Transition of young people with chronic conditions: a cross-sectional study of patient perceptions before and after transfer from pediatric to adult health care.

UNLABELLED: The aim of this study was to compare perceived barriers to and the most preferred age for successful transition to adult health care between young people with chronic disorders who had not yet transferred from pediatric to adult health care (pre-transfer) and those who had already transferred (post-transfer). In a cross-sectional study, we compared 283 pre-transfer with 89 post-transfer young people, using a 28-item questionnaire that focused on perceived barriers to transition and beliefs about the most preferred age to transfer. Feeling at ease with the pediatrician was the most important barrier to successful transition in both groups, but was rated significantly higher in the pre-transfer compared to the post-transfer group (OR = 2.03, 95 %CI 1.12-3.71). Anxiety and lack of information were the next most important barriers, rated equally highly by the two groups (OR = 0.67, 95 %CI 0.35-1.28 and OR = 0.71, 95 %CI 0.36-1.38, respectively). More than 80 % of the respondents in both groups reported that 16-19 years was the most preferred age to transfer; more than half of all the respondents reported 18-19 years and older as the most preferred age. CONCLUSION: Better transition planning through the provision of regular and more detailed information about adult health-care providers and the transition process could reduce anxiety and contribute to a more positive attitude to overcome perceived barriers to transition from young people's perspective. Young people's preferences about transferring to adult health care provide a challenge to those children's hospitals that transfer to adult health care at a younger age.

Référentiel de pratiques professionnelles: soins et surveillance des accès veineux centraux de l'adulte pour la nutrition parentérale [Formative assessment in clinical nutrition: Care management of parenteral nutrition central venous access]

Les voies veineuses centrales (VVC) sont essentielles pour l'administration de la nutrition parentérale. Le risque de complications est dépendant de la qualité des soins apportés à la VVC qui influence de ce fait la qualité de vie des patients et le coût des soins. Beaucoup de complications des VVC, infectieuses ou non, peuvent être prévenues par l'existence de protocoles de soins appropriés et standardisés. L'information sur les soins des VVC et les éventuelles complications est essentielle pour le dépistage et le traitement précoce de ces complications ; elle doit faire l'objet de protocoles partagés entre les patients et les soignants. Cet article décrit une évaluation des pratiques professionnelles sous la forme d'un audit clinique destiné à améliorer la qualité de soins des patients en nutrition parentérale porteurs de VVC. Central venous access devices (CVAD) are essential for the administration of parenteral nutrition. The quality of the care of CVAD influences the risk of complications and so the quality of life of the patients and the costs of care. Numerous infectious or non-infectious complications of CVAD can be prevented by appropriate, standardized protocols of care. Information about the care of CVAD and complications is essential for the early recognition and treatment of complications and should be shared between patients and caregivers. This article describes an audit for CAVD care that can be used to improve quality of care in a professional practice evaluation program.

Services "amis des jeunes": promouvoir des soins adaptés aux adolescents [Youth friendly health services: how to promote quality health care for adolescents].

Beaucoup de jeunes éprouvent des difficultés à demander une aide médicale et psychosociale alors qu'ils en auraient bien besoin. Cela est lié au processus d'autonomisation propre à cette période de la vie : les adolescents souhaitent résoudre leurs problèmes eux-mêmes. Pour améliorer la qualité des soins aux jeunes, l'Organisation mondiale de la santé, avec l'UNICEF et d'autres organismes, a développé le concept de youth friendly health services ; services amis des jeunes. Ce concept repose sur plusieurs principes, comme l'accessibilité, la flexibilité, une formation spécifique du personnel, le respect de la neutralité et de la confidentialité, compétences communicationnelles, etc. L'application de cette approche ne se limite pas aux centres spécialisés en médecine de l'adolescence, mais devra être progressivement implantée dans toutes les structures de soins accueillant des jeunes. Many young people have difficulties requesting medical or psychosocial support, although some badly need it. This difficulty is related to the fact that, as part of their search for autonomy, young people prefer to solve their problems by themselves. To improve the quality of care, the World Health Organization, UNICEF and allied organizations have developed the concept of "Youth friendly health services". This concept includes policies and strategies to improve the accessibility and flexibility, staff's competence and communication skills, etc. Such an approach should not be limited to specialized centers for adolescent health. It should be adopted by all health care institutions dealing with young people.

Pediatric advance care planning from the perspective of health care professionals: a qualitative interview study.

BACKGROUND: Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective. AIM: We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. DESIGN: This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. SETTING/PARTICIPANTS: We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. RESULTS: Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. CONCLUSION: Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.

A measurement framework for quality health care for adolescents in hospital.

PURPOSE: Despite growing interest in measurement of health care quality and patient experience, the current evidence base largely derives from adult health settings, at least in part because of the absence of appropriately developed measurement tools for adolescents. To rectify this, we set out to develop a conceptual framework and a set of indicators to measure the quality of health care delivered to adolescents in hospital. METHODS: A conceptual framework was developed from the following four elements: (1) a review of the evidence around what young people perceive as "adolescent-friendly" health care; (2) an exploration with adolescent patients of the principles of patient-centered care; (3) a scoping review to identify core clinical practices around working with adolescents; and (4) a scoping review of existing conceptual frameworks. Using criteria for indicator development, we then developed a set of indicators that mapped to this framework. RESULTS: Embedded within the notion of patient- and family-centered care, the conceptual framework for adolescent-friendly health care (quality health care for adolescents) was based on the constructs of experience of care (positive engagement with health care) and evidence-informed care. A set of 14 indicators was developed, half of which related to adolescents' and parents' experience of care and half of which related to aspects of evidence-informed care. CONCLUSIONS: The conceptual framework and indicators of quality health care for adolescents set the stage to develop measures to populate these indicators, the next step in the agenda of improving the quality of health care delivered to adolescents in hospital settings.

Care delivery value chains for ophthalmic clinics in Switzerland

Perceived patient value is often not aligned with the emerging expenses for health care services. In other words, the costs are often supposed as rising faster than the actual value for the patients. This fact is causing major concerns to governments, health plans, and individuals. Attempts to solve the problem have habitually been on the operational effectiveness side: increasing patient volume, minimizing costs, rationing, or closing hospitals, usually resulting in a zero-sum game. Only few approaches come from the strategic positioning side and "competition" among hospitals is still perceived rather as a danger than as a chance to create a positive-sum game and stimulate patient value. In their 2006 book, "Redefining Health Care", the renowned Harvard strategy professor Michael E. Porter and hospital management expert Professor Elizabeth Olmsted Teisberg approach the challenge from the positive-sum perspective: they propose to form Integrated Practice Units (IPUs) and manage hospitals in a modern, patient value oriented way. They argue that creating value-based competition on results should have the same effect on the health care sector like transparency and competition turned other industries with out-dated management models (like recently the inert telecommunication industry) into highly competitive and customer value creating businesses. The objective of this paper is to elaborate Care Delivery Value Chains for Integrated Practice Units in ophthalmic clinics and gather a first feedback from Swiss hospital managers, ophthalmologists, and patients, if such an approach could be a realistic way to improve health care management. First, Porter's definition of competitiveness (distinction between operational effectiveness and strategic positioning) is explained. Then, the Care Delivery Value Chain is introduced as a key element for understanding value-based management, followed by three practice examples for ophthalmic clinics. Finally, recommendations are given how the Care Delivery Value Chain can be managed efficiently and how the obstacles of becoming a patient-oriented organization can be overcome. The conclusion is that increased transparency and value-based competition on results has the potential to change the mindset of hospital managers-which will align patient value with the emerging health care expenses. Early adapters of this management approach will gain a competitive advantage. [Author, p. 6]

Health care utilization among immigrants and native-born populations in 11 European countries. Results from the Survey of Health, Ageing and Retirement in Europe

This study examines health care utilization of immigrants relative to the native-born populations aged 50 years and older in eleven European countries. Methods. We analyzed data from the Survey of Health Aging and Retirement in Europe (SHARE) from 2004 for a sample of 27,444 individuals in 11 European countries. Negative Binomial regression was conducted to examine the difference in number of doctor visits, visits to General Practitioners (GPs), and hospital stays between immigrants and the native-born individuals. Results: We find evidence those immigrants above age 50 use health services on average more than the native-born populations with the same characteristics. Our models show immigrants have between 6% and 27% more expected visits to the doctor, GP or hospital stays when compared to native-born populations in a number of European countries. Discussion: Elderly immigrant populations might be using health services more intensively due to cultural reasons.

Older consumers adopting information and communication technology: Evaluating opportunities for health care applications

The purpose of this dissertation is to analyse older consumers' adoption of information and communication technology innovations, assess the effect of aging related characteristic, and evaluate older consumers' willingness to apply these technologies in health care services. This topic is considered important, because the population in Finland (as in other welfare states) is aging and thus offers a possibility for marketers, but on the other hand threatens society with increasing costs for healthcare. Innovation adoption has been under research from several aspects in both organizational and consumer research. In the consumer behaviour, several theories have been developed to predict consumer responses to innovation. The present dissertation carefully reviews previous research and takes a closer look at the theory of planned behaviour, technology acceptance model and diffusion of innovations perspective. It is here suggested that there is a possibility that these theories can be combined and complemented to predict the adoption of ICT innovations among aging consumers, taking the aging related personal characteristics into account. In fact, there are very few studies that have concentrated on aging consumers in the innovation research, and thus there was a clear indent for the present research. ICT in the health care context has been studied mainly from the organizational point of view. If the technology is thus applied for the communication between the individual end-user and service provider, the end-user cannot be shrugged off. The present dissertation uses empirical evidence from a survey targeted to 55-79 year old people from one city in Southern-Carelia. The empirical analysis of the research model was mainly based on structural equation modelling that has been found very useful on estimating causal relationships. The tested models were targeted to predict the adoption stage of personal computers and mobile phones, and the adoption intention of future health services that apply these devices for communication. The present dissertation succeeded in modelling the adoption behaviour of mobile phones and PCs as well as adoption intentions of future services. Perceived health status and three components behind it (depression, functional ability, and cognitive ability) were found to influence perception of technology anxiety. Better health leads to less anxiety. The effect of age was assessed as a control variable, in order to evaluate its effect compared to health characteristics. Age influenced technology perceptions, but to lesser extent compared to health. The analyses suggest that the major determinant for current technology adoption is perceived behavioural control, and additionally technology anxiety that indirectly inhibit adoption through perceived control. When focusing on future service intentions, the key issue is perceived usefulness that needs to be highlighted when new services are launched. Besides usefulness, the perception of online service reliability is important and affects the intentions indirectly. To conclude older consumers' adoption behaviour is influenced by health status and age, but also by the perceptions of anxiety and behavioural control. On the other hand, launching new types of health services for aging consumers is possible after the service is perceived reliable and useful.

Re-visiting the health care luxury good hypothesis: Aggregation, precision, and publication biases?

[cat] Mentre que una creixent literatura que ha examinat la relació entre la renda i la despesa sanitària suggereix que els serveis sanitaris són un be de luxe (elasticitat renda superior a la unitat), aquesta conclusió es contínuament debatuda atesa l'heterogeneïtat dels resultats. Aquest article testa la hipòtesis dels serveis sanitaris com bens de luxe fent server anàlisi de meta- regressió, particularment analitzant l'existència de biaixos de selecció de publicació, precisió així com biaixos d'agregació. Els resultats apunten l'existència d'un biaix de publicació, robust independentment dels controls analitzats. Els biaixos de precisió i agregació semblen tenir un paper en la generació de les estimacions de l'elasticitat renda. Els nostres resultat suggereixen que l'elasticitat renda dels serveis sanitaris un cop corregir pels biaixos esmentat varien entre 0.26 i 0.84, però no podem rebutjar que la elasticitat renda es igual a la unitat en algunes estimacions de l'elasticitat corregides.

Re-visiting the health care luxury good hypothesis: Aggregation, precision, and publication biases?

[cat] Mentre que una creixent literatura que ha examinat la relació entre la renda i la despesa sanitària suggereix que els serveis sanitaris són un be de luxe (elasticitat renda superior a la unitat), aquesta conclusió es contínuament debatuda atesa l'heterogeneïtat dels resultats. Aquest article testa la hipòtesis dels serveis sanitaris com bens de luxe fent server anàlisi de meta- regressió, particularment analitzant l'existència de biaixos de selecció de publicació, precisió així com biaixos d'agregació. Els resultats apunten l'existència d'un biaix de publicació, robust independentment dels controls analitzats. Els biaixos de precisió i agregació semblen tenir un paper en la generació de les estimacions de l'elasticitat renda. Els nostres resultat suggereixen que l'elasticitat renda dels serveis sanitaris un cop corregir pels biaixos esmentat varien entre 0.26 i 0.84, però no podem rebutjar que la elasticitat renda es igual a la unitat en algunes estimacions de l'elasticitat corregides.

Supporting older people’s independent living at home through social and health care collaboration

Tässä tutkimuksessa tarkasteltiin ikäihmisten kotona asumista sosiaali- ja terveydenhuollon yhteistyön näkökulmasta. Tutkimuksen tarkoituksena oli lisätä ymmärrystä iäkkäiden kotihoidon asiakkaiden voimavaroista arjesta selviytymisen näkökulmasta, ja tutkia miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutuu. Tutkimus oli poikkileikkaustutkimus, jossa sovellettiin kuvailevaa ja vertailevaa tutkimusasetelmaa. Tutkimusaineisto kerättiin yhden länsisuomalaisen kunnan kotihoidon asiakkailta (≥65 v.) ja heitä hoitavilta ammattihenkilöiltä. Kotihoidon 21 iäkästä asiakasta kuvasivat omia voimavarojaan arjesta selviytymisen näkökulmasta sekä kokemuksiaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin avoimella haastattelulla ja analysoitiin sisällön analyysillä. Lisäksi 25 kotihoidon ammattihenkilöä: 13 kotipalvelun työntekijää, 11 kotisairaanhoitajaa ja lääkäri kuvasivat kokemuksiaan iäkkään asiakkaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin fokusryhmähaastattelulla ja analysoitiin sisällön analyysillä. Näiden tulosten sekä aikaisemman kirjallisuuden perusteella laadittiin strukturoitu kyselylomake, jolla analysoitiin ja vertailtiin asiakkaiden ja ammattihenkilöiden näkemyksiä siitä, miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutui. Esitestausten jälkeen kyselylomake lähetettiin 200 kotihoidon asiakkaalle ja 570 heitä hoitavalle kotihoidon työntekijälle: 485 kotipalvelun työntekijälle, 81 kotisairaanhoitajalle ja 4 lääkärille. Kyselyyn vastasi 120 asiakasta (60 %) ja 370 ammattihenkilöä (65 %). Ryhmien välisten erojen tarkastelussa käytettiin ristiintaulukointia, Pearsonin khin neliötestiä ja Fisherin tarkan todennäköisyyden testiä. Iäkkäiden asiakkaiden kuvauksissa voimavarat muodostuivat elämänhallinnan tunteesta ja toimintatahdon säilymisestä. Asiakkaat ammensivat arkeen voimaa harrastuksista ja sosiaalisesta verkostosta, mutta ulkopuolisten asettamat elämisen ehdot, terveydentilan heikkeneminen sekä yksinäisyys asettivat ikäihmisen ja hänen voimavaransa suurten haasteiden eteen. Tulokset osoittivat, että ammattihenkilöiden toiminta oli osittain ristiriidassa ikäihmisten omien odotusten kanssa, eikä se kaikilta osin tukenut asiakkaiden omia voimavaroja. Ammattihenkilöt tekivät hoitoon liittyviä päätöksiä ja toimintoja asiakkaiden puolesta, vaikka asiakkaille itselleen oli tärkeää elämänhallinnan tunne ja toimintatahdon säilyminen. Asiakkaiden voimavarojen tukemista moniammatillisena yhteistyönä vaikeuttivat ammattihenkilöiden vaikeus tunnistaa asiakkaiden omia voimavaroja sekä niitä uhkaavia tekijöitä, tiedon kulun ongelmat, tavoitteeton ja epäyhtenäinen tapa toimia sekä ammattihenkilöiden vastakkain asettuvat näkemyserot ja toimintatavat. Asiakkaiden ja ammattihenkilöiden näkemykset toteutetusta hoidosta erosivat toisistaan tilastollisesti merkitsevästi (p<0.05). Asiakkaat arvioivat sekä itsenäiseen toimintaan tukemisen että fyysisen, psyykkisen ja sosiaalisen tuen toteutuneen työntekijöitä huonommin. Yhteistyön kehittämishaasteita kotihoidossa ovat asiakkaan oman elämänsä asiantuntijuuden vahvistaminen, toimintakulttuurin muuttaminen asiakaslähtöiseksi tavoitteelliseksi toiminnaksi, ammattihenkilöiden roolien ja vastuun selkiyttäminen sekä tiedon kulun menetelmien kehittäminen. Tutkimus vahvistaa gerontologisen hoitotieteen tietoperustaa ja tuottaa uutta tietoa, jota voidaan soveltaa sosiaali- ja terveysalan koulutuksessa ja johtamisessa

Sustainable drugs and global health care

Each day, Earth's finite resources are being depleted for energy, for material goods, for transportation, for housing, and for drugs. As we evolve scientifically and technologically, and as the population of the world rapidly approaches 7 billion and beyond, among the many issues with which we are faced is the continued availability of drugs for future global health care. Medicinal agents are primarily derived from two sources, synthetic and natural, or in some cases, as semi-synthetic compounds, a mixture of the two. For the developed world, efforts have been initiated to make drug production "greener", with milder reagents, shorter reaction times, and more efficient processing, thereby using less energy, and reactions which are more atom efficient, and generate fewer by-products. However, most of the world's population uses plants, in either crude or extract form, for their primary health care. There is relatively little discussion as yet, about the long term effects of the current, non-sustainable harvesting methods for medicinal plants from the wild, which are depleting these critical resources without concurrent initiatives to commercialize their cultivation. To meet future public health care needs, a paradigm shift is required in order to adopt new approaches using contemporary technology which will result in drugs being regarded as a sustainable commodity, irrespective of their source. In this presentation, several approaches to enhancing and sustaining the availability of drugs, both synthetic and natural, will be discussed, including the use of vegetables as chemical reagents, and the deployment of integrated strategies involving information systems, biotechnology, nanotechnology, and detection techniques for the development of medicinal plants with enhanced levels of bioactive agents.

Very preterm infants in Finland - Use of health care services and economic consequences during the first five years of life

The aim of this thesis was to study the health, the hospitalisations, and the use of communal health care services in very preterm children during the first five years of life. In addition, the effect of very preterm birth and prematurity-related morbidities on the costs of hospitalisations, other health care services and the cost per quality adjusted life years (QALY) were studied. This population-based study included all very preterm children (gestational age (GA) <32 weeks or birth weight<1501g, N=2 064) and full-term controls (GA 37+0−41+6, N=200 609) born in Finland during 2000-2003. The data sources included national register data, costing data from the participating hospitals and parental questionnaires. This study showed that most very preterm infants born in Finland survived without prematurity-related morbidities diagnosed during the first years of life. They required relatively little hospital care after the initial discharge, which accounted for the vast majority of the total four-year hospitalisation costs. However, a minority of children born very preterm later developing morbidities had a long initial length of stay and more re-admissions and outpatient visits during the five-year follow-up period. In particular, the number and costs of non-emergency outpatient visits were considerable in individuals with prematurity-related morbidities. The need and costs of hospitalisations decreased clearly with each follow-up year, even in individuals with morbidities. The health-care related costs during the fifth year of life in children born very preterm without prematurity-related morbidities were close to the costs in infants born healthy at term. The cost per QALY of 19,245 € was at an acceptable level already by four years of age in the very preterm population as a whole. Prematurity-related later morbidities and decreasing GA increased the costs per QALY. As the initial hospital stay accounted for a great majority of the total four-year costs, and the costs of hospitalisation decreased with each follow-up year, the cost per QALY is likely to decrease with age. In conclusion, the majority of costs arising after the initial hospitalisation were associated with morbidities related to prematurity. Therefore offering high-quality neonatal care to prevent later morbidities in very preterm survivors has a long-term impact on the cost per QALY. In addition, this study indicates that when estimating the costs of prematurity after the first year of life, one should calculate not only the hospitalisation costs, but also other costs for social welfare services, primary care, and therapies, as these exceed the hospitalisation costs in very preterm infants during the fifth year of life.