Abstract
Background and Aims
Management of inflammatory bowel disease IBD is complex and IBD Comprehensive Care Units ICCUs facilitate the delivery of quality care to IBD patients. The objective of ...this study was to update the existing set of quality indicators QIs for ICCUs, based on a nationwide quality certification programme carried out in Spain, from a multi-stakeholder perspective and using multicriteria decision analysis MCDA methodology.
Methods
An MCDA comprising three different phases was conducted. In phase 1, a systematic literature review was performed, and after validation by a scientific committee comprising 11 experts, a preliminary set of QIs was developed. In phase 2, a larger group of 49 experts determined the relevance and relative importance of each QI by prioritising and weighing the preliminary set. Finally in phase 3, the scientific committee reviewed the results and made a final selection via a deliberative process.
Results
The final set comprised 67 QIs, classified as Structure 23 QIs, Process 35 QIs and Outcome 9 QIs, which were ranked according to their relative importance. Multidisciplinary management was the most important requirement in ICCUs, followed by continuity of care, standardisation of clinical care and, especially, the incorporation of patients’ reported outcomes.
Conclusions
This updated set of QIs comprises a weighted and prioritised set of items that represent the essential minimum of criteria for ensuring appropriate quality of care in the management of IBD patients.
To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (≥2 hospitalizations or ≥1 pediatric ...intensive care unit PICU admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program.
We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care, n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (nPost-trial = 233, including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and nTrial = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study.
In intent-to-treat analyses, rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio RR, 0.36; 95% CI, 0.20-0.64; cost ratio CR, 0.68; 95% CI, 0.28-1.68), the trial's comprehensive care group (RR, 0.74; 95% CI, 0.39-1.41; CR, 0.67; 95% CI, 0.51-0.89), and among all children given comprehensive care (RR, 0.97; 95% CI, 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99).
Major benefits of comprehensive care did not diminish with post-trial program expansion.
Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize ...factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital.
Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission.
Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 1.4-8.5; P < .01).
Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.
The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to ...evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management.
We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention.
Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management.
Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.
•Rising US healthcare expenditure has stimulated interest in specialty condition-based care models, such as integrated practice units. The financial viability of these models in managing common, quality-of-life impacting conditions, such as hip or knee osteoarthritis, requires a better understanding of total costs of care.•This case study describes a scalable model for evaluating total costs and potential cost savings of specialty condition-based osteoarthritis care, compared with traditional care, using time-driven activity-based costing.•Our study establishes costs, cost savings, and drivers of these differences that aim to guide measurement and decision making related to care delivery and healthcare utilization.
Health care providers have highlighted the need for tools and resources that support promotion of exercise behavior within comprehensive multiple sclerosis (MS) care. This study involved a final ...quality improvement evaluation of exercise promotion models and materials for inclusion within this setting.
Our research team distributed a paper-based survey containing Likert scales, open answer questions, and copies of the models for editing. We distributed this survey among health care providers across the United States. We conducted a novel mixed-methods analysis evaluating quantitative, qualitative, and creative data.
We received completed surveys from 13 health care providers who strongly rated the clarity and applicability of the models and materials, and reported that no major improvements were necessary. The minor improvements were specific per comprehensive MS care center. The feedback indicated that the "Exercise in Medicine" models and materials are guides such that the processes should be integrated into real world practice by amending roles and responsibilities with the team members and structure per comprehensive MS care center.
This paper presents finalized models and materials for exercise promotion within comprehensive MS care that are ready to be tested for feasibility and efficacy in a clinical trial.
IMPLICATIONS FOR REHABILITATION
Health care providers require support to promote exercise within the context of comprehensive MS care.
The practice models in this article provide guides regarding how to promote exercise in this context.
Implementing these exercise promotion guides can reduce the burden of neurologists, and ensure patients receive exercise support from appropriate providers.
These guides should be implemented within the context of each individual care center, and not as an explicit step by step guide as each care center is unique.
Drug resistant epilepsy (DRE) is defined as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs (ASD) used at efficacious daily dose. Despite the increasing number of ...available ASD, about a third of patients with epilepsy still suffer from drug resistance. Several factors are associated with the risk of evolution to DRE in patients with newly diagnosed epilepsy, including epilepsy onset in the infancy, intellectual disability, symptomatic epilepsy and abnormal neurological exam. Pharmacological management often consists in ASD polytherapy. However, because quality of life is driven by several factors in patients with DRE, including the tolerability of the treatment, ASD management should try to optimize efficacy while anticipating the risks of drug-related adverse events. All patients with DRE should be evaluated at least once in a tertiary epilepsy center, especially to discuss eligibility for non-pharmacological therapies. This is of paramount importance in patients with drug resistant focal epilepsy in whom epilepsy surgery can result in long-term seizure freedom. Vagus nerve stimulation, deep brain stimulation or cortical stimulation can also improve seizure control. Lastly, considering the effect of DRE on psychologic status and social integration, comprehensive care adaptations are always needed in order to improve patients' quality of life. Keywords: drug resistant epilepsy, epilepsy surgery, antiseizure drugs, comprehensive care
La médecine interne est une spécialité médicale mal connue du grand public et parfois mal identifiée. À l’heure de la surspécialisation et de l’ultra-technicité, elle se caractérise par une approche ...globale centrée sur l’évaluation clinique. Contrairement à ce qui est observé dans la plupart des pays développés où les maladies auto-immunes systémiques sont prises en charge par les spécialistes d’organe en fonction de leur mode de présentation, les internistes français sont en première ligne pour diagnostiquer et prendre en charge ces maladies et leur formation multidisciplinaire leur donne toute légitimité pour justifier ce positionnement. Les internistes ont un exercice principalement hospitalier et sont également fortement impliqués dans la prise en charge des patients relevant d’hospitalisations non programmées en aval des urgences et en lien avec la médecine de ville. Afin de mieux définir la médecine interne, son positionnement dans les activités de soins, mais aussi d’enseignement et de recherche et ses perspectives, les internistes ont organisé les états généraux de la médecine interne qui ont eu lieu le 28 septembre 2023 à Paris. Construits autour de groupes de réflexions portant sur les activités de soins, d’enseignement et de recherche, ces états généraux avaient pour objectif d’améliorer la visibilité de la médecine interne et des internistes. Cet article relate les débats qui ont animé cette réunion et met en avant les principales idées qui ont émergé. Ces états généraux constituent une étape fondatrice, et seront suivis d’une Conférence de concertation qui permettra de mieux identifier et faire connaître la médecine interne et les internistes, quels que soient leurs types et lieux d’exercice.
Internal medicine is a medical specialty that is often poorly understood by the general public and sometimes misidentified. In an era of increasing subspecialization and high technicality, it is characterized by a comprehensive approach centered on clinical evaluation. Unlike what is observed in most developed countries, where systemic autoimmune diseases are managed by organ specialists based on their mode of presentation, French internists are at the forefront for diagnosing and managing these diseases. Their multidisciplinary training gives them legitimacy to justify this role. Internists also play a crucial role in the management of patients requiring unplanned hospitalizations downstream from emergency departments and in connection with primary care. Internists primarily practice in a hospital setting, with a specific position in the French healthcare system aligned with the training frameworks of all medical specialties. To better define internal medicine, its role in care activities, as well as in education and research, internists organized a General Assembly of internal medicine that took place on September 28, 2023, in Paris. Structured around think tanks focusing on care, education, and research activities, the general assembly aimed to improve visibility on internal medicine and internists. This article recounts the discussions that animated this meeting and highlights the main ideas that emerged. These general assemblies constitute a foundational step and will be followed by a Consultation Conference in order to better identify and promote internal medicine and internists, regardless of their types and places of practice.
The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there ...is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost.
We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population.
We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio OR 2.51, 95% confidence interval CI 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost.
A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.
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