Regional Healthcare Service Research Articles

The strategy role of transitional care units to support Integrated Care and Personalised pathways for frail persons

The paper presents a comparative analysis of three models of transitional care units that have been set up in Italy in the last three years within the processes of Regional Healthcare Services and healthcare organisations’ reforms. The comparative analysis is worth of providing interesting insights and generalizable lessons learnt from integrated care in practice. The three cases of transitional care units belong to a similar background wherein greater needs for care coordination across the supply chain have risen, but the implementation has brought to different organizational solutions to meet the contextual features. The common base-line scenario can be described by four fundamentals: 1) the merge and establishment of larger Local Health Authorities, serving a population of 1.2mln inhabitants on average; 2) the set-up of integrated care models between hospital care and primary care (as intermediate care, rehab., residential care, palliative care, home care or hospital at home); 3) the use of clinical governance tools and methods (as Integrated care pathways (ICPs), clinical networks), exploiting approaches deriving from the population health management (PHM); 4) the efforts to strengthen the integration between health and social care, foremost by using tools and targeted case management models for the most fragile persons. From this scenario, three different models of transitional care units rose, in Veneto Region, in Tuscany and in Lombardy, to build up integrated care by streamline ICPs across the supply chain of services and professionals within the newly established LHAs. The paper discusses comparatively the three cases of transitional care units. It analyses in depth three cases, one from each Region, based on different healthcare organization unit. The case study analysis allows to tackle out the organizational, professional and operational tools applied distinctively, based on the data collection of their initial activities and interviews with the key players. From the comparisons, lesson learnt can be drawn for generalization, detangling the contextual organizational features and service design’s needs (the path and resources dependency of each model) from more general observations and tips that could foster the sustainability and efficacy of similar services.

Variability of adverse events in the public health-care service of the Tuscany region.

The objective of the study is to analyze the variation of adverse events (AEs) according to the different structure of hospitals. The study is a multicenter, retrospective study. It involves 4 teaching hospitals (THs) and 32 community hospitals, distributed in 12 local trusts (LTs), of the Tuscany Regional Healthcare Service (RHS). A random sample of the clinical records of patients admitted in LTs and THs in 2008 was selected from the database of the hospital discharge records of the centers. Among 11,293 clinical records included, a total of 354 adverse events were identified. There was a significant higher incidence of AEs in the male and elderly (>65years) population, and the incidence of AEs was more relevant in the THs (5.3, 95% CI 4.7-6.1) than in the LTs (1.8, 95% CI 1.5-2.2). AEs related to falls were significantly more preventable in THs (OR 19.22, 95% CI 2.45-151.02), while in LTs, AEs related to infections were the most preventable (OR 6.22, 95% CI 1.35-28.67). Concerning the consequence of AE, death is significantly more probable for AEs related to unexpected cardiac arrest in LTs, while disability and prolongation of the stay are significantly more probable consequences associated with re-admission in THs, and to transfer to ICU or HDU in LTs. Re-interventions, surgical complications and falls are the factors more correlated with AEs. In conclusion, the study shows a higher risk of incurring adverse events for the THs compared to the LTs, presumably connected with a major complexity of the clinical cases. Furthermore, the preventability of AEs is higher in the LTs (56.1 vs 42.2%), and this might be associated with lower expertise in managing complications in these settings. Concerning specialties, there are no significant differences in AEs distribution.

Adult Deterioration Detection System (ADDS): An evaluation of the impact on MET and Code blue activations in a regional healthcare service

AimsTo evaluate the impact of Acute Deterioration Detection System (ADDS) charts introduced to a regional healthcare service. BackgroundTo assist health professionals in identifying essential elements for recognizing patient clinical deterioration, a national initiative introduced track and trigger observation charts, to hospitals in Australia. This study investigated whether the introduction of ADDS charts had an impact on the number of Medical Emergency Team (MET) and Code Blue activations at one regional healthcare service, according to their incident recording database. MethodA retrospective study of all Code Blue and MET activations was undertaken at a regional hospital, pre and post the introduction of ADDS charts in a two year period, June 2012 to June 2014. ResultsThere was a significant increase in MET activations from 5.91 to 11.27 per 1000 admissions (p<0.01) after the implementation of ADDS charts. There was also an unexplained non-significant increase from 0.50 to 0.88 per 1000 admissions in the activations of Code Blue during this period (p=0.05). It was also found that ADDS charts did not overly influence the activation criteria for calling a MET/Code Blue, except for an increase in reports of high heart rate and a decrease in the use of the criteria ‘worried’. ConclusionThe introduction of ADDS charts has provided health professionals with a clear track and trigger set of criteria, improving the detection of early signs of deterioration in patients. This study demonstrated an increase in activations as a result of the introduction of ADDS charts in one regional healthcare service.

A descriptive qualitative study of childhood cancer challenges in South Africa: Thematic analysis of 68 photovoice contributions

&lt;strong&gt;Background:&lt;/strong&gt; Many childhood cancers are treatable with cure rates between 70% and 80% in well-resourced countries, while approximately 80% of African children with cancer die without access to adequate care. South Africa has an established oncology health care service with overburdened infrastructure, low cancer awareness in the primary health care service and widespread service delivery challenges.&lt;br /&gt;&lt;strong&gt;Aim:&lt;/strong&gt; The aim of this study was to explore, document and analyse the subjective experience of childhood cancer-related challenges in South Africa, and to make the results available to stakeholders.&lt;br /&gt;&lt;strong&gt;Setting:&lt;/strong&gt; A total of 58 patient-participants (childhood cancer patients, parents and guardians of children with cancer) and 10 paediatric oncology workers (oncology social workers, oncology nurses and interim home carers) were selected from tertiary oncology centres and from the Childhood Cancer Foundation of South Africa (CHOC) interim care homes across South Africa.&lt;br /&gt;&lt;strong&gt;Method:&lt;/strong&gt; Participants were selected via convenience sampling and qualitative data were derived from face-to-face photovoice interviews conducted by psychologists and social workers and supported by translators when necessary.&lt;br /&gt;&lt;strong&gt;Results:&lt;/strong&gt; Nine themes of cancer challenges were identified via thematic content analysis of the photo-narratives, that is, physical and treatment challenges, emotional, poor services, transport, finances, information, powerlessness, stigma and schooling challenges.&lt;br /&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Lack of awareness and knowledge about cancer at the African traditional healer, primary and regional health care service levels were frequent challenges. Important feedback included lack of patient-centred care, separation of children with cancer from guardians, diagnostic delays, permanent disabilities for children because of cancer, emotional trauma, special needs of teenagers and a lack of community and palliative care support.

Trends in heart failure hospitalizations, patient characteristics, in-hospital and 1-year mortality: A population study, from 2000 to 2012 in Lombardy

BackgroundThis study was undertaken to evaluate trends in heat failure hospitalizations (HFHs) and 1-year mortality of HFH in Lombardy, the largest Italian region, from 2000 to 2012. MethodsHospital discharge forms with HF-related ICD-9 CM codes collected from 2000 to 2012 by the regional healthcare service (n=699797 in 370538 adult patients), were analyzed with respect to in-hospital and 1-year mortality; Group (G) 1 included most acute HF episodes with primary cardiac diagnosis (70%); G2 included cardiomyopathies without acute HF codes (17%); and G3 included non-cardiac conditions with HF as secondary diagnosis (13%). Patients experiencing their first HFH since 2005 were analyzed as incident cases (n=216782). ResultsAnnual HFHs number (mean 53830) and in-hospital mortality (9.4%) did not change over the years, the latter being associated with increasing age (p<0.0001) and diagnosis Group (G1 9.1%, G2 5.6%, G3 15.9%, p<0.0001). Incidence of new cases decreased over the years (3.62 [CI 3.58–3.67] in 2005 to 3.13 [CI 3.09–3.17] in 2012, per 1000 adult inhabitants/year, p<0.0001), with an increasing proportion of patients aged ≥85y (22.3% to 31.4%, p<0.0001). Mortality lowered over time in <75y incident cases, both in-hospital (5.15% to 4.36%, p<0.0001) and at 1-year (14.8% to 12.9%, p=0.0006). ConclusionsThe overall burden and mortality of HFH appear stable for more than a decade. However, from 2005 to 2012, there was a reduction of new, incident cases, with increasing age at first hospitalization. Meanwhile, both in-hospital and 1-year mortality decreased in patients aged <75y, possibly due to improved prevention and treatment.

A web-based information system for a regional public mental healthcare service network in Brazil

BackgroundRegional networking between services that provide mental health care in Brazil’s decentralized public health system is challenging, partly due to the simultaneous existence of services managed by municipal and state authorities and a lack of efficient and transparent mechanisms for continuous and updated communication between them. Since 2011, the Ribeirao Preto Medical School and the XIII Regional Health Department of the Sao Paulo state, Brazil, have been developing and implementing a web-based information system to facilitate an integrated care throughout a public regional mental health care network.Case presentationAfter a profound on-site analysis, the structure of the network was identified and a web-based information system for psychiatric admissions and discharges was developed and implemented using a socio-technical approach. An information technology team liaised with mental health professionals, health-service managers, municipal and state health secretariats and judicial authorities. Primary care, specialized community services, general emergency and psychiatric wards services, that comprise the regional mental healthcare network, were identified and the system flow was delineated. The web-based system overcame the fragmentation of the healthcare system and addressed service specific needs, enabling: detailed patient information sharing; active coordination of the processes of psychiatric admissions and discharges; real-time monitoring; the patients’ status reports; the evaluation of the performance of each service and the whole network. During a 2-year period of operation, it registered 137 services, 480 health care professionals and 4271 patients, with a mean number of 2835 accesses per month. To date the system is successfully operating and further expanding.ConclusionWe have successfully developed and implemented an acceptable, useful and transparent web-based information system for a regional mental healthcare service network in a medium-income country with a decentralized public health system. Systematic collaboration between an information technology team and a wide range of stakeholders is essential for the system development and implementation.

HIV Clinical Pathway: A New Approach to Combine Guidelines and Sustainability of Anti-Retroviral Treatment in Italy

The present article describes the case study of a “real world” HIV practice within the debate concerning the strategic role of Clinical Governance (CG) tools in the management of a National Healthcare System’s sustainability. The study aimed at assessing the impact of a Clinical Pathway (CP) implementation, required by the Regional Healthcare Service, in terms of effectiveness (virological and immunological conditions) and efficiency (economic resources absorption), from the budget holder perspective. Data derived from a multi-centre cohort of patients treated in 6 Hospitals that provided care to approximately 42% of the total HIV+ patients, in Lombardy Region, Italy. Two phases were compared: Pre-CP (2009–2010) vs. Post-CP implementation (2011–2012). All HIV infected adults, observed in the participating hospitals during the study periods, were enrolled and stratified into the 3 categories defined by the Regional CP: first-line, switch for toxicity/other, and switch for failure. The study population was composed of 1,284 patients (Pre-CP phase) and 1,135 patients (Post-CP phase). The results showed that the same level of virological and immunological effectiveness was guaranteed to HIV+ patients: 81.2% of Pre-CP phase population and 83.2% of Post-CP phase population had undetectable HIV-RNA (defined as <50 copies/mL) at 12-month follow up. CD4+ cell counts increased by 28 ± 4 cells/mm3 in Pre-CP Phase and 39 ± 5 cells/mm3 in Post-CP Phase. From an economic point of view, the CP implementation led to a substantial advantage: the mean total costs related to the management of the HIV disease (ART, hospital admission and laboratory tests) decreased (-8.60%) in the Post-CP phase (p-value < 0.0001). Results confirmed that the CP provided appropriateness and quality of care, with a cost reduction for the budget holder.

The CreG (Chronic Related Group) model to prompt integrated chronic care management: the experience of Lombardy Region

Nearly one-third of the population live with some chronic conditions in Lombardy (3.5 millions out of more than 10 million residents), while expenditure on chronic diseases in the region accounts for about 75% of the of the Region’s overall health care spending. In order to improve chronic care management through a population-based approach, in 2011 the Region launched a new model for chronic care, named CReG (Chronic Related Groups), starting with five Local Health Authorities (LHAs) as piloting settings, built on a health-based risk-adjusted capitated payment system, and on the provision of integrated and personalised care pathways (PCP). The paper presents the most significant achievements of the CReG model, and highlights the main methodological and organisational challenges, in comparison with similar experience at international level. The CReG clinical-risk adjustment model is built on three fundamental steps: classification of diseases, a grouping system, and a tariff rate estimation and validation model. Chronic patients to be enrolled in the pilot study were identified through disease-specific algorithms combining data on inpatient diagnosis/procedures (ICD-9-CM), outpatient drug delivery and services, systematically collected by the regional administrative databases (the BDA or ‘Banca Dati Assistito’). All diagnoses were ranked based on the overall associated costs to the Regional Healthcare Service (RHS). The hierarchical grouping system (CReG grouper) relied on this ranking, providing a classification of the regional population into clinically-homogeneous categories (approximately 200), each corresponding to mono- or polypathologic conditions, according to a decreasing order of disease severity and costs. A prospective payment system was set up for each CReG Category, to provide an overall bundle tariff accounting for a one-year period of care (including pharmacy and outpatient services). The pilot programme has been managed in the Primary Care setting, through GP-cooperatives (CReG Manager) with several tools supporting care planning activities and the actual implementation of integrated clinical pathways (ICPs), based on prospective and flexible Personalized Care Plans (PCP), in particular: - Evidence-Based Clinical Pathways (EBCPs), - the so-called ‘Expected Healthcare Service List’ (EHSL), statistically estimated on the basis of 1-year historical consumptions, - an IT system developed ad-hoc, - a Care Management Service (CMS), set up by the GP-Cooperatives to support the implementation of PCPs, and ensure patients’ compliance and adherence to care plans. The paper discusses the results of a prospective matched-cohort study, based on patients registered with 484 participating GPs, used as the base-line ‘CReG cohort’, and a control sample of patients registered with GPs from the same 5 LHAs, but not managed according to the CReG protocol. More than 60.000 patients were enrolled and followed up for three years (2010-2013). Preliminary study results suggest the effectiveness of the CReG model on reducing hospitalization rates and risk of admissions to emergency departments, even though a longer observational period is needed to draw conclusions about the impact of CReG on quality and overall costs of care. The paper provides insights on the regional strategy to set up the CReG model and to handle the change management process, with the adoption of a new payment system. The CReG model has been fully developed internally, relying on a consolidated regional information system, which allows record linkage at individual level of administrative data on healthcare services and users’ consumptions data, taking into account both mono- and polypathological conditions. The historical amount of available data sustained the set-up of a robust and promising model for clinical risk adjustment at the individual level. The CReG Prospective Payment System indeed was introduced as a mean to overcome service delivery fragmentation and to promote better care coordination across the whole care pathway. While the proposed care delivery innovations were properly accomplished by GPs Cooperatives, with the assistance of Care Management Services, some conflicts arose during the contract management process between the GPs Cooperatives and the LHAs. Finally, the paper discusses the current challenges for future developments of the CReG-model in Primary Care, and also for exporting the CReG experience on prospective payment systems to other chronic care settings, in the context of current trends due to a Regional healthcare reform Act, issued in August 2015.

Developing online accreditation education resources for health care services: An Australian Case Study.

In 2013, 'National Safety and Quality Health Service Standards' accreditation became mandatory for most health care services in Australia. Developing and maintaining accreditation education is challenging for health care services, particularly those in regional and rural settings. With accreditation imminent, there was a need to support health care services through the process. A needs analysis identified limited availability of open access online resources for national accreditation education. A standardized set of online accreditation education resources was the agreed solution to assist regional and rural health care services meet compulsory requirements. Education resources were developed over 3 months with project planning, implementation and assessment based on a program logic model. Resource evaluation was undertaken after the first 3 months of resource availability to establish initial usage and stakeholder perceptions. From 1 January 2015 to 31 March 2015, resource usage was 20 272, comprising 12 989 downloads, 3594 course completions and 3689 page views. Focus groups were conducted at two rural and one metropolitan hospital (n = 16), with rural hospitals reporting more benefits. Main user-based recommendations for future resource development were automatic access to customizable versions, ensuring suitability to intended audience, consistency between resource content and assessment tasks and availability of short and long length versions to meet differing users' needs. Further accreditation education resource development should continue to be collaborative, consider longer development timeframes and user-based recommendations.

Abstract B83: Development of a cancer coalition to promote colorectal cancer screening in rural underserved communities in New Mexico

Abstract Introduction: Cancer continues to be one of the leading causes of death in the US; colorectal cancer (CRC) for example, has high incidence and mortality rates, even though much CRC is preventable. The rates of preventable cancers could be reduced through the promotion of early detection and screening. However, providing access to screening services to rural underserved communities, such as those found along the US – Mexico border can be difficult. Developing multidisciplinary collaborative screening efforts may expand the reach of regional healthcare services. Specifically, cancer coalitions have the potential to advance culturally competent health promotion programs because they include locally vested organizations and individuals working together to build a foundation for health promotion and social change. This study established the Southern New Mexico Cancer Coalition (SNMCC) to promote CRC education and increase access to CRC screening in Doña Ana County, New Mexico. Methods: Organizations and individuals from southern NM came together to address low CRC screening rates, a leading health concern in the state. SNMCC was created in October 2014 and included members representing New Mexico State University (NMSU), a local cancer center and endoscopy center, 2 federally qualified health centers (FQHC) who participated in the state CRC Control program, and a local community organization whose mission is to provide financial assistance to cancer patients in the county. Over a period of six months, the SNMCC planned and implemented a multi-component screening program that included the distribution of fecal immunochemical tests (FIT) in two regions of Doña Ana County, NM. The FITs were distributed by the Community Health Educator at NMSU and by promotoras de salud from the two FQHC's throughout February 2015. Individuals who received the FITs were asked to complete the tests and return them at the March Colorectal Cancer Awareness Day event held at a community center in southern Doña Ana County and at a church in northern Doña Ana County. All individuals who completed the test were entered into the FQHC's CRC Control Program and those with positive FITs were navigated to schedule colonoscopies. Results: A total of 100 FITs were distributed in Doña Ana County (50 in the southern sector and 50 in the northern sector) and had a 75% screening rate. In the southern sector of the county, 34 individuals completed and returned FITs at the event and at follow-up at the clinic. Of these, three were positive for blood in the stool; two of these received a follow-up colonoscopy. In the northern sector, a total of 41 individuals completed and returned FITs. Of these, 4 were positive for blood in the stool; three of these individuals received a follow-up colonoscopy, and have follow-up appointments scheduled for the colonoscopy results. Discussion: CRC continues to be a leading cause of cancer-related deaths in NM. Health promotion and prevention programs have the potential to address and reduce CRC incidence and mortality rates by promoting screening in regions where CRC screening is underutilized. Community-research collaborative efforts are crucial in increasing access to such healthcare and screening services and assist in closing the gaps in cancer health disparities found in the region. The development of the SNMCC was a comprehensive public health response to a major cancer issue affecting communities in southern NM. These coordinated efforts to promote colorectal cancer screening and improve access to cancer control programs had high screening rates (75%), identified at risk individuals at a high frequency, ~ 10% and navigated at risk individuals to treatment and further care. This program therefore has the potential to reduce CRC incidence and mortality among minority and underserved populations. Citation Format: Janeth I. Sanchez, Lynn Arnold, Daniel Armistead, Diana Dorado, Tara Lucero, Cliff Sanders, Frances Scappaticci, Tim Washburn, Yolanda Diaz, Beti Thompson, Mary O'Connell. Development of a cancer coalition to promote colorectal cancer screening in rural underserved communities in New Mexico. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B83.

Attempts in building a smart healthcare system at a research hospital

Described in the paper are contents and characteristics of building smart healthcare system at a research hospital, and practices of the hospital in exploring smart healthcare. Specific measures include staged building of an e-hospital emphasizing information security; closed-loop transformation with mobile and barcode technology for higher efficiency and patient safety; optimizing the service flow with smart interconnection to create an orderly outpatient environment; implementing healthcare regulations with information systems to ensure a homogeneous medical environment; and integrating the entire medical system to promote coordinated development of regional healthcare service. These measures help upgrade the information service effectiveness and quality of care of the hospital. Key words: Research hospital; Smart healthcare; System; Building

Self-administration of Recombinant Human Growth Hormone with an Electronic Device: Clinical, Economic and Management Benefits of Objective Adherence Monitoring

Purpose: The aim was to identify factors affecting treatment adherence and to assess the clinical, economic and management impact of growth hormone deficiency treatment using an electronic auto-injector for recombinant human growth hormone (r-hGH) administration in children. Patients and Methods: A literature review was conducted in PubMed up to 31JUL2013, including the following search terms: “growth hormone deficiency”, “human-recombinant growth hormone” and “treatment adherence”. An economic model was developed to estimate the economic benefits of using an electronic injection device. In order to quantify this benefit, potential savings due to growth hormone cartridge optimization were analyzed. Results: From the literature review, the following key factors were found to affect treatment adherence: type of device used, discomfort, complexity of treatment regimens, long-term treatment, age and patient or family understanding of treatment benefits were assessed. A better adjustment to prescribed daily dose (accuracy up to 0.01 mg) with the electronic device results in a better optimization of vials and could save an average of 5% of total treatment costs in terms of doses not wasted, amounting to €245 of potential savings per patient and year of treatment. Conclusion: The use of an electronic device for r-hGH administration and monitoring may provide a better identification of responder and adherent patients. It may also generate savings in annual r-hGH consumption by hospitals and regional healthcare services.

Fact-finding survey on regional healthcare services for patients with epilepsy based on a questionnaire administered to public health centers in Japan

Epilepsy is a common chronic neurological disorder characterized by recurrent unprovoked seizures. The prevalence of epilepsy is about 1%, and its incidence is increasing with the aging population. In addition to their medical problems, epilepsy patients face many social problems, including schooling, working, and maintaining their driver's licenses. However, these problems are not fully recognized by the regional healthcare centers (HCCs), and the inadequacy of collaboration between medical services, healthcare, and welfare is sometimes pointed out. Under these circumstances, this fact-finding survey was administered in the form of a questionnaire to HCCs across the nation for the purpose of improving the support system and educational activities for epilepsy in Japan. A mail-back survey on regional healthcare services for epilepsy patients was sent out to 490 HCCs across the nation. Public health nurses (PHNs) responded to the self-completed questionnaire on behalf of each HCC. The questionnaire was comprised of the presence or absence of consultations on epilepsy, content of the consultations, and holding of workshops, lectures, or conferences in the community covered by the HCC. We obtained responses from 347 HCCs (response rate 71%). Seventy-three percent of the PHNs had experience with consultations regarding the medical and healthcare issues associated with epilepsy. However, only 10% of the PHNs responded that they could provide appropriate consultation for these issues. The content of the consultations mainly included medical services, clinical symptoms of epilepsy, and anxieties about their social life and their future. Workshops, lectures, or conferences on epilepsy were held for residents or health and welfare professionals in only 8% of the communities. This percentage is lower than those (21-70%) for other intractable or mental disorders that are mainly managed by HCCs (P<0.01). On the other hand, 76% of PHNs in the HCCs felt the need for knowledge about epilepsy, and 60% wanted to join the epilepsy educational programs. Although many PHNs belonging to HCCs conduct consultations regarding epilepsy-related issues, many feel they cannot adequately respond to these issues. Furthermore, they feel the need for further knowledge about epilepsy but are not able to gain such knowledge because of financial and geographical restrictions. To improve these situations, regional education programs for epilepsy should be established in each local municipality in the future with support provided by medical facilities, regional medical associations, the Japan Epilepsy Society, and the Government.

Diversity and consistency: a case study of regionalised clinical placements for medical students.

A major challenge for medical schools is the provision of clinical skills training for increasing student numbers. This case study describes the expansion of the clinical school network at The University of Queensland (UQ). The purpose of the study was to investigate consistency in medical education standards across a regional clinical teaching network, as measured by academic performance. A retrospective analysis of academic records for UQ medical students (n = 1514) completing clinical rotations (2009-2012) was performed using analysis of covariance (ANCOVA) for comparisons between clinical school cohorts and linear mixed-effects modelling (LEM) to assess predictors of academic performance. In all, 13 036 individual clinical rotations were completed between 2009 and 2012. ANCOVA found no significant differences in rotation grades between the clinical schools except that Rural Clinical School (RCS) cohorts achieved marginally higher results than non-RCSs in the general practice rotation (5.22 vs 5.10-5.18; P = 0.03) and on the final clinical examination (objective structured clinical examination; 5.27 vs 5.01-5.09; P < 0.01). LEM indicated that the strongest predictor of academic performance on clinical rotations was academic performance in the preclinical years of medical school (= 0.38; 95% confidence interval 0.35-0.41; P < 0.001). The decentralised UQ clinical schools deliver a consistent standard of clinical training for medical students in all core clinical rotations across a range ofurban, regional and rural clinical settings. Further research is required to monitor the costs versus benefits of regionalised clinical schools for students, local communities and regional healthcare services.

A Qualitative Exploration of Key Informant Perspectives Regarding the Nature and Impact of Contemporary Legislation on Professional Development: A Grounded Theory Study of Chiropractic in Denmark

ObjectiveThe purpose of this study was to construct a substantive framework of the manner in which the Danish government interacts with the Danish chiropractic profession and influences professional practice. MethodsAn exploratory, qualitative study was performed using a substantive grounded theory (GT) approach. Unstructured, face-to-face, individual interviews were conducted during the years 2012 and 2013 and thematically analyzed. Six people were interviewed for this study including a gatekeeper and witness to legislative history, a previous chiropractic political representative and witness to legislative history, a previous Department of Health negotiator and previous administrator of chiropractic affairs and witness to legislative history, a current administrator of chiropractic affairs, an active chiropractic political representative and witness to legislative history, and a chief negotiator for Danish Regional Health Care Services. ResultsOpen and axial coding yielded 2 themes centering on licensing chiropractors in Denmark and the resultant developmental issues encountered. Through further selective coding, the GT core construct, “chiropractic practice in the Danish heath care system” emerged. The GT highlights the tension between the strategic political importance of legislation and the restrictive nature of the overly specific act currently regulating chiropractic practice. Moreover, the GT also revealed the perceived negative effect that the National Board of Health may exert on clinical practice due to its conservative interpretation of the act. ConclusionsThe Danish government is perceived to act as a countervailing power related to chiropractic practice. The derived substantive GT suggests that the Danish government's dualistic action relative to the Danish chiropractic community may inhibit the spontaneous evolution of contemporary Danish chiropractic practice. Although historically narrow legislation may limit chiropractic practice, conservative interpretations by the Danish National Board of Health may also play an important role.

A budget impact analysis of bronchial thermoplasty for severe asthma in clinical practice.

Fully 80% of asthma-related deaths occur in patients with uncontrolled disease and 50% of all costs are attributable to this subgroup. Although asthma is costly, direct costs and loss of productivity have only recently been extensively studied, partly as a result of the introduction of new and more costly treatment options. A 5-year population-based budget impact model in the perspective of the Emilia Romagna of Italy regional healthcare service compared the impact of adding adjuvant bronchial thermoplasty (BT) for a population of patients with severe, uncontrolled asthma treated with standard care (SC) with or without adjuvant omalizumab (OMAL). The model compared the budget impact of two scenarios: the first examined a population treated either with SC alone or with administration of OMAL concurrent to SC; the second examined a population treated either with SC alone or with either the concurrent administration of OMAL or BT. The cost for treating asthmatics patients in Emilia Romagna with BT would require 17.7 million Euros during the initial year; these costs would be offset by savings of 1 million Euros, 10.5 million Euros, and up to 19.2 million Euros during third, fourth, and fifth years, respectively. Despite the increase in direct costs, the complementary treatment of patients with either BT or OMAL in addition to SC may not only help the clinician to meet the needs of a greater number of patients, but also decreases emergency room visits and hospitalizations, as well as generates economic savings in the longer term.

Study on the path of comprehensive reform and development of the People's Hospital of Shimian County.

The People's Hospital of Shimian County is located in the underdeveloped agricultural county of western China with a population of 120,000. In light of the region's geographic location and cultural characteristics, the hospital has laid out a development strategy of becoming a regional healthcare service center-in Shimian and extends services to surrounding regions. Its reform process would start with the overhaul of the personnel system to rejuvenate the hospital's internal operation, and then move towards more comprehensive reforms on corporate governance structure and trans-regional integration of medical resources. On the basis of constructing a digital hospital, we would build an information platform to explore the 'Shimian model' of information-based healthcare reform through regional medical coordination and whole-sector oversight. An appropriate strategy and development roadmap, comprehensively internal and external reforms and persistent culture building, as well as the use of information technology will help put the hospital onto a track of fast and healthy development and in the right direction of healthcare reform that accords with our national circumstances. This article makes a review, summary and analysis of the process and further discusses about how to overhaul the healthcare system through reform and development.

Statistische Methoden der kleinräumigen Versorgungsforschung

Accurate modeling of spatial dependencies between observations is a significant challenge in research on regional health-care services. This article provides insight into current methods of modeling relationships in regional health-care service research, with consideration of spatial dependencies. Spatial dependencies may be triggered by spillover effects between neighboring regions and spatially distributed differences in - e.g., morbidity - which are not observable. If not considered in the model, the results of the analyses may be biased. Spatial dependencies can be added to the regression model as a spatial lag or a spatial error term. Using an example study, we illustrate that failing to consider spatial autocorrelation may lead to biased coefficients and/or standard errors. Research on regional health-care services should, therefore, if possible, test for spatial autocorrelation in the data and adjust the model accordingly.

Screening physical health? Yes! But…: nurses’ views on physical health screening in mental health care

To explore nurses' views on the role of nurses in screening and monitoring for physical care of consumers with serious mental illness, at a regional mental health care service. People with serious mental illness experience heightened incidence of preventable and treatable physical illnesses such as cardiovascular disease and diabetes. Screening and monitoring are considered universal clinical safeguards. Nurses can potentially facilitate systematic screening, but their views on physical health care practices are rarely investigated. Qualitative exploratory study. Focus group interviews with 38 nurses of a regional mental health care service district of Australia. To facilitate discussion, participants were presented with a screening system, called the Health Improvement Profile (HIP), as an exemplar of screening of physical health risks by nurses. Inductive data analysis and theme development were guided by a thematic analysis framework. Nurses argued that treatable and preventable physical health problems were common. Four main themes were identified: screening - essential for good practice; the policy-practice gap; 'screening then what?' and, is HIP the answer? Screening and monitoring were considered crucial to proper diagnosis and treatment, however, were not performed systematically or consistently. Nurse readiness for an enhanced role in screening was shaped by: role and responsibility issues, legal liability concerns, funding and staff shortages. Participants were concerned that lack of follow up would limit effectiveness of these interventions. Screening was considered an important clinical step in effective diagnosis and treatment; however, identified barriers need to be addressed to ensure screening is part of a systemic approach to improve physical health of consumers with serious mental illness. Nurses have potential to influence improvement in physical health outcomes for consumers of mental health services. Such potential can only be realised if a systematic approach to physical health care is taken.

Web-Based Integrated Public Healthcare Information System of Korea: Development and Performance

ObjectivesThe Web-based integrated public healthcare information system (PHIS) of Korea was planned and developed from 2005 to 2010, and it is being used in 3,501 regional health organizations. This paper introduces and discusses development and performance of the system.MethodsWe reviewed and examined documents about the development process and performance of the newly integrated PHIS. The resources we analyzed the national plan for public healthcare, information strategy for PHIS, usage and performance reports of the system.ResultsThe integrated PHIS included 19 functional business areas, 47 detailed health programs, and 48 inter-organizational tasks. The new PHIS improved the efficiency and effectiveness of the business process and inter-organizational business, and enhanced user satisfaction. Economic benefits were obtained from five categories: labor, health education and monitoring, clinical information management, administration and civil service, and system maintenance. The system was certified by a patent from the Korean Intellectual Property Office and accredited as an ISO 9001. It was also reviewed and received preliminary comments about its originality, advancement, and business applicability from the Patent Cooperation Treaty. It has been found to enhance the quality of policy decision-making about regional healthcare at the self-governing local government level.ConclusionsPHIS, a Web-based integrated system, has contributed to the improvement of regional healthcare services of Korea. However, when it comes to an appropriate evolution, the needs and changing environments of community-level healthcare service and IT infrastructure should be analyzed properly in advance.