Predicting Patient Satisfaction: A Study of Two Emergency Departments

To identify perceptions that predict overall patient (dis)satisfaction with Emergency Department (ED) care, we studied responses to a survey mailed to all discharged patients over a 6-month period (Academic Hospital), and to a telephone interview of a random sample of discharged patients over a 1-year period (Community Hospital). The survey and interview both assessed overall satisfaction, as well as satisfaction with perceived waiting times, information delivery, and expressive quality of physicians, nurses, and staff. Data for 1176 patients (training sample) and 1101 patients (holdout sample) who rated overall satisfaction as either very good or very poor (Academic Hospital), and for 856 patients (training sample) and 431 patients (holdout sample) who rated overall satisfaction as either excellent or poor (Community Hospital), were retained for analysis. For both hospitals, nonlinear tree models efficiently achieved overall classification accuracy exceeding 98% in training analysis and 95% in holdout analysis (all p < .0001). The findings suggest that overall patient (dis)satisfaction with care received in the ED is nearly perfectly predictable on the basis of patient-rated expressive qualities of ED staff, particularly physicians and nurses. Interventions designed to reinforce positive (and extinguish negative) expressive health-care provider behaviors may cut the number of extremely dissatisfied patients in half.     

Cost‐Effectiveness of Orthogeriatric and Fracture Liaison Service Models of Care for Hip Fracture Patients: A Population‐Based Study

Fracture liaison services are recommended as a model of best practice for organizing patient care and secondary fracture prevention for hip fracture patients, although variation exists in how such services are structured. There is considerable uncertainty as to which model is most cost‐effective and should therefore be mandated. This study evaluated the cost‐ effectiveness of orthogeriatric (OG)‐ and nurse‐led fracture liaison service (FLS) models of post‐hip fracture care compared with usual care. Analyses were conducted from a health care and personal social services payer perspective, using a Markov model to estimate the lifetime impact of the models of care. The base‐case population consisted of men and women aged 83 years with a hip fracture. The risk and costs of hip and non‐hip fractures were derived from large primary and hospital care data sets in the UK. Utilities were informed by a meta‐regression of 32 studies. In the base‐case analysis, the orthogeriatric‐led service was the most effective and cost‐effective model of care at a threshold of £30,000 per quality‐adjusted life years gained (QALY). For women aged 83 years, the OG‐led service was the most cost‐effective at £22,709/QALY. If only health care costs are considered, OG‐led service was cost‐effective at £12,860/QALY and £14,525/QALY for women and men aged 83 years, respectively. Irrespective of how patients were stratified in terms of their age, sex, and Charlson comorbidity score at index hip fracture, our results suggest that introducing an orthogeriatrician‐led or a nurse‐led FLS is cost‐effective when compared with usual care. Although considerable uncertainty remains concerning which of the models of care should be preferred, introducing an orthogeriatrician‐led service seems to be the most cost‐effective service to pursue. © 2016 American Society for Bone and Mineral Research.     

The experience of supporting a dying relative: reflections of caregivers

Abstract

This article describes family caregivers' responses to a National Inquiry into the Social Impact of Caregiving for Terminally Ill, initiated by Palliative Care Australia, which aimed to influence policy and practice to support caregivers. Caregivers recounted their experiences of supporting a dying relative and reported their unmet needs and the impact that the caregiving role had on their financial, physical and psychosocial wellbeing. The issues raised by caregivers were consistent with data obtained from a wide cross-section of service providers and a number of findings were congruent with empirical literature related to family caregiving. Caregivers' reports confirm that, to maintain their health and well-being, they need adequate resources, fairer remuneration, quality respite care, education about the role, equipment, psychosocial support, home-help, improved access to the paid workforce and to gain community recognition. Such collected evidence reinforced the importance of policy responses and resource allocations that are focused on helping caregivers perform a vital role into the future.     

Non-fatal Occupational Injuries among Non-governmental Employees in Malaysia

Abstract

We analyzed data on non-fatal occupational injuries reported to Malaysia's social security organization from 2002 to 2006. There was a decrease in both the absolute number and the incidence rates of these injuries over time. About 40% of cases occurred in the manufacturing sector followed by the service (17%) and trading (17%) sectors. The agriculture sector reported the highest incidence rate (24.1/1,000), followed by the manufacturing sector subcategories of wood-product manufacturing (22.1/1,000) and non-metallic industries (20.8/1,000). Men age 40 to 59 and persons of Indian ethnicity had a greater tendency to sustain injuries. Government and non-governmental organizations should strive to develop strategies to reduce the occupational injuries targeting vulnerable groups. Enforcement of safety measures will further play an important role to ensure that both employees and employers take special precautions to address workplace hazards.     

Recent developments in managing breathlessness: International researchers' meeting on Breathlessness in London,November 2006

Abstract

Intractable breathlessness is the most common and distressing symptom in far-advanced cardiopulmonary disease. It affects millions of people world-wide. Despite advances in research over recent years there are still many unresolved questions regarding the pathophysiology and aetiology of breathlessness as well as the best management options. At an international meeting in London, researchers discussed how to improve and extend breathlessness research. Topics ranged from qualitative through to biomedical research and included: (i) the aetiology of breathlessness in cancer and its relation to deconditioning; (ii) the personal experience of breathlessness and social effects of chronic obstructive pulmonary disease (COPD); (iii) the measurement of breathlessness; (iv) the use of grey literature; (v) the latest developments in functional brain imaging (fMRI); and (vi) the effects of a breathlessness intervention service (BIS) to help patients cope with their breathlessness. Various areas for further research were identified such as understanding the genesis of breathlessness, the role of pulmonary rehabilitation in cancer patients and the need for functional imaging studies in patients with breathlessness.     

Responses to VCT for HIV among young people in Kampala,Uganda

Attitudes to voluntary counselling and testing (VCT) for HIV among young men and women in a slum area of Kampala, Uganda, were studied through 22 individual semi-structured interviews and 5 focus group discussions. Attitudes to VCT ranged from having no problem with the procedure to being very reluctant. Despite fear of stigma, the participants perceived 'positive living' after HIV testing as realistic. VCT was regarded as an important step to avoid HIV infection, but informants expressed the need for the service to be more accessible in terms of cost, time and quality of pre- and post-test counselling. We argue that counselling without HIV testing should be available for those who are reluctant to test. Poverty and gender power imbalances appeared to limit youths' possibility of making rational decisions about sexual behaviour and accessing VCT. The importance of considering the context in which such issues are being negotiated and decided is highlighted.     

Extended scope physiotherapists in the emergency department: a literature review

Abstract

Background: Emergency departments (EDs) are one of the main providers of minor injury care in the UK. The use of extended scope physiotherapists (ESPs), independently managing patients from arrival to discharge, has not been widely considered in the UK or internationally. It is possible that ESPs will contribute to the staffing of the twenty-first-century EDs, and their role is gaining momentum in Australia, Canada, and several European counties.

Objectives: The aim of the review was to establish the UK and international evidence for clinical effectiveness and cost efficiencies for ESPs independently managing a case load of 'minor injuries' in the ED setting.

Methods: A comprehensive review of the published and non-published international literature was undertaken.

Results: ESPs are independent professionals with pre-existing skills in the assessment and diagnosis of musculoskeletal injuries. Evidence was only found from UK hospitals regarding the clinical effectiveness and cost efficiencies. ESPs obtain equivalent clinical outcomes compared to the care provided by doctors of all grades, and they are likely to be equivalent in cost, but patients may take longer to return to normal activities when treated by an ESP. ESPs can work to existing ED protocols and achieve significantly higher patient satisfaction than other professional groups, but spend longer with patients.

Conclusions: ESPs can provide a high standard of care at an affordable cost, whilst positively influencing patient satisfaction. The use of ESPs working in the ED, carrying out duties traditionally undertaken by doctors, could provide one of the solutions to staffing shortages in emergency care.     

The Potential Economic Benefits of Improved Postfracture Care: A Cost‐Effectiveness Analysis of a Fracture Liaison Service in the US Health‐Care System

Fractures related to osteoporosis are associated with $20 billion in cost in the United States, with the majority of cost born by federal health‐care programs, such as Medicare and Medicaid. Despite the proven fracture reduction benefits of several osteoporosis treatments, less than one‐quarter of patients older than 65 years of age who fracture receive such care. A postfracture liaison service (FLS) has been developed in many health systems but has not been widely implemented in the United States. We developed a Markov state‐transition computer simulation model to assess the cost‐effectiveness of an FLS using a health‐care system perspective. Using the model, we projected the lifetime costs and benefits of FLS, with or without a bone mineral density test, in men and women who had experienced a hip fracture. We estimated the costs and benefits of an FLS, the probabilities of refracture while on osteoporosis treatment, as well as the utilities associated with various health states from published literature. We used multi‐way sensitivity analyses to examine impact of uncertainty in input parameters on cost‐effectiveness of FLS. The model estimates that an FLS would result in 153 fewer fractures (109 hip, 5 wrist, 21 spine, 17 other), 37.43 more quality‐adjusted life years (QALYs), and save $66,879 compared with typical postfracture care per every 10,000 postfracture patients. Doubling the cost of the FLS resulted in an incremental cost‐effectiveness ratio (ICER) of $22,993 per QALY. The sensitivity analyses showed that results were robust to plausible ranges of input parameters; assuming the least favorable values of each of the major input parameters results in an ICER of $112,877 per QALY. An FLS targeting patients post‐hip fracture should result in cost savings and reduced fractures under most scenarios. © 2014 American Society for Bone and Mineral Research.     

Association Between Recurrent Fracture Risk and Implementation of Fracture Liaison Services in Four Swedish Hospitals: A Cohort Study

Structured secondary preventions programs, called fracture liaison services (FLSs), increase the rate of evaluation with bone densitometry and use of osteoporosis medication after fracture. However, the evidence regarding the effect on the risk of recurrent fracture is insufficient. The aim of this study was to investigate if implementation of FLS was associated with reduced risk of recurrent fractures. In this retrospective cohort study, electronic health records during 2012 to 2017 were used to identify a total of 21,083 patients from four hospitals in Western Sweden, two with FLS (n = 15,449) and two without (n = 5634). All patients aged 50 years or older (mean age 73.9 [SD 12.4] years, 76% women) with a major osteoporotic index fracture (hip, clinical spine, humerus, radius, and pelvis) were included. The primary outcome was recurrent major osteoporotic fracture. All patients with an index fracture during the FLS period (n = 13,946) were compared with all patients in the period before FLS implementation (n = 7137) in an intention-to-treat analysis. Time periods corresponding to the FLS hospitals were used for the non-FLS hospitals. In the hospitals with FLSs, there were 1247 recurrent fractures during a median follow-up time of 2.2 years (range 0–6 years). In an unadjusted Cox model, the risk of recurrent fracture was 18% lower in the FLS period compared with the control period (hazard ratio = 0.82, 95% confidence interval [CI] 0.73–0.92, p = .001), corresponding to a 3-year number needed to screen of 61, and did not change after adjustment for clinical risk factors. In the hospitals without FLSs, no change in recurrent fracture rate was observed. Treatment decisions were made according to the Swedish treatment guidelines. In conclusion, implementation of FLS was associated with a reduced risk of recurrent fracture, indicating that FLSs should be included routinely at hospitals treating fracture patients. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.     

Health Service Integration in Oregon School-Based Health Centers: Meeting the Mental Health Needs of Young People

School-based health centers (SBHCs) break down traditional barriers encountered by young people in the healthcare system. Along with physical health services, all of Oregon's SBHCs provide some level of mental health services. As more evidence reveals the connection between mental and physical health, integrated care systems that improve health outcomes for those with mental health concerns become increasingly important. Oregon's SBHCs have varying levels of ability to address physical and mental health service integration, based on community resources and logistical limitations. Using data from an assessment of Oregon's SBHC mental health system, this article offers recommendations for how more integrated services in an SBHC can help fill gaps to better meet young people's mental health needs in Oregon.