Rearranging the deckchairs on the Titanic: failure of an augmented home help scheme after discharge to reduce the length of stay in hospital

An augmented home help service was set up in the Rhondda Valley in South Wales in order to facilitate discharge from hospital of elderly subjects who were kept in hospital because of mainly social problems. Patients were allocated to the new service or the pre-existing services according to their date of birth. The extra social support did not result in a faster discharge from hospital, nor in any improvement in well-being of the intervention group, largely because the small extra amount of service input was inadequate to ameliorate the extreme physical, mental and social problems experienced by the study group.     

Anticipating care needs of patients after discharge from hospital: Frail and elderly patients without physiological abnormality on day of admission are more likely to require social services input

IntroductionAcute admissions to hospital are rising. As a part of a service evaluation we examined pathways of patients following hospital discharge depending on data available on admission to hospital.MethodsWe merged data available on admission to the Wrexham Maelor hospital from an existing data-base in the Acute Medical Unit with follow up data from local social services as part of a data sharing agreement. Patients requiring support by social services post-discharge were matched with patients not requiring social services from the same post-code.ResultsStepwise logistic regression analysis identified candidate variables predicting likely support need. Decision tree analysis identified sub-groups of patients with higher likelihood to require support by social services after discharge from hospital. We found patients with normal physiology on admission as evidenced by a value of zero for the National Early Warning Score who were frail or older than 85 years were most likely to require support after discharge.ConclusionsInformation available on admission to hospital might inform long term care needs. Prospective testing is needed. The algorithms are prone to be dependent on availability of local services but our methodology is expected to be transferable to other organizations.     

The impact of family interactions on recovery from stroke: help or hindrance?

The family networks of 47 geriatric stroke patients were examined for social supports and social problems as they related to well-being after hospital discharge. Structured interviews assessed positive and negative family interactions and patients' independence in activities of daily living (ADL), time use, personal adjustment, and cognitive functioning. After controlling for patients' medical status at hospital discharge, social supports were not associated with any of the outcomes examined. Social problems explained additional variance in personal adjustment and ADL independence.     

Persistent social disparities in the risk of hospital admission of paediatric diabetic patients in Germany-prospective data from 1277 diabetic children and adolescents.

BACKGROUND: Reduction of social inequality in health care is a major target in many countries. The risk of hospital admission is thought to be higher in diabetic children from socially deprived families but actual data are lacking. METHODS: Based on a nationwide prospective computer-based documentation program (DPV), we determined the association between three social parameters (parental professional education, one-parent family vs. complete family, migration background) and the risk for post-onset hospital admission, as well as the number of hospital admission days in children and adolescents < 20 years of age with diabetes onset in 2002-2005 [n = 1277, 56% male, mean age at onset 8.5 (4.1) years]. We estimated relative risks with 95% confidence intervals, adjusting for age, sex, and diabetes centre (cluster), using random effect models. RESULTS: Forty-two per cent of the study subjects were admitted to hospital at least once during follow-up. The incidence of hospital admissions was 0.46 (0.43-0.49) per person year, and there were 2.72 (2.65-2.80) hospital days per person year. Hospital admissions and hospital days were higher in girls than in boys (significant for hospital days, P < 0.05), and significantly lower in adolescents aged 15-19 compared with children aged 0-4 years (P < 0.05 in all models). Hospital admission rates were significantly higher in children from lower-educated parents, single-parent families, and families with a migration background (all P < 0.05). DISCUSSION: We found post-onset hospital admission rates to be higher in diabetic children and adolescents from socially deprived families. In comparison with an analysis in the 1990s, no decrease in social disparity in hospital admission risk was found.     

The impact of social factors on the content of care. Treatment of ischemic heart disease at a public and a voluntary hospital.

To assess the impact of social factors on the content of care, panels of patients with ischemic heart disease at a public and its affiliated voluntary hospital were followed up through their acute hospitalizations and 3 months after discharge. Data were collected from firsthand observation of rounds, chart review, and a 3-month patient follow-up survey. Among patients for whom cardiac catheterization was indicated, 100% from the voluntary hospital underwent this procedure compared with 41% from the public institution. For patients for whom exercise stress testing was indicated, 90% from the voluntary hospital compared with 50% from the public institution underwent the procedure. Factors observed to contribute to these patterns emanated from the hospital setting as well as from the patients' social environment, including difficulties in arranging transfers for procedures, obstacles to coordinating inpatient and ambulatory care, and patient problems in keeping outpatient appointments.     

Risk factors for social isolation in post-hospitalized older adults

IntroductionSocial isolation in older adults is associated with high rates of adverse health outcomes. Older adults who have had a recent significant health event are likely to be at risk of social isolation following hospitalization. This study aims to identify risk factors amongst older adults at hospital discharge that are associated with social isolation at three months post-hospitalization.MethodsOlder adults were surveyed at hospital discharge and three months post-hospitalization. Baseline data including demographics, self-reported quality of life, physical activity and capacity levels, lifestyle factors, symptoms of depression and anxiety were collected at discharge. Social isolation was measured using the Friendship Scale at the three-month follow-up. Regression analyses were used to examine the relationship between baseline characteristics and social isolation at three months post-hospitalization.ResultsOlder adults (n = 311) participated in the baseline survey, of whom 241 (78 %) completed the three-month survey. Higher depressive and anxiety symptoms at hospital discharge, comorbidity of cancer, history of cigarette smoking, prior access to community and respite service, and arrangement for shopping assistance post-discharge were factors independently associated with an increased risk of social isolation at three months post-hospitalization.DiscussionThis study identified risk factors for social isolation that are unique to older post-hospitalized adults. These findings can help clinicians identify individuals at risk of social isolation and to target interventions that address these risk factors for the prevention of social isolation in older adults after hospitalization.     

The attitude of stationary hospital patients towards the old people home and the nursing home (author's transl)

Changes in our health and hospital policy towards shorter stays in hospital as well as changes in our social and family structures have led to a lot of problems in geriatrics. It is complicated to insure a necessary continuing home-treatment or a supply of daily necessities which are often necessary with advancing age after acute sicknesses. This has resulted in that many of the old peoples' or nursing home places are filled directly from the hospital. During investigations of 496 patients of an internal clinic we found that a rather high number of geriatric patients accepted a change into an old peoples or nursing home in contrast to investigations conducted outside the clinic. But the hospital patients complained about the same points in these institutions as the non-hospitalized. Therefore hospital personnel (doctors, sisters, nurses, therapeuts and social workers) ought to try all possibilities for rehabilitation inside and outside the usual stationary institutions (Reha-clinic, day-clinic) to insure the reintegration of old people in familiar or neighbourly surroundings. If this is not possible, the patients should be given enough time and opportunity to adjust themselves to the new life situation and to make independent decisions.     

The First 100 Referrals to a Scottish Drug Addiction Treatment Centre*

This is a report on the first 3 years' experience at the Drug Addiction Treatment Centre which was established at the Royal Edinburgh Hospital in April, 1968, The statutory requirements, and the hospital polity for dealing with persons addicted to dangerous drugs are outlined, followed by a demographic and social analysis of the 100 probands including childhood circumstances, work record, delinquent background, and known record of non-drug offences. Drug taking habits are surveyed, together with medical and pyschiatric complications reported. The reasons given for coming to hospital, and the attitudes of these drug-takers are presented in detail, showing the problems of management to which they give rise. Local difficulties impeding social rehabilitation are also discussed. It is questioned whether hospital addiction centres, as at present organised, can be effective in the treatment of young unmotivated drug misusers.     

医院经营管理中成本控制效果分析

目的对坪山人民医院实行医院经营管理中成本控制的效果进行分析。方法通过实施成本控制,加强内部管理,降低医疗成本。结果实行成本控制后有效地减轻病人了负担,以低成本的优势赢取竞争优势。结论医院经营管理中实行成本控制,能有效提高医院社会效益和经济效益,增强医院的竞争力。     

Intensive care unit patient follow-up. Mortality, functional status, and return to work at six months

Six months after hospital discharge, we followed up 1545 patients who had received care in the general medical-surgical intensive care unit (ICU) of a tertiary care hospital. Vital status could not be ascertained for 200 of these patients. Of the 1345 former ICU patients for whom a determination of vital status could be made, 1261 (94%) were alive and 84 (6%) had died. Of those known to be living, 887 (70%) responded to a questionnaire regarding employment, functional, and social status. A large proportion of survivors less than 40 years of age had returned to work. Younger patients admitted to the hospital for elective surgery reported as much compromise of physical and psychological activity as did older patients admitted for emergency reasons. Older survivors reported an increase of interaction with family members and a decrease of social interaction with those other than family.     

Aspects of social support associated with depression at hospitalization and follow-up assessment among cardiac patients

PURPOSE: High levels of depressive symptoms have been shown to affect the morbidity, mortality, and functioning of patients with myocardial infarction (MI). Findings have shown that social support is associated with depression in both patient and community samples. This study examined various aspects of social support as they relate to depressive symptoms in patients with MI, both in the hospital and 2 weeks later. METHODS: As part of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) pilot study, measures of perceived social support, social networks, social support received, and social conflict were administered to 196 patients with MI. These patients also were administered the Beck Depression Inventory and the Hamilton Rating Scale for Depression. Depression was reassessed 2 weeks later. Relations between social support indicators and the depression measures were examined. RESULTS: The prevalence of depression symptoms was high, especially among poorer and younger patients. There was modest improvement across time. Patients with high social support scores, particularly those reflecting perceived support, had lower scores on depression measures at baseline. High levels of perceived support and low social conflict at baseline were associated with less follow-up depression, as measured by the Beck cognitive scale, but not the Beck somatic scale nor the Hamilton scale. There were few associations with measures of social networks and received support. CONCLUSIONS: Social support indicators were differentially related to depression among patients with MI while in the hospital and 2 weeks later. The pattern of associations also depended on the measure of depression. A broad assessment strategy of both social support and depression is needed for a full understanding of their interrelations.     

Role of social status of new cases of tuberculosis in choosing a therapy regimen

Two hundred and sixty-seven new cases of pulmonary tuberculosis were examined to study their social characteristics of wishes in choosing a therapy regimen. It has been found that the males who are 30-59 years old, live in rural areas, unemployed, have a low education level, bad habits, and no family prefer to treat at a day-and-night hospital. Those who are 20-59 years, have secondary and higher education wish to treat at a day hospital and in a polyclinic. Pension-age individuals choose to treat at a day-and-night hospital nearly equally frequently. The patients stopped treating at a day-and-night hospital 2 times more frequently than those in a polyclinic or at a day hospital.     

Collaboration between a local medical community and a university hospital

Here we report the current status and problems in collaboration between a local medical community and a university hospital. It is important for the university hospital to clearly define its role in the local medical community, collaborate with local medical and welfare institutes and establish a local medical and care network that supports patients and their families. For this purpose, the social service department is expected to play a role as a coordinator between the university hospital and the local medical community so that the patients can make the best use of medical and care resources.     

Are physically frail older persons more at risk of adverse outcomes if they also suffer from cognitive,social, and psychological frailty?

Frailty is considered a predictor for negative outcomes such as disability, decreased quality of life, and hospital admission. Frailty measures have been developed that include different dimensions. We examined whether people who are physically frail are more at risk for negative outcomes of frailty if they also suffer from psychological, cognitive, or social frailty. Frailty was measured at baseline by means of the Groningen Frailty Indicator (GFI), which comprises a physical, cognitive, social, and psychological dimension. Only frail persons were included in the study (GFI ≥ 5) that, in addition, had to be frail in the physical dimension (i.e., ≥1 on this dimension). IADL disability and quality of life were measured at baseline and at 12 months. Hospital admission was assessed during this period. In this, physically frail sample effects of the other three frailty dimensions were studied in regression models. The sample (n = 334, mean age 78.1, and range 70–92) included 40.1 % frail men and 59.9 % frail women. Overall, no additional effects for the cognitive, social, or psychosocial dimensions were found: other frailty dimensions did not have an additional impact on disability, quality of life, or hospital admission in people who already suffered from physical frailty. Higher scores of physical frailty were significantly related to IADL disability (p < 0.05) and hospital admission (p < 0.05). Additional analysis showed that the physical frailty score predicted IADL disability and hospital admission better than the GFI overall score. Results of this study suggest that persons, who are physically frail, according to the GFI, are not more at risk for negative outcomes of frailty (i.e., IADL disability, decreased quality of life, and hospital admission) if they in addition suffer from cognitive, social, or psychological frailty. In addition, for the prediction of IADL disability or hospital admission, the focus for screening should be on the physical frailty score instead of the GFI overall score including different dimensions.     

The use of health and social services in the management of stroke in the community: results from a controlled trial

The use of hospital and community services during the follow-up of a controlled trial which evaluated the effectiveness of a stroke unit and medical units in the management of acute stroke in the elderly is described. Patients from the stroke unit received more health and social services compared with medical unit patients, particularly in the initial follow-up period. The use of services was not related to the functional outcome of patients at hospital discharge. No overall difference occurred between stroke unit and medical unit patients in hospital bed days used throughout the study.     

A health insurance scheme for hospital care in Bwamanda district, Zaire: lessons and questions after 10 years of functioning

Summary A voluntary insurance scheme for hospital care was launched in 1986 in the Bwamanda district in North West Zaire. The paper briefly reviews the rationale, design and implementation of the scheme and discusses its results and performance over time. The scheme succeeded in generating stable revenue for the hospital in a context where government intervention was virtually absent and external subsidies were most uncertain. Hospital data indicate that hospital services were used by a significantly higher proportion of insured patients than uninsured people. The features of the environment in which the insurance scheme thrived are discussed and the conditions that facilitated its development reviewed. These conditions comprise organizational-managerial, economic-financial, social and political factors. The Bwamanda case study illustrates the feasibility of health insurance — at least for hospital-based inpatient care - at rural district level in sub-Saharan Africa, but also exemplifies the managerial and social complexity of such financing mechanisms.     

Social factors influencing hospital utilisation by tuberculosis patients in the Russian Federation: analysis of routinely collected data.

OBJECTIVE: To establish whether admissions, discharges and hospital utilisation for tuberculosis (TB) in Russia are independent of sex, age, disability and employment status. STUDY POPULATION AND METHODS: Analysis of hospital admissions, discharges and in-patient utilisation using routinely collected data in Samara Region of the Russian Federation. RESULTS: Male, unemployed and disabled adults were significantly more likely to be hospitalised (P < 0.001). The unemployed and pensioners were more likely to have multiple admissions. Unemployed adults were more likely to have longer average lengths of stay per admission (P < 0.001), with a cumulative length of stay for unemployed and disabled adults significantly greater than for employed adults and adults with no disability. Interruption of hospital care was significantly more frequent in male, disabled and unemployed patients (P < 0.001). CONCLUSIONS: Socio-economic factors influence hospital admission patterns and the length of stay for patients when hospitalised, as the providers of TB services attempt to mitigate the lack of social care provision for patients. For the WHO DOTS strategy to be effectively implemented and sustained in the Russian Federation health system, social sector linkage issues need to be addressed.     

Factors influencing the length of hospital stay of patients with heart failure

INTRODUCTION: Heart failure (HF) is characterised by frequent hospital admissions and prolonged length of hospital stay. Admissions for HF have increased over the last decade while length of stay has decreased; the reasons for this change in length of stay are uncertain. This study investigates the effect of patient-related variables, in-hospital progress and complications on length of stay. METHODS: Patients admitted to Auckland Hospital general medical service and randomised into the Auckland Heart Failure Management Programme were included in this study. RESULTS: One hundred and ninety-seven patients were included in this study. Mean age 73 years, mean left ventricular ejection fraction 32%; 52% had one or more previous HF admissions and 75% were New York Heart Association class IV at admission. Median length of hospital stay was 6 days (IQR 4, 9) which is comparable to the national average from New Zealand admission databases. Longer than average length of stay, defined as >6 days, was associated with the presence of peripheral congestion, duration of treatment with intravenous diuretic, the development of renal impairment, other acute medical problems at admission, iatrogenic complications during hospital stay, and social problems requiring intervention. Factors independently associated with length of stay in the top quartile (>10 days) on logistic regression included the presence of oedema at admission (OR 10.5), change in weight during stay (OR 1.3), duration of treatment with iv diuretic (OR 7.5), the development of renal impairment (OR 9.8), concurrent respiratory problems requiring specific treatment (OR 3.8), and social problems requiring intervention (OR 6.8). CONCLUSIONS: Peripheral congestion, concomitant acute medical problems requiring specific treatment, the development of renal impairment and the presence of social problems were related to a longer than average length of hospital stay. Multivariate models only partly explained variance in hospital stay, suggesting the importance of pre-admission and post-discharge factors, including the healthcare environment, the availability of primary and secondary care resources, and the threshold for hospital admission.     

Comprehensive geriatric care in a day hospital: a demonstration of the British model in the United States

A geriatric day hospital (GDH) was developed in a community hospital to meet the complex medical and social needs of the frail elderly. A review of medical records (n = 273) and interviews with referring physicians (n = 42 on 96 patients) revealed that the GDH provided intensive outpatient care, geriatric assessment, rehabilitation, and an alternative to hospitalization. In all, 21% of physician-referred patients would have been hospitalized without the GDH, 7% would have had longer hospital stays, and care would have been deferred for 18%.     

新形势下加强基本医疗保险服务的探讨

我国城镇职工基本医疗保险制度及有关医疗责任事故处罚法规的全面实施，给医院带来严峻的生存危机和崭新的发展机遇，为适应形势，我院在增强服务质量、改变服务观念、提高效益和深化改革方面做了有益的探索，提高经济效益和社会效益，取得了可喜的成绩和宝贵的经验，值得推广。