The authors developed a screening instrument to detect patients in need of complex care coordination at admission to a general hospital. On the basis of a series of risk factors for care complexity, ...the authors constructed a short, care complexity prediction instrument (COMPRI) and assessed its qualities. The COMPRI is an easily administered screening instrument that detects patients at risk for complex care needs for whom care coordination is indicated. COMPRI’s predictive power exceeds all currently available case-mix instruments.
There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy ...for hospital-based care complexity. The authors’ four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.
To document and compare the costs of treatment of psoriasis with 2 established systemic agents that differ substantially in their unit costs: methotrexate vs cyclosporine.
Cost-minimization analysis ...within a randomized controlled trial.
Outpatient dermatology department at an academic hospital.
Adults with moderate to severe plaque psoriasis, with no previous methotrexate or cyclosporine treatment.
Sixteen weeks of treatment with methotrexate or cyclosporine and an additional 36 weeks of follow-up.
Direct and indirect medical and nonmedical costs associated with resource utilization during treatment and follow-up.
Average cumulative total costs associated with 16 weeks of treatment were 1593 US dollars for methotrexate and 2114 US dollars for cyclosporine (521 US dollars less for methotrexate); during 36 weeks of follow-up, these costs were 2418 US dollars and 2306 US dollars, respectively. The overall difference in cumulative 1-year costs was 409 US dollars, or approximately 10% of the total costs.
After 1 year, the overall difference in total costs between methotrexate and cyclosporine for 16 weeks of treatment and follow-up is relatively small. Systemic medication costs are only a fraction of the costs directly and indirectly generated by utilization of health care resources and associated with individual patients rather than with methotrexate or cyclosporine. Economic arguments can be supportive of but not decisive for individual patient decisions and guidelines for systemic therapy. Rational decision making for the treatment of psoriasis may include costs only within a long-term horizon and may consider the societal and patient benefits of different alternatives.
AbstractObjectivesRecruitment to pragmatic trials is often difficult, and little is known about factors associated with key participation and treatment decisions. These were explored in the Prostate ...cancer testing and Treatment (ProtecT) study. Study Design and SettingBaseline sociodemographic, patient-reported outcome, clinical history, and prostate cancer biopsy data were collected for all patients eligible to take part in the ProtecT trial, in a comprehensive cohort design. Men who rejected randomization specified a preferred option and were followed up identically to the randomized cohort. Factors associated with participation decisions, patient preferences, and reasons for changing treatment were explored. ResultsOf 2,664 men with clinically localized prostate cancer, 997 (37%) rejected randomization. Their treatment preferences and subsequent treatment choices/changes in both randomized and treatment choice cohorts were strongly associated with prostate cancer risk features: toward active monitoring for low-risk disease and toward radical options with higher risk prostate cancer. Among many factors measured, only a small number of weak associations were found for occupation groups and some patient symptoms. Similar percentages changed from the random allocation and initially stated preference. ConclusionThe comprehensive cohort design provided new insights into trial recruitment and participation decisions. Opportunities to improve recruitment by supporting recruiters with equipoise and patient preferences were identified.
The authors linked admission risk factors to a series of indicators for complex care delivery to enable detection of patients in need of care coordination at the moment of admission to the general ...hospital. The authors found 13 risk factors to be predictive of more than one indicator of care complexity. An admission risk screening procedure to detect patients in need of care coordination should focus on these risk factors and should include predictions made by doctors and nurses at admission and information collected from the patient and the medical chart.
This paper describes the development and testing of the Patient Registration Form (PRF), a standardized instrument for the description of patients seen by consultation-liaison (C-L) psychiatrists and ...psychosomatists in general hospitals, the referral patterns, the C-L interventions and their outcomes. The PRF study is part of a large multi-centre, European investigation on the effectiveness of mental health service delivery, conducted by the European C-L Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW) and performed in the framework of the of the E.C. 4th Medical and Health Research Program.
The final version of the PRF consists of 68 items. It was developed by the Program Management Group (PMG) and National Coordinators (NC) after long preparatory studies to assure both face and content validity and pilot testing. Two hundred and twenty consultants, who required 40 hours of training and came from 14 different European countries and 90 different sites, participated in the final reliability study. The PRF was tested in 13 written case histories. A ‘gold standard’ for the correct answers in each item was decided by ‘consensus ratings’ of the PMG and a subsequent 80% agreement by the NCs. A high standard (average kappa (
κ) ≥ 0.70; at least
2
3
of the PRF items,
κ ≥ 0.70) was required for the rater to be considered as ‘reliable’ (RR).
The consultants considered the PRF both ‘feasible’ and ‘acceptable’ and 93.2% of them fulfilled the RR criteria. The calculated rater-‘gold standard’ reliability was satisfactory: only four PRF items were identified with low agreement coefficients and no biases were observed cross-nationally in the ratings. Given the implications of misclassification for evaluating C-L effectiveness and services, these results are important and the achievement unprecedented.
To gain an insight into the costs and health outcomes of effectiveness studies in obstetrics at a national level.
Budget impact analysis.
We searched for obstetric effectiveness studies. The possible ...budget impact of implementation in all patients in the Netherlands was calculated, as well as health benefits for mothers and their children.
We used eight multicentre randomized trials with almost 11,000 patients in total. The total potential cost reduction for these trials was € 9.6 million per year, on the basis of a one-time investment in the trials of € 3.1 million. When implementing the results of these studies, a health benefit is shown in women with hypertension or pre-eclampsia at term, women in whom labour is induced and women with fetal monitoring. This also applied to the children of these women. Furthermore, removal or non-implementation of interventions that have no positive effect on health such as prolonged tocolysis, the use of progestogens in twin pregnancies, intrauterine pressure catheters, and induction of labour in preterm ruptured membranes reduces care costs.
Adequate application of the results of effectiveness studies in obstetrics should result in considerable health gains and cost reduction when compared with provision of non-scientifically supported care.
The authors identified variations in the characteristics of patients referred to 56 consultationliaison (C-L) services in 11 European countries. The authors found differences in the types of patients ...referred to the services, and there were significant differences between countries. The first difference lays in whether services saw patients for deliberate self-harm and for substance abuse. German psychosomatic C-L services saw virtually no such patients, although in other C-L services these patients constituted one-quarter to one-third of the patients referred. The second difference lays in the remaining group of referred patients. This group is best characterized by two dimensions. One describes the severity of psychopathology — ranging from organic mental conditions to somatization. The other describes the clarity of the physical diagnosis — ranging from patients referred by surgical wards to those referred by general medicine and neurology wards.
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