The effects of predetermined payment rates for Medicare home healthcare.

OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.     

用捕获-再捕获法估计三峡库区居民出生和死亡水平

目的 评价出生死亡监测质量，校正三峡库区报告人口出生率和死亡率。方法 采用分层随机整群抽样方法，对抽取的7061户居民逐户调查人口出生和死亡情况，再与同期监测系统所报告的出生、死亡资料进行核对，计算漏报率以及总体出生率和死亡率95％可信区间（C1）。结果 三峡库区人群健康监测系统出生漏报率为13．91％，死亡漏报率为15．60％，婴儿死亡漏报率为33．33％。校正报告出生率为8．92‰，估计总体出生率95％CI：8．38‰～9．45‰，校正报告死亡率为6．88‰，估计总体死亡率95％CI：6．37‰～7．38‰。结论 三峡库区人群健康监测系统出生和死亡报告质量符合国家疾病监测点质量要求。2002—2004年三峡库区人口出生率和死亡率在10．00‰以下。     

Reduction of surgical site infection rates associated with active surveillance.

OBJECTIVE: To evaluate whether surgical site infection (SSI) rates decrease in surgical departments as a result of performing active SSI surveillance. DESIGN: Retrospective multiple logistic regression analyses. SETTING: A group of 130 surgical departments of German hospitals participating in the Krankenhaus Infektions Surveillance System (KISS). METHODS: Data for 19 categories of operative procedures performed between January 1997 and June 2004 were included (119,114 operations). Active SSI surveillance was performed according to National Nosocomial Infections Surveillance system (NNIS) methods and definitions. Departments' SSI rates were calculated individually for each year of surveillance and for each operative procedure category, taking into account when the individual departments had begun their surveillance activities. Multiple logistic regression analyses on a single operation basis were carried out with stepwise variable selection to predict outcomes for patients with SSI. The variables included were as follows: the department's year of participation, NNIS risk index variables, patients' age and sex, and the hospitals' structural characteristics, such as yearly operation frequency, number of beds, and academic status. RESULTS: For 14 of 19 operative procedure categories analyzed, there was a tendency toward lower SSI rates that was associated with increasing duration of SSI surveillance. In multiple logistic regression analyses of pooled data for all operative procedures, the departments' participation in the surveillance system was a significant independent protective factor. Compared with the surveillance year 1, the SSI risk decreased in year 2 (odds ratio, 0.84; 95% confidence interval, 0.77-0.93) and in year 3 (odds ratio, 0.75; 95% confidence interval, 0.68-0.82), and there was no change in year 4. CONCLUSION: The SSI incidence was reduced by one quarter as a result of the surveillance-induced infection control efforts, which indicates the usefulness of a voluntary surveillance system.     

A case of the birth and death of a high reliability healthcare organisation

High reliability organisations (HROs) are those in which errors rarely occur. To accomplish this they conduct relatively error free operations over long periods of time and make consistently good decisions resulting in high quality and reliability. Some organisational processes that characterise HROs are process auditing, implementing appropriate reward systems, avoiding quality degradation, appropriately perceiving that risk exists and developing strategies to deal with it, and command and control. Command and control processes include migrating decision making, redundancy in people or hardware, developing situational awareness, formal rules and procedures, and training. These processes must be tailored to the specific organisation implementing them. These processes were applied to a paediatric intensive care unit (PICU) where care was derived from problem solving methodology rather than protocol. After a leadership change, the unit returned to the hierarchical medical model of care. Important outcome variables such as infant mortality, patient return to the PICU after discharge, days on the PICU, air transports, degraded. Implications for clinical practice include providing caregivers with sufficient flexibility to meet changing situations, encouraging teamwork, and avoiding shaming, naming, and blaming.     

2012—2013年医院感染现患率调查

目的通过连续两年医院感染现患率调查了解某院医院感染情况。方法采用床旁调查及查阅住院病历相结合的方法,于2012年8月2日、2013年10月10日对该院住院患者进行调查。结果2012、2013年医院感染现患率分别为2.65%（62例）、3.23%（57例）,两年医院感染现患率比较,差异无统计学意义（χ2=1.14,P=0.29）。2012、2013年医院感染部位均以下呼吸道为主,分别占43.75%、45.90%;其次为手术部位,分别占12.50%、6.56%。2012、2013年抗菌药物使用率分别为33.36％、34.73%,其中治疗性使用抗菌药物所占比率分别为52.20%、52.85%。2012年治疗性使用抗菌药物患者细菌培养送检率为63.52%（350例）,2013年为58.85%（256例）。结论该院连续两年医院感染现患率及抗菌药物使用率均不高。通过此次调查有助于了解医院感染情况,为抗菌药物的合理应用,医院感染预防控制措施的制订提供依据。     

血液病住院患者3年医院感染现患率调查

目的了解某院血液病医院住院患者医院感染情况,为有效控制和预防医院感染提供依据。方法采用病历查阅和床旁调查相结合的方法,调查该院2012—2014年血液病住院患者医院感染情况。结果共调查患者1 963例,2012—2014年医院感染现患率分别是20.44%、20.76%、22.70%;感染部位主要以下呼吸道为主(34.50%~36.18%),其次为皮肤与软组织和上呼吸道。检出病原菌207株,其中革兰阴性杆菌139株(67.15%),革兰阳性球菌47株(22.71%),真菌21株(10.14%),主要致病菌为大肠埃希菌(50株)、肺炎克雷伯菌(24株)、铜绿假单胞菌(17株)。医院感染现患率3年均以移植科最高(30.16%~32.69%),其次为白血病科(25.26%~29.35%)和骨髓增生异常综合征(MDS)科(21.95%~25.00%)。血液儿科3年现患率比较,差异有统计学意义(χ2=9.66,P=0.008),其他科室3年现患率比较,差异无统计学意义。多重耐药菌由2012年的12株增加至2014年的22株,以大肠埃希菌为主。结论医院感染现患率较高,大肠埃希菌为主要致病菌和多重耐药菌,应加强对感染高发科室、部位以及重点致病菌感染等高危因素的监测,并采取相应干预措施,减少医院感染。     

The moral dangers of home birth: parents' perceptions of risks in home birth in Finland

This study explored Finnish home-birth parents' perceptions of risks in home birth through interviews. It was found that the parents considered three types of risks in their decision-making: medical risks of pregnancy and birth, iatrogenic risks of medical practice and moral risks of going against medical authoritative knowledge. While the parents' choice was guided by their image of the hospital as an iatrogenic environment for birth, they did not refuse prenatal examinations but, rather, negotiated the extent of their use to ensure the medical safety of their home-birth plan. Yet, they often concealed the plan from prenatal care staff in order not to be confronted with being labelled as a 'risk parent'. It is argued that the authoritative medical definition of childbirth as risky and as requiring hospitalisation contains a moral subtext which defines home birth as risky behaviour, for which the parents can be blamed and stigmatised.     

Dying at home or in an institution using death certificates to explore the factors associated with place of death

INTRODUCTION: The knowledge of determinants of place of death is important for public health policy aimed at improving the quality of end-of-life care. METHODS: We investigated the influence of clinical, socio-demographic, residential and health care system factors on the place of death, using data from all 55,759 deaths in 2001 in Flanders (Belgium), gathered via official death certificates and data from anonymously linked health care statistics. A multivariate logistic regression was used to examine the associated factors (home versus hospital as dependent categories). RESULTS: Of all deaths in Flanders, 53.7% took place in hospital, 24.3% at home and 19.8% in a care home. The probability of home deaths varied by region, by rural or urban residence and by the hospital bed availability in the region and dying at home was less likely among those suffering from certain non-malignant chronic diseases, the less educated and those living alone. CONCLUSION: Although most people wish to die at home, most deaths in Flanders (Belgium) in 2001 did not take place there. The clinical, socio-demographic and residential factors found to be associated with the place of death could serve as focal points for a policy to facilitate dying in the place of choice, including at home.     

Skeletal muscle mass abnormalities are associated with survival rates of institutionalized elderly nursing home residents

Background

Knowledge about the changes in skeletal muscle mass in nursing home residents is very limited. We hypothesized that such patients have different types of skeletal muscle mass abnormalities that may affect mortality rates. Therefore, the objective of this study was to evaluate the prevalence and extent of skeletal muscle mass decline, its different clinical phenotypes (sarcopenia, wasting/atrophy and cachexia) and the mortality rates associated with these abnormalities.

Methods

A retrospective chart-review study comprising 109 institutionalized nursing home residents. Body mass index, body fat mass, fat free mass, skeletal muscle mass and survival rates were assessed.

Results

Skeletal muscle mass abnormalities were found among 73 out of 109 (67.0%) patients and were more prevalent in males compared with females (97.8% and 43.8%, respectively, p<0.001). Most of these patients had muscle wasting/atrophy (51.4%) or sarcopenia (40.3%), and 9.7% suffered from cachexia. One third of the patients with abnorrmal skeletal muscle mass showed a moderate decline of skeletal muscle mass (34.7%) while the remainder (65.3%) had very low levels of skeletal muscle mass. Each group was characterized by typical medical conditions associated with skeletal muscle mass abnormality. A Kaplan-Meier survival plot of mortality showed only lower one-year survival rates in the group with sarcopenia (60%) and muscle atrophy or cachexia (53%), compared with elderly participants with a normal skeletal muscle mass (73%), (p<0.0001). There were no significant differences in 1-year mortality rates between patients with abnormal skeletal muscle mass (whether sarcopenia, cachexia or wasting).

Conclusion

About two thirds of nursing home patients show skeletal muscle mass abnormalities, most within the range of very low skeletal muscle mass rather than moderately low skeletal muscle mass, that are associated with shorter survival rates, compared with normal skeletal muscle mass patients.     

Season of birth is not associated with risk of early adult death in rural Senegal

BACKGROUND: In a rural area of the Gambia, West Africa, young adults born in the 'hungry' season had a high excess of deaths (mortality ratios (MR): 3.7 from 14.5 years and 10.3 from 25 years, P < 0.0001). Among several potential causal factors, fetal undernutrition was considered the most plausible. This study is a similar analysis of children and young adults living in rural Senegal, close to the Gambia. METHODS: A cohort of 9192 subjects born 1962-2001 with prospectively collected dates of birth and death was analysed. MR by season of birth (July-December/January-June) was estimated using Cox's proportional hazards analysis. The nutritional status of non-pregnant women was analysed at monthly intervals 1990-1996. RESULTS: MR by season of birth was slightly greater than 1 during infancy, and close to 1 from 1-5 years and from 5-14.5 years. From 14.5 years old the MR was 0.77 (95% CI: 0.47, 1.25, P = 0.29), compared with 0.53 (95% CI: 0.28, 1.02, P = 0.056) from 20 years and 0.33 (95% CI: 0.09, 1.25, P = 0.10) from 25 years. The weight of women varied strongly by season: means were 3.0-3.9 kg lower at the end of the rainy season (September-November) than during the dry season (February-May, P < 0.001 for each year). CONCLUSIONS: This study found no increased risk of death among young adults born during the hungry season in a rural West African area despite large seasonal variations in women's nutritional status. The strongly increased risk in adult Gambians is probably not explained by fetal undernutrition.     

心脏死亡器官捐献肾移植受者术后医院感染目标性监测

目的探讨心脏死亡器官捐献(DCD)肾移植受者术后医院感染发病率及病原体分布,为制定相应预防和控制措施提供理论依据。方法采用前瞻性研究方法对某三级医院2014年1月—2016年12月DCD肾移植受者进行医院感染目标性监测,分析DCD肾移植受者术后医院感染的发病率、医院感染病原学特点。结果 2014年1月—2016年12月共监测DCD肾移植患者313例,其中发生医院感染患者48例,共63例次,医院感染发病率为15.34%,例次发病率为20.13%。2016年DCD肾移植受者术后医院感染发病率为10.11%(19/188),2014年为28.57%(14/49),2015年为19.74%(15/76),各年份医院感染发病率比较,差异有统计学意义(P0.05)。居前三位的医院感染部位分别为下呼吸道(22/63,34.92%)、手术部位(16/63,25.39%)及血液系统(11/63,17.46%)。共检出病原体42株,主要为革兰阴性菌(27株,64.29%),其次是真菌(9株,21.43%)和革兰阳性菌(6株,14.28%);居前三位的病原体依次为肺炎克雷伯菌(9株,21.43%)、热带假丝酵母菌(7株,16.67%)、大肠埃希菌(5株,11.90%)。42株病原体中多重耐药菌(MDRO)15株(35.71%),其中革兰阴性菌10株(66.67%),以耐碳青霉烯类肠杆菌科(4株)及不动杆菌属(3株)为主;革兰阳性菌5株(33.33%),以耐甲氧西林金黄色葡萄球菌(3株)为主。结论 DCD肾移植受者术后医院感染发病率较高,应采取综合干预措施加强对下呼吸道感染、手术部位感染及血流感染的预防和控制,同时加强对MDRO感染的预防和控制,改善抗菌药物使用策略降低碳青霉烯类耐药菌株的产生。     

武汉地区住院患者医院感染与社区感染现患率调查

目的了解武汉地区住院患者医院感染与社区感染现况,为医院感染的预防与控制提供依据。方法便利抽取武汉市33所医院,采用床旁调查和病例调查相结合的方法对住院患者进行调查,应用SPSS 16.0软件进行数据分析。结果调查住院患者36 222例,医院感染1 116例,医院感染现患率3.08%,社区感染6 968例,社区感染现患率19.24%。医院床位数≥900张者医院感染现患率最高(3.40%),医院床位数300张者社区感染现患率最高(43.70%)。医院感染现患率最高的科室为综合ICU(32.88%),社区感染现患率最高的科室为呼吸科(78.34%)。医院感染病例共检出病原体699株,主要为铜绿假单胞菌(18.03%)、鲍曼不动杆菌(16.31%)和金黄色葡萄球菌(12.88%),社区感染病例共检出病原体1 149株,主要为大肠埃希菌(14.45%)、铜绿假单胞菌(11.23%)和支原体(10.01%)。医院感染和社区感染主要部位均为下呼吸道,分别为48.24%和45.15%。结论该地区医院感染与社区感染呈现不同的特点,应根据重点科室、重点部位有针对性地采取措施,有效减少医院感染的发生。     

2012—2014年某院医院感染现患率调查

目的了解某院医院感染现状、常见感染部位及抗菌药物使用情况。方法采取床旁调查和查阅病例相结合的方法,分别于2012、2013、2014年的某日对该院所有住院患者进行调查。结果共调查住院患者6 205例,实查 6 062例,实查率为97.70%;2012—2014年医院感染现患率分别为4.04%、3.17%、4.51%,社区感染现患率为13.90%、14.93%、16.53%。医院感染高发科室依次为内科重症监护病房（ICU）、外科ICU、肾病一科,感染高发部位依次为下呼吸道、上呼吸道、表浅切口、泌尿道。3年中抗菌药物使用率分别为21.81%、24.29%、24.67%,以治疗为目的的抗菌药物细菌培养送检率依次为65.93%、74.07%、66.49%。结论该院医院感染科室以ICU为主,感染部位以下呼吸道最常见。