Healthcare utilization of elderly persons hospitalized after a noninjurious fall in a Swiss academic medical center.

OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03-3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs.

Patients satisfaction in an academic walk-in centre: a new model of residents training achieved by family doctors.

BACKGROUND: Walk-in centres may improve access to healthcare for some patients, due to their convenient location and extensive opening hours, with no need for an appointment. Herein, we describe and assess a new model of walk-in centre, characterised by care provided by residents and supervision achieved by experienced family doctors. The main aim of the study was to assess patients' satisfaction about the care they received from residents and their supervision by family doctors. The secondary aim was to describe walk-in patients' demographic characteristics and to identify potential associations with satisfaction. METHODS: The study was conducted in the walk-in centre of Lausanne. Patients who consulted between 11th and 31st April were automatically included and received a questionnaire in French. We used a five-point Likert scale, ranging from "not at all satisfied" to "very satisfied", converted from values of 1 to 5. We focused on the satisfaction regarding residents' care and supervision by a family doctor. The former was divided in three categories: "Skills", "Treatment" and "Behaviour". A mean satisfaction score was calculated for each category and a multivariable logistic model was applied in order to identify associations with patients' demographics. RESULTS: The overall response rate was 47% [184/395]. Walk-in patients were more likely to be women (62%), young (median age 31), with a high education level (40% of University degree or equivalent). Patients were "very satisfied" with residents' care, with a median satisfaction score between 4.5 and 5, for each category. Over 90% of patients were "satisfied" or "very satisfied" that a family doctor was involved in the consultation. Age showed the greatest association with satisfaction. CONCLUSION: Patients were highly satisfied with care provided by residents and with the involvement of a family doctor in the consultation. Older age showed the greatest positive association with satisfaction with a positive impact. The high level satisfaction reported by walk-in patients supports this new model of walk-in centre.

Characteristics of highly frequent users of a Swiss academic emergency department: a retrospective consecutive case series.

OBJECTIVES: The aim of this study was to describe the demographic, social and medical characteristics, and healthcare use of highly frequent users of a university hospital emergency department (ED) in Switzerland. METHODS: A retrospective consecutive case series was performed. We included all highly frequent users, defined as patients attending the ED 12 times or more within a calendar year (1 January 2009 to 31 December 2009). We collected their characteristics and calculated a score of accumulation of risk factors of vulnerability. RESULTS: Highly frequent users comprised 0.1% of ED patients, and they accounted for 0.8% of all ED attendances (23 patients, 425 attendances). Of all highly frequent users, 87% had a primary care practitioner, 82.6% were unemployed, 73.9% were socially isolated, and 60.9% had a mental health or substance use primary diagnosis. One-third had attempted suicide during study period, all of them being women. They were often admitted (24.0% of attendances), and only 8.7% were uninsured. On average, they cumulated 3.3 different risk factors of vulnerability (SD 1.4). CONCLUSION: Highly frequent users of a Swiss academic ED are a highly vulnerable population. They are in poor health and accumulate several risk factors of being even in poorer health. The small number of patients and their high level of insurance coverage make it particularly feasible to design a specific intervention to approach their needs, in close collaboration with their primary care practitioner. Elaboration of the intervention should focus on social reinsertion and risk-reduction strategies with regard to substance use, hospital admissions and suicide.

Rate of undesirable events at beginning of academic year: retrospective cohort study.

OBJECTIVE: To determine whether an increase in the rate of undesirable events occurs after care provided by trainees at the beginning of the academic year. DESIGN: Retrospective cohort study using administrative and patient record data. SETTING: University affiliated hospital in Melbourne, Australia. PARTICIPANTS: 19,560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000). MAIN OUTCOME MEASURES: Absolute event rates, absolute rate reduction, and rate ratios of undesirable events. RESULTS: The rate of undesirable events was higher at the beginning of the academic year compared with the rest of the year (absolute event rate 137 v 107 per 1000 patient hours, relative rate reduction 28%, P<0.001). The overall adjusted rate ratio for undesirable events was 1.40, 95% confidence interval 1.24 to 1.58. This excess risk was seen for all residents, regardless of their level of seniority. The excess risk decreased progressively after the first month, and the trend disappeared fully after the fourth month of the year (rate ratio for fourth month 1.21, 0.93 to 1.57). The most important decreases were for central and peripheral nerve injuries (relative difference 82%), inadequate oxygenation of the patient (66%), vomiting/aspiration in theatre (53%), and technical failures of tracheal tube placement (49%). CONCLUSIONS: The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.

Réflexions sur les céramiques fines en Gaule interne de La Tène finale au début du Haut-Empire : comparaisons d'ensembles et essai de caractérisation des phénomènes d'acculturation

Le concept de romanisation ne revêt d'utilité que s'il peut être qualifié, et donc analysé en différents « niveaux », afin de comparer les rythmes et les formes du phénomène dans les régions de l'Empire. Avant même de chercher à tenir un discours global sur la romanisation, il faut donc en étudier les multiples aspects de manière spécifique. C'est dans ce cadre que s'inscrit cette thèse de doctorat dont le but est de quantifier et de qualifier l'acculturation des céramiques fines en Gaule interne (200 BC - 50 AD). Fondée sur un corpus de quelques 130 ensembles, provenant de 21 sites urbains localisés entre le centre ouest de la France, l'Auvergne, le Plateau suisse et le Luxembourg, cette étude se caractérise par la mise en place de nouvelles approches méthodologiques, s'appuyant sur le calcul d'un « indice de romanisation » (quantifiant la romanisation d'un ensemble sur une échelle de 1 à 100) et sur l'analyse des modalités du phénomène. L'examen diachronique et cartographique des résultats obtenus montrant de fortes disparités dans les processus d'acculturation des céramiques fines, des niveaux de romanisation ont pu être définis, dont le principal intérêt est d'ouvrir la comparaison avec les autres aspects de l'acculturation des Gaules (instrumentum culinaire, technique de construction, romanisation de l'anthroponymie...). The concept of Romanisation can only be considered useful if it can be qualified and analysed at different levels in order to compare the acculturation rates, frequency and form of the phenomenon among the regions in the Empire. But before an overview of Romanisation can be considered, its multiple aspects must be examined in a specific manner. Among the French speaking areas, it is only recently that research concerning Gaulish and Roman periods has risked expanding the scope to a supra regional scale. Against this background, the purpose of my doctoral thesis is to examine the qualitative and quantitative aspects of acculturation among Gaulish fine wares (200 BCE - 50 CE). Based on a corpus of 130 assemblages from 21 urban sites from the western centre of France, Auvergne, the Swiss plateau and Luxembourg, the study is characterised by new methodological techniques relying on the calculation of a 'Romanisation index' (quantifying the level of Romanisation of an assemblage on a scale of 1 to 100) and the analysis of the methods of the phenomenon. The diachronic and cartographic examination of the results obtained showed large disparities in the acculturation processes concerning fine wares. The level of Romanisation could be defined, thus allowing a comparison with other aspects of the acculturation process among other aspects of Gaulish culture such as tools, cuisine, construction techniques and Romanisation of anthroponyms.

Improving low achievers' academic performance at university by changing the social value of mastery goals

Recent research has shown that, in a University context, mastery goals are highly valued, and that students may endorse these goals either because they believe in their utility (i.e., social utility), in which case mastery goals are positively linked to achievement, or to create a positive image of themselves (i.e., social desirability), in which case mastery goals do not predict academic achievement. The present two experiments induced high vs. neutral levels of mastery goals' social utility and social desirability. Results confirmed that mastery goals predicted performance only when these goals were presented as socially useful but not socially desirable, especially among low achievers, those who need mastery goals the most to succeed.