them. Therefore, patient experiences should be considered when planning or reorganizing care. Specifically, our data suggest the need to enhance non-physician staff to support patients through their care pathway and to consider a better link between PC and specialists.

Pharmacy stewardship to reduce recurrent hypoglycemia

BackgroundInpatient hypoglycemia is associated with increased morbidity and mortality. After a hypoglycemic event, the likelihood of additional episodes increases. The Joint Commission recommends evaluating all episodes of hypoglycemia for root-cause analysis. Studies have shown that pharmacists’ involvement with glycemic control protocols can prevent hypoglycemia. ObjectivesThis study aimed to assess whether the implementation of pharmacists’ real-time assessment of hypoglycemic events using an electronic alert messaging system contributes to the reduction of the number of recurrent hypoglycemia during hospitalization. Practice descriptionA community hospital that provides a wide range of health care services. The pharmacy department provides fully decentralized clinical services and team-based specialist services. Practice innovationThe pharmacist-led hypoglycemia stewardship initiative included a comprehensive review of hypoglycemic alerts received via an automated message. The alerts generated in the electronic health record (EHR) every time a patient’s blood glucose resulted in less than 70 mg/dL if there was a documented administration of a hypoglycemic agent 48 hours before the hypoglycemia event. Once the alert was received by the pharmacists via an EHR in-basket, a real-time review was conducted to identify the potential causes of the event and opportunities for therapy modification. Evaluation methodsA single-center retrospective observational study including a pre- and post-implementation phase from January 1 to June 3, 2020, and January 1 to June 30, 2021, respectively. Continuous data were analyzed using paired and equal variance t test. Noncontinuous data were analyzed using Fisher exact and chi-square test. Descriptive statistics were used to describe distribution and frequency of data. ResultsThere was a 5.1% absolute reduction in recurrent hypoglycemic events (P < 0.001) and a 0.6% reduction of severe hypoglycemic days (P = 0.269) in the postimplementation group. The average time to pharmacist intervention was 4 (± 3.5) hours with a 92% acceptance rate. ConclusionThis study demonstrated the utility of pharmacist-led hypoglycemia reviews in the reduction of recurrent hypoglycemic events in the inpatient setting.

Assessing Patient Satisfaction with Medical Services: A Quantitative Study in a Private Clinic in Constanta, Romania

Abstract Medical services refers to the range of health care services and treatments provided to individuals in order to promote, maintain or restore their physical and mental well-being. Patient satisfaction refers to the degree to which patients are satisfied with their healthcare experiences. It is a subjective measure that reflects patients’ opinions and perceptions of the health services they receive. The purpose of the research is therefore to test the patient’s satisfaction with medical services in the respective clinic, taking into account the essential aspects that emerged after consulting the specialized literature on patient satisfaction. The research methodology provides for the use of a quantitative method, namely the questionnaire, which also represents personal contribution to the development of knowledge in the respective field. The questionnaire has 25 questions and is addressed it to a number of 50 patients of a private clinic in Constanta, Romania,.

Understanding categories of postpartum care use among privately insured patients in the United States: a cluster-analytic approach.

The postpartum period is critical for the health and well-being of birthing people, yet little is known about the range of health care services and supports needed during this time. Maternity care patients are often targeted for clinical interventions based on "low risk" or "high risk" designations, but dichotomized measures can be imprecise and may not reflect meaningful groups for understanding needed postpartum care. Using claims data from privately insured patients with childbirths between 2016 and 2018, this study identifies categories and predictors of postpartum care utilization, including the use of maternal care and other, nonmaternal, care (eg, respiratory, digestive). We then compare identified utilization-based categories with typical high- and low-risk designations. Among 269 992 patients, 5 categories were identified: (1) low use (55% of births); (2) moderate maternal care use, low other care use (25%); (3) moderate maternal, high other (8%); (4) high maternal, moderate other (7%); and (5) high maternal, high other (5%). Utilization-based categories were better at differentiating postpartum care use and were more consistent across patient profiles, compared with high- and low-risk dichotomies. Identifying categories of postpartum care need beyond a simple risk dichotomy is warranted and can assist in maternal health services research, policymaking, and clinical practice.

Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions.

ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well-recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice. A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta-analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions. We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice-related research priorities are proposed for each of the four of the areas explored. Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence-based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small-scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

Ethical issues with geographical variations in the provision of health care services

Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.

Kafka Lives: Consideration of Psychological Wellbeing on Staff under Investigation Procedures in the NHS

Culture change in the UK National Health Service (NHS) became a national concern following the Francis enquiry (2013) with increasing initiatives to develop models of compassionate management. This call was intended to create an environment to address investigations in the best possible manner creating a nurturing environment for staff and in turn their patients; a truly no-blame culture. Whilst principles of justice and compassionate are intended to underpin staff investigations, our clinical experience at the coal-face in working with Staff under Investigation (SUI) has proved that this is (too often) not the case. SUI often find they have little information about the complaint against them, little communication to clarify and await the outcome in general isolation from organisational or team access, until they are invited to the attend and explain their position. The resultant anxiety and distress mean that they are left traumatised by the investigation procedure itself. This brief paper aims to highlight the avoidable stressors caused by investigation procedures in the UK NHS themselves and aims to highlights aspects of these polices which require greater attention. This in turn would support a beneficial outcome for the investigation procedures overall. Whilst focusing on the UK, the generic processes of investigation have a number of commonalities which allow this information to be applicable to a range of health care services and investigation procedures.

Patient-Generated Health Photos and Videos Across Health and Well-being Contexts: Scoping Review.

BackgroundPatient-generated health data are increasingly used to record health and well-being concerns and engage patients in clinical care. Patient-generated photographs and videos are accessible and meaningful to patients, making them especially relevant during the current COVID-19 pandemic. However, a systematic review of photos and videos used by patients across different areas of health and well-being is lacking.ObjectiveThis review aims to synthesize the existing literature on the health and well-being contexts in which patient-generated photos and videos are used, the value gained by patients and health professionals, and the challenges experienced.MethodsGuided by a framework for scoping reviews, we searched eight health databases (CINAHL, Cochrane Library, Embase, PsycINFO, PubMed, MEDLINE, Scopus, and Web of Science) and one computing database (ACM), returning a total of 28,567 studies. After removing duplicates and screening based on the predefined inclusion criteria, we identified 110 relevant articles. Data were charted and articles were analyzed following an iterative thematic approach with the assistance of NVivo software (version 12; QSR International).ResultsPatient-generated photos and videos are used across a wide range of health care services (39/110, 35.5% articles), for example, to diagnose skin lesions, assess dietary intake, and reflect on personal experiences during therapy. In addition, patients use them to self-manage health and well-being concerns (33/110, 30%) and to share personal health experiences via social media (36/110, 32.7%). Photos and videos create significant value for health care (59/110, 53.6%), where images support diagnosis, explanation, and treatment (functional value). They also provide value directly to patients through enhanced self-determination (39/110, 35.4%), social (33/110, 30%), and emotional support (21/110, 19.1%). However, several challenges emerge when patients create, share, and examine photos and videos, such as limited accessibility (16/110, 14.5%), incomplete image sets (23/110, 20.9%), and misinformation through photos and videos shared on social media (17/110, 15.5%).ConclusionsThis review shows that photos and videos engage patients in meaningful ways across different health care activities (eg, diagnosis, treatment, and self-care) for various health conditions. Although photos and videos require effort to capture and involve challenges when patients want to use them in health care, they also engage and empower patients, generating unique value. This review highlights areas for future research and strategies for addressing these challenges.

Healthcare patterns among medical professionals

The article is focused on attitudes of healthcare workers towards their health. The outbreak of the COVID-19 pandemic, followed by a substantial increase in media coverage of public health-related issues, has dramatically altered many people’s normal routines and caused a shift in our collective perception of normal. In this context, examining the attitudes of health care workers toward their health becomes particularly topical as this group possesses first-hand knowledge about the pandemic and various medical subjects. We consider medical professionals as specially-trained people who possess evidence-based knowledge about our body, mental, and physical health. Since it is a challenging job that involves being in close contact with people who are sick or recovering from illness, the risks of which have been exacerbated by the pandemic, this group has privileged access to professional medical services. We conducted a quantitative sociological survey among medical professionals who work for the Moscow Health Care System. This research allows us to analyze patterns of health care utilization and health behavior among health care workers and the correlation between their attitudes and perceptions of the problem and the actual patterns of their behavior. This paper aims to answer the following question: how do the level of medical knowledge and privileged access to a wide range of health care services and resources affect the attitudes toward one’s own health that are common among the so-called expert groups?

Association Between Work Status and the Use of Healthcare Services Among Women in the Republic of Korea

IntroductionPrevious studies on occupational health focussed predominately on the occurrence of occupational diseases. Relatively few studies have measured how employment is associated with the use of healthcare services. This study investigates the association between employment and the extent and range of healthcare use, such as medical expenditures, of women in South Korea. MethodsWe analyze data of the Korean Health Panel, an ongoing longitudinal national representative survey, from 2008 to 2017, to identify the status of economic activity of women by year and age group. We estimate the association between female employment status and medical expenditures by using random effect panel Tobit models. Furthermore, we investigate the association between employment status and the range of healthcare services in biomedicine and traditional Korean medicine (KM) by conducting conditional fixed-effects logistic regression analyses. ResultsFor women aged between 25 and 65 in 2017, the majority of them were employed or self-employed. (The proportion of employment of self-employment equals 64.80%). In addition, working women spent 11.6% less on healthcare than nonworking women, and self-employment lowered the healthcare expenditure by 13.1%. Neither work nor the type of work is related to the types and range of healthcare service use. Being employed or self-employed is negatively associated with women’s expenditure on healthcare. ConclusionsThe findings show that employment is associated with less spending on healthcare. They imply that employment has a positive impact on women’s health.

A Pediatric Hospital Physical Therapy and Occupational Therapy Department's Response to COVID-19: An Administrative Case Report.

ObjectiveThe purpose of this case report is to describe the challenges that COVID-19 presented for therapists in a pediatric hospital and the response to these challenges.Methods (Case Description)The case report setting is a physical therapy and occupational therapy department (department) of an academic pediatric medical center that provides a range of health care services for children and youth. Challenges that COVID-19 presented to the Department included: (1) managing safety concerns for patients, their families, and staff; (2) continuing to provide high-quality therapy services within state mandated restrictions; (3) triaging patients; and (4) keeping clinicians employed and working productively.ResultsThe Department therapists responded to these challenges by: (1) increasing communication huddles, (2) developing procedures for staffing and triaging of patients, (3) developing procedures for telehealth therapy services, and (4) designing a remote work program for all department employees. The number of patients and staff on site were reduced by initiating telehealth services, triaging patients, and developing a remote work plan. Communication huddles, department meetings, and supervision meetings were converted to virtual meetings. Staffing rates, patient-care productivity, and department project work were maintained.ConclusionIn response to COVID-19, the department developed new protocols provided information about the protocols, which might be helpful for other pediatric hospitals or outpatient settings when planning for future pandemics or other issues that challenge the ability to provide usual care. Increasing the frequency of verbal and written communication on operational topics is recommended. Primary sources of information from national organizations (eg, the American Physical Therapy Association and the American Occupational Therapy Association) can assist with determining the scope of practice and code of conduct during a pandemic.ImpactCOVID-19 posed challenges to operations and delivery of patient care. Although this case report is specific to COVID-19, principles applied and lessons learned from this experience can be applied to other emergency situations.

Using Dental Health Care Personnel During a Crisis : COVID-19 Pandemic in the Bronx, New York.

The first few months of the coronavirus disease 2019 (COVID-19) pandemic challenged health care facilities worldwide in many ways. Inpatient and intensive care unit (ICU) beds were at a premium, and personnel shortages occurred during the initial peak of the pandemic. New York State was the hardest hit of all US states, with a high concentration of cases in New York City and, in particular, Bronx County. The governor of New York and leadership of hospitals in New York City called upon all available personnel to provide support and patient care during this health care crisis. This case study highlights the efforts of Jacobi Medical Center, located in the northeast Bronx, from March 1 through May 31, 2020, and its use of nontraditional health care personnel, including Department of Dentistry/OMFS (Oral and Maxillofacial Surgery) staff members, to provide a wide range of health care services. Dental staff members including ancillary personnel, residents, and attendings were redeployed and functioned throughout the facility. Dental anesthesiology residents provided medical services in support of their colleagues in a step-down COVID-19-dedicated ICU, providing intubation, ventilator management, and critical and palliative care. (Step-down units provide an intermediate level of care between ICUs and the general medical-surgical wards.) Clear communication of an acute need, a well-articulated mission, creative use of personnel, and dedicated staff members were evident during this challenging time. Although not routinely called upon to provide support in the medical and surgical inpatient areas, dental staff members may provide additional health care personnel during times of need.

Virtual primary care in high-income countries during the COVID-19 pandemic: Policy responses and lessons for the future

Background Telemedicine, once defined merely as the treatment of certain conditions remotely, has now often been supplanted in use by broader terms such as ‘virtual care’, in recognition of its increasing capability to deliver a diverse range of healthcare services from afar. With the unexpected onset of COVID-19, virtual care (e.g. telephone, video, online) has become essential to facilitating the continuation of primary care globally. Over several short weeks, existing healthcare policies have adapted quickly and empowered clinicians to use digital means to fulfil a wide range of clinical responsibilities, which until then have required face-to-face consultations. Objectives This paper aims to explore the virtual care policies and guidance material published during the initial months of the pandemic and examine their potential limitations and impact on transforming the delivery of primary care in high-income countries. Methods A rapid review of publicly available national policies guiding the use of virtual care in General Practice was conducted. Documents were included if issued in the first six months of the pandemic (March to August of 2020) and focussed primarily on high-income countries. Documents must have been issued by a national health authority, accreditation body, or professional organisation, and directly refer to the delivery of primary care. Results We extracted six areas of relevance: primary care transformation during COVID-19, the continued delivery of preventative care, the delivery of acute care, remote triaging, funding & reimbursement, and security standards. Conclusion Virtual care use in primary care saw a transformative change during the pandemic. However, despite the advances in the various governmental guidance offered, much work remains in addressing the shortcomings exposed during COVID-19 and strengthening viable policies to better incorporate novel technologies into the modern primary care clinical environment.

Courts Strike Down Trump’s ‘Refusal of Care’ Conscience Rule

Courts Strike Down Trump’s ‘Refusal of Care’ Conscience Rule

Performing Analysis of Quality of Service Parameters of 4G Long Term Evolution in Health Care System

Long Term Evolution (LTE) is a leading 4G wireless broadband technology developed by the Third Generation Partnership Project (3GPP) Release 8. LTE is expected to provide very fast, highly responsive and cost effective data services and appears itself to be the right technology at the right time. LTE is becoming an ultimate choice for 4G services around the world due to its higher data rates and lower latency objectives. E-Health services comprise a wide range of healthcare services delivered by utilizing information and communication technology. In order to help existing and emerging e-Health services over converged next generation network (NGN) architectures, there is a need for network QoS control mechanisms that meet the often stringent requirements of such services. The mobile Health (m-health) is currently uniting major academic research worldwide to achieve innovative arrangements in the areas of healthcare. However, there are several challenges and issues that need to be addressed. In this paper we have proposed m-health care system based on 4G LTE network communication instead of existing 3G communication system. We will be monitoring QoS parameters like Delay, Throughput, Jitter, Energy Efficiency and Packet Data Rate for comparing 3G and 4G LTE usage over health care applications. We will further experiment the parameters with graph based analysis.

Solidarity against healthcare access restrictions on undocumented immigrants in Spain: the REDER case study

BackgroundIn the context of public expenditure reduction and cuts, in 2012, the Spanish government approved the RDL 16/2012, which significantly affected the core values of the national health system. The measure particularly affected undocumented immigrants over 18 years of age, excluding them from accessing the full range of healthcare services in Spain, except for emergency care. In 2014, Red de Denuncia y Resistencia al RDL 16/2012 (REDER) was created as a public awareness and resistance network to defend universal access to healthcare and to stop its infringement. This study aims to analyse the social impact of REDER as a solidarity movement in response to the exclusion of undocumented immigrants from their universal right to health.MethodsQualitative research methodologies were used for the research. Data were collected between November 2017 and December 2017, using eight semi-structured interviews with key informants from the main REDER stakeholders. Additionally, key publications, documents, and presentations of researchers and experts in the field were analysed. For data analysis, a framework extracted from the literature on exclusionary and transformative dimensions of solidarity was used to identify barriers and drivers in REDER’s intervention.ResultsFrom its creation to the present, REDER has been able to achieve many of its objectives to defend the right to medical care of groups in irregular situations, contributing to the identification of 4,755 cases of discrimination in healthcare access and helping solve over 90% of these cases by delivering either healthcare assistance or administrative support. REDER has also played an important role in: stimulating social activation and empowering citizens to claim their fundamental rights, organising actions against restrictions on accessibility and creating synergies to restore universal healthcare coverage.ConclusionsREDER has been shown to be effective in leading the defence of universal healthcare rights, and some achievements in the years following 2012 could be directly attributed to the work done by the network, such as the elimination of legal requirements to obtain health cards or the reduction of the minimum time required to access healthcare. Despite context particularities, the initiatives and main actions of this network may be implemented in other settings that are facing similar limitations to healthcare access, in order to address injustices and promote solidarity.

A Qualitative Synthesis of the Effects of Rising Cost-Sharing Requirements in the United States

In diesem Beitrag evaluiere und synthetisiere ich Ergebnisse aus zehn Jahren qualitativer Forschung zu den Effekten steigender Selbstbeteiligungsanforderungen in der Gesundheitsversorgung. Wahrend das Gros an Forschung in diesem Feld quantitativ ausgerichtet war und ist, will ich mit meiner Analyse dazu beitragen, die Perspektiven und Erfahrungen der Patient/innen und der Dienstanbieter/innen nachzuvollziehen. Ein Ergebnis ist, dass steigende Selbstbeteiligungsanforderungen viele Amerikaner/innen veranlassen, auf Gesundheitsdienstleistungen zu verzichten. Dies gilt auch fur medizinisch erforderliche Behandlungen fur sie selbst und fur ihre Familienmitglieder, und zwar auch im Falle von der Mittelklasse zugehorigen Familien, bei denen Angehorige in regularen Arbeitsverhaltnissen stehen und versichert sind. Zweitens zeige ich, dass diese Anforderungen zu Konfusion, Sorge, Stress und einer allgemeinen Angstlichkeit aufseiten der Patient/innen beitragen. Meine Befunde sind komplementar zu denen aus dem RAND Health Insurance Experiment, einer grosen experimentellen Studie zu Gesundheitskosten und der Nutzung von Gesundheitsdienstleistungen, die von 1974 bis 1982 durchgefuhrt wurde, um die Effekte von Krankheitsfolgekosten nachvollziehen zu konnen. Diese Befunde sind kritisch, weil aufseiten einiger politischer Entscheidungstrager/innen eine weitere Steigerung der Selbstbeteiligung unterstutzt wird. Ich diskutiere auch Grenzen und mogliche Folgerichtungen solcher Untersuchungsansatze.

Co-designing an Integrated Care Pathway for Children and Families with a Neuromuscular Disorder in Ireland

Introduction: Children, adolescents and their families with a suspected or confirmed diagnosis of a neuromuscular disorder NMD require access to a broad range of healthcare services and supports in the community and acute hospital, from a range of different providers and agencies at any given point in time, due to the complexity of their condition. A neuromuscular disorder is a rare disease which is complex and progressive, often affecting multiple body systems. Neuromuscular disorders are often the result of genetic mistakes or mutations that affect muscle stability, the ability of muscle to regenerate or interrupt the communication between nerves and muscles. Examples of neuromuscular disorders include; Duchenne Muscular Dystrophy DMD, Congenital Muscular Dystrophy CMA and Spinal Muscular Atrophy SMA. Context: While clinical pathways exist for some children with NMD, they relate to children with a specific diagnosis, different points in the child’s care journey, or areas of specific clinical management. No integrated care pathway exists to capture the entire care journey, to give guidance to service providers with regard to delivering standardised, child and family centred, integrated care. Targetted objective: The objective of the project, established by the Integrated Care Program for Children, is to standardise the care journey of a child with NMD and their family from initial presentation and diagnosis to transition to adult services through the co-design and implementation of an Integrated Care Pathway with parents, young adults with NMD and healthcare providers. The pathway focuses on standardisation and integration of services and, critically, on how services communicate with children and families themselves, and with each other. Highlights: Innovations: Focus groups and telephone interviews were conducted with parents and young adults with NMD in relation to their personal experience of services and their perspective on how services could be improved. A multidisciplinary steering group was established which included a consultant neurologist as clinical lead and two parent representatives. A project group and patient reference group were established to ensure a collaborative model of design was applied throughout. Impacts: Three distinct phases emerged during the co-design stage: Phase One: Recognition and/or Diagnosis, Phase Two: On-going Care and Phase Three: Transition. Within each phase a number of themes were agreed, and a specific set of standards was developed for each theme. A suite of practical family resources have also been co- designed as part of the pathway to help meet the agreed standards. Further resources have been identified for co-design in 2018. Outcomes: Co-design and formal consultation stages of the pathway are complete. The pathway is now going through a formal approval process. Launch of the integrated care pathway is planned for early 2018. The pathway will be tested in two geographical areas in 2018, prior to phased national implementation. Learning & transferability: The project gives a unique insight into the needs and priorities of children and families with neuromuscular disorders and has provided an opportunity to co-design what families feel will meet their needs. This learning could be applied to children with a range of diagnoses over time.

Childhood full and under-vaccination in Nigeria, 2013

BackgroundNigeria’s government is challenged with vaccinating the world’s third largest birth cohort within a culturally and socioeconomically diverse country. This study estimated full childhood immunization coverage in Nigeria and characterizes the association between vaccination status and urbanicity, region of residence, ethnicity, and other factors. MethodsIn 2013, households throughout Nigeria were enrolled in the Demographic and Health Survey which included questions about vaccination. We defined full vaccination of a child as having received a single dose of bacillus Calmete-Guerin (BCG), one dose of measles-containing vaccine (MCV), three doses of diphtheria, pertussis, tetanus (DPT), and four doses of oral polio vaccine (OPV). Using a multinomial logistic regression model, full vaccination and under-vaccination versus non-vaccination was regressed onto various demographic and socioeconomic characteristics. ResultsAmong 5759 children 1 year of age, 25.5% were fully vaccinated, 47.9% were under-vaccinated, and 26.6% had not received any vaccinations. Children were more likely to be fully vaccinated if they belonged to wealthier families, resided in southern regions of the country, were Christian, belonged to the Igbo or Yoruba ethnic group, had mothers who made ≥5 antenatal care visits, delivered at an institution, or were more highly educated. ConclusionsFull vaccination among children in Nigeria is exceptionally low by global standards and certain groups, such as Muslims and individuals in northern regions who are higher risk of non- or under-vaccination should be targeted by vaccination programs. Providing a wide range of health care services for mothers and pregnant women could improve full vaccination of children.