Health services utilization associated with cognitive impairment and dementia in older patients undergoing post-acute rehabilitation.

OBJECTIVE: To investigate the relationship between levels of cognitive impairment and health services utilization in older patients undergoing post-acute rehabilitation. DESIGN: Cross-sectional study. SETTING: Post-acute rehabilitation facility. PARTICIPANTS: Patients (N = 1764) aged 70 years and older admitted over 3 years. MEASUREMENTS: Sociodemographic, medical, and functional data were collected upon admission. Based on discharge diagnoses, patients were classified as cognitively intact, cognitively impaired with no dementia (CIND), and demented. RESULTS: Dementia and CIND were diagnosed in 425 (24.1%) and 301 (17.1%) patients, respectively. Gradients from cognitively intact to cognitively impaired to demented patients were observed in median length of stay (19, 22, and 25 days, P < .001), and institutionalization rates at discharge (4.2%, 7.6%, and 28.8%, P < .001). Among patients discharged home, similar gradients were observed in utilization of home care (68.2%, 79.7%, and 83.3%, P < .001) and day care (3.1%, 7.1%, and 14.3%, P < .001). After adjustment, compared with cognitively intact patients, only those with dementia still had longer stays (+2.7 days) and increased odds of institutionalization (adjOR 6.1, 95% CI 4.0-9.3, P < .001). Among patients discharged home, use of home and day care remained higher in those with dementia (adjOR 1.8, 95% CI 1.2-2.7, P = .005, and adjOR 1.8, 95% CI 1.2-2.7, P = .005, respectively), while CIND patients had higher odds of using home care (adjOR 1.6, 95% CI 1.1-2.4, P = .028). CONCLUSION: Among patients undergoing post-acute rehabilitation, those with dementia had increased use of both institutional and community care, whereas those with CIND had increased use of home care services only. Future studies should investigate specific strategies susceptible to reduce the related burden on health care systems.

Fallers in postacute rehabilitation have worse functional recovery and increased health services use.

OBJECTIVES: To determine characteristics associated with single and multiple fallers during postacute rehabilitation and to investigate the relationship among falls, rehabilitation outcomes, and health services use. DESIGN: Retrospective cohort study. SETTING: Geriatric postacute rehabilitation hospital. PARTICIPANTS: Patients (n = 4026) consecutively admitted over a 5-year period (2003-2007). MEASUREMENTS: All falls during hospitalization were prospectively recorded. Collected patients' characteristics included health, functional, cognitive, and affective status data. Length of stay and discharge destination were retrieved from the administrative database. RESULTS: During rehabilitation stay, 11.4% (458/4026) of patients fell once and an additional 6.3% (253/4026) fell several times. Compared with nonfallers, fallers were older and more frequently men. They were globally frailer, with lower Barthel score and more comorbidities, cognitive impairment, and depressive symptoms. In multivariate analyses, compared with 1-time fallers, multiple fallers were more likely to have lower Barthel score (adjOR: 2.45, 95% CI: 1.48-4.07; P = .001), cognitive impairment (adjOR: 1.43, 95% CI: 1.04-1.96; P = .026), and to have been admitted from a medicine ward (adjOR: 1.55, 95% CI: 1.03-2.32; P = .035). Odds of poor functional recovery and institutionalization at discharge, as well as length of stay, increased incrementally from nonfallers to 1-time and to multiple fallers. CONCLUSION: In these patients admitted to postacute rehabilitation, the proportion of fallers and multiple fallers was high. Multiple fallers were particularly at risk of poor functional recovery and increased health services use. Specific fall prevention programs targeting high-risk patients with cognitive impairment and low functional status should be developed in further studies.

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts.

Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.

Frailty and use of health and community services by community-dwelling older men: the Concord Health and Ageing in Men Project.

BACKGROUND: frailty is a concept used to describe older people at high risk of adverse outcomes, including falls, functional decline, hospital or nursing home admission and death. The associations between frailty and use of specific health and community services have not been investigated. METHODS: the cross-sectional relationship between frailty and use of several health and community services in the last 12 months was investigated in 1,674 community-dwelling men aged 70 or older in the Concord Health and Ageing in Men study, a population-based study conducted in Sydney, Australia. Frailty was assessed using a modified version of the Cardiovascular Health Study criteria. RESULTS: overall, 158 (9.4%) subjects were frail, 679 (40.6%) were intermediate (pre-frail) and 837 (50.0%) were robust. Frailty was associated with use of health and community services in the last 12 months, including consulting a doctor, visiting or being visited by a nurse or a physiotherapist, using help with meals or household duties and spending at least one night in a hospital or nursing home. Frail men without disability in activities of daily living were twice more likely to have seen a doctor in the previous 2 weeks than robust men (adjusted odds ratio 2.04, 95% confidence interval 1.21-3.44), independent of age, comorbidity and socio-economic status. CONCLUSION: frailty is strongly associated with use of health and community services in community-dwelling older men. The high level of use of medical services suggests that doctors and nurses could play a key role in implementation of preventive interventions.

Violence: les femmes font confiance au milieu médical [Partner violence: women trust health professionals]

In 2008, the department of gynaecology and obstetrics of a university hospital centre implemented a program addressing interpersonal partner violence (screening, prevention and care of the patient victims). A qualitative survey was conducted to identify the needs and feelings of patients. The results show that patients are in favour of being actively and directly questioned about violence during the consultation and that they trust medical doctors and nurses to help and support them.

Work and health : remodelling perspectives of working life research, as proposed by Järvholm et al. (2009)

Järvholm and Co-workers (2009) proposed a conceptual model for research on working life. Models are powerful communication and decision tools. This model is strongly unidirectional and does not cover the mentioned interactions in the arguments.With help of a genealogy of work and of health it is shown that work and health are interactive and have to be analysed on the background of society.Key words: research model, work, health, occupational health, society, interaction, discussion paperRemodellierung der von Järvholm et al. (2009) vorgeschlagenen Forschungsperspektiven in Arbeit und GesundheitJärvholm und Kollegen stellten 2009 ein konzeptionelles Modell für die Forschung im Bereich Arbeit und Gesundheit vor. Modelle stellen kraftvolle Kommunikations- und Entscheidungsinstrumente dar. Die Einflussfaktoren im Modell verlaufen jedoch nur in einer Richtung und bilden die interaktiven Argumente im Text nicht ab. Mit Hilfe einer Genealogie der Begriffe Arbeit und Gesundheit wird aufgezeigt, dass Arbeit und Gesundheit sich gegenseitig beeinflussen und nur vor dem Hintergrund der jeweiligen gesellschaftlichen Kontextfaktoren zu analysieren sind.Introduction : After an interesting introduction about the objectives of research on working life, Järvholm and Co-workers (2009) manage to define a conceptual model for working life research out of a small survey of Occupational Safety and Health (OSH) definitions. The strong point of their model is the entity 'working life' including personal development, as well as career paths and aging. Yet, the model Järvholm et al. (2009) propose is strangely unidirectional; the arrows point from the population to working life, from there to health and to disease, as well as to productivity and economic resources. The diagram only shows one feed-back loop: between economic resources and health. We all know that having a chronic disease condition influences work and working capacity. Economic resources have a strong influence on work, too. Having personal economic resources will influence the kind of work someone accepts and facilitate access to continuous professional education. A third observation is that society is not present in the model, although this is less the case in the arguments. In fact, there is an incomprehensible gap between the arguments brought forth by Järvholm and co-workers and their reductionist model.Switzerland has a very low coverage of occupational health specialists. Switzerland is a long way from fulfilling the WHO's recommendations on workers' access to OSH services as described in its Global plan of action. The Institute for Work and Health (IST) in Lausanne is the only organisation which covers the major domains of OSH research that are occupational medicine, occupational hygiene, ergonomic and psychosocial research. As the country's sole occupational health institution we are forced to reflect the objectives of working life research so as not to waste the scare resources available.I will set out below a much shortened genealogy of work and of health, with the aim of extending Järvholm et al's (2009) analyses on the perspectives of working life research in two directions. Firstly towards the interactive nature of work and health and the integration of society, and secondly towards the question of what working life means or where working life could be situated.Work, as we know it today - paid work regulated by a contract as the basis for sustaining life and as a base for social rights - was born in modern era. Therefore I will start my genealogy in the pre-modern era, focus on the important changes that occurred during industrial revolution and the modern era and end in 2010 taking into account the enormous transformations of the past 20-30 years. I will put aside some 810 years of advances in science and technology that have expanded the world's limits and human understanding, and restrict my genealogy to work and to health/body implicating also the societal realm. [Author]

Variations régionales du recours aux soins: quelques problèmes méthodologiques. [Regional variations in health services: various methodological problems].

Many studies show strong variation of health consumption between regions, suggesting that theses variations are related to the uncertainty of medical practice or to other factors related to health services or patients attitude. However the statistical interpretation of these variations is far from easy: apart from usual and specific information bias, there are statistical problems when observing incidence of events like health care consumption: it is in fact a rare event, which is observed within small population, and among regions with unequal number of person. Therefore, most of the variation reported might be well explained by a purely statistical phenomenon. This paper presents some aspects of this variability for three common indicators of variation, and suggest the use of ad hoc simulation to get statistical criteria.

Effectiveness of a pediatric palliative home care team as experienced by parents and health care professionals.

OBJECTIVES: Little data are available on palliative home care for children. The objective of this study was to evaluate the effectiveness of a specialized pediatric palliative home care team (PPHCT) as experienced by parents and health care professionals (HCPs). METHODS: Parents and HCPs involved in the care of terminally ill children who died and whom the PPHCT was in charge of were surveyed with questionnaires focusing on satisfaction with the PPHCT, satisfaction with the course of the dying phase, and the development of anxiety, depression, and prolonged grief disorder. RESULTS: Forty-three parent dyads participated (return rate, 88%). Satisfaction with the PPHCT scored a median of 10 (numeric rating scale, 0-10). The child's death was predominantly experienced as very peaceful (median, 9); 71% died at home. According to parents, involvement of the PPHCT led to highly significant (p<0.001) improvements in the children's symptoms and quality of life, as well as in aspects of communication and administrative barrier reduction. Anxiety was detected in 25% of parents, depression in 19%, and prolonged grief disorder in 13%. HCPs (return rate, 83%) evaluated all investigated care domains (particularly cooperation/communication/family support) as being significantly improved (p<0.001). Thirty-five percent of HCPs felt uncertain concerning pediatric palliative care; 79% would welcome specific training opportunities. CONCLUSIONS: Involvement of a PPHCT is experienced as a substantial improvement of care by parents and HCPs. Coordination of palliative care during the last phase of life appears to be an important quality factor for the home care of dying children and their families.

Smoking, prevalence of disease and health service utilization among the Swiss population.

The data of the 1981-83 Swiss National Health Survey "SOMIPOPS", based on a randomly selected sample of 4,235 individuals aged 20 or over representative of the whole Swiss population, were used to investigate the relation between smoking, prevalence of disease and frequency of health care utilization. The risks of several conditions, including hypertension, myocardial infarction and other heart diseases, asthma, tuberculosis and kidney disease were elevated among ex-smokers. The diseases showing elevated risks among current smokers and significantly positive dose-risk trends included acute bronchitis (relative risk, RR = 3.2 for heavy cigarette smokers vs never smokers), chronic bronchitis or lung emphysema (RR = 2.0), gastro-duodenal ulcer (RR = 1.8) and bone fractures (RR = 1.6). For respiratory conditions, the risk of pipe or cigar smokers was comparable to that of moderate cigarette smokers, whereas for ulcer (RR = 4.1) or fractures (RR = 2.0) the point estimates were even higher than for heavy cigarette smokers. Smokers tended to consult more frequently general practitioners, used more other outpatients services, and were more frequently admitted to hospital during the year preceding the interview. These effects were consistent across strata of age, socio-economic indicators, and persisted after allowance for major identified potential distorting factors. Thus, the results of this survey confirm that smoking is an important cause of morbidity and a major contributory factor to the use of health services.

Education, disease prevalence and health service utilization in the Swiss National Health Survey "SOMIPOPS".

The relation among education, disease prevalence, and frequency of health service utilization was analyzed using data from the Swiss National Health Survey SOMIPOPS, conducted in 1981-1983 on a randomly selected sample of 4,255 individuals, representative of the entire Swiss population. The prevalence of several important cardiovascular, respiratory, digestive, osteoarticular, and psychiatric disorders was higher among less educated individuals; only allergic conditions were directly associated with indicators of social class. More educated individuals reported lower frequencies of general practitioner visits, but higher frequencies of specialized consultations. These findings confirm that education is an important determinant not only of mortality but also of morbidity and health-care utilization and require careful consideration in terms of the planning and evaluation of health services.