Suicide and recency of health care contacts - A systematic review

Background Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play. Method Asystematic review of the literature. Results Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up-to 9% may commit suicide within one day of discharge. The corresponding figures are I I and 4% for community-based psychiatric care and 83 and 20% for general practitioners. Conclusions Among those who die by suicide. contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Cash, customers, and care: The experience and meaning of differential payment for high care places in aged care facilities

The introduction of new asset/income tested charges for high care residents was the 1997-98 Commonwealth government policy response to concerns about financing residential aged care. This in-depth study of residents, families, staff and managers in three aged care facilities explores issues of equity, access and empowerment arising when some residents pay more for the same level of care and amenity. The study reports little evidence of financial contributions affecting access to high care places and the delivery of care, the potential for differential access to amenities such as single rooms linked to the extra payments, and no evidence of a sense of empowerment linked to payment of the new charges. The complexity of current financial arrangements, access to appropriate financial advice at the time of entry, and the potential for an informal two tier system in relation to the allocation Of amenities are identified as developing policy issues.

DOTS in primary care units in the city of Rio de Janeiro, Southeastern Brazil

OBJECTIVE: To describe the implantation and the effects of directly-observed treatment short course (DOTS) in primary health care units. METHODS: Interviews were held with the staff of nine municipal health care units (MHU) that provided DOTS in Rio de Janeiro City, Southeastern Brazil, in 2004-2005. A dataset with records of all tuberculosis treatments beginning in 2004 in all municipal health care units was collected. Bivariate analyses and a multinomial model were applied to identify associations between treatment outcomes and demographic and treatment process variables, including being in DOTS or self-administered therapy (SAT). RESULTS: From 4,598 tuberculosis cases treated in public health units administrated by the municipality, 1,118 (24.3%) were with DOTS and 3,480 (75.7%) with SAT. The odds of DOTS were higher among patients with age under 50 years, tuberculosis relapse and prior history of default or treatment failure. The odds of death were 52.0% higher among patients on DOTS as compared to SAT. DOTS modality including community health workers (CHWs) showed the highest treatment success rate. A reduction of 21.0% was observed in the odds of default (vs. cure) among patients on DOTS as compared to patients on SAT, and a reduction of 64.0% among patients on DOTS with CHWs as compared to those without CHWs. CONCLUSIONS: Patients with a "low compliance profile" were more likely to be included in DOTS. This strategy improves the quality of care provided to tuberculosis patients, although the proposed goals were not achieved.

Evaluation of maternal and neonatal hospital care: quality index of completeness

OBJECTIVE Develop an index to evaluate the maternal and neonatal hospital care of the Brazilian Unified Health System.METHODS This descriptive cross-sectional study of national scope was based on the structure-process-outcome framework proposed by Donabedian and on comprehensive health care. Data from the Hospital Information System and the National Registry of Health Establishments were used. The maternal and neonatal network of Brazilian Unified Health System consisted of 3,400 hospitals that performed at least 12 deliveries in 2009 or whose number of deliveries represented 10.0% or more of the total admissions in 2009. Relevance and reliability were defined as criteria for the selection of variables. Simple and composite indicators and the index of completeness were constructed and evaluated, and the distribution of maternal and neonatal hospital care was assessed in different regions of the country.RESULTS A total of 40 variables were selected, from which 27 single indicators, five composite indicators, and the index of completeness of care were built. Composite indicators were constructed by grouping simple indicators and included the following variables: hospital size, level of complexity, delivery care practice, recommended hospital practice, and epidemiological practice. The index of completeness of care grouped the five variables and classified them in ascending order, thereby yielding five levels of completeness of maternal and neonatal hospital care: very low, low, intermediate, high, and very high. The hospital network was predominantly of small size and low complexity, with inadequate child delivery care and poor development of recommended and epidemiological practices. The index showed that more than 80.0% hospitals had a low index of completeness of care and that most qualified heath care services were concentrated in the more developed regions of the country.CONCLUSIONS The index of completeness proved to be of great value for monitoring the maternal and neonatal hospital care of Brazilian Unified Health System and indicated that the quality of health care was unsatisfactory. However, its application does not replace specific evaluations.

Validity and reliability of a health care service evaluation instrument for tuberculosis

OBJECTIVE To evaluate the validity and reliability of an instrument that evaluates the structure of primary health care units for the treatment of tuberculosis.METHODS This cross-sectional study used simple random sampling and evaluated 1,037 health care professionals from five Brazilian municipalities (Natal, state of Rio Grande do Norte; Cabedelo, state of Paraíba; Foz do Iguaçu, state of Parana; Sao José do Rio Preto, state of Sao Paulo, and Uberaba, state of Minas Gerais) in 2011. Structural indicators were identified and validated, considering different methods of organization of the health care system in the municipalities of different population sizes. Each structure represented the organization of health care services and contained the resources available for the execution of health care services: physical resources (equipment, consumables, and facilities); human resources (number and qualification); and resources for maintenance of the existing infrastructure and technology (deemed as the organization of health care services). The statistical analyses used in the validation process included reliability analysis, exploratory factor analysis, and confirmatory factor analysis.RESULTS The validation process indicated the retention of five factors, with 85.9% of the total variance explained, internal consistency between 0.6460 and 0.7802, and quality of fit of the confirmatory factor analysis of 0.995 using the goodness-of-fit index. The retained factors comprised five structural indicators: professionals involved in the care of tuberculosis patients, training, access to recording instruments, availability of supplies, and coordination of health care services with other levels of care. Availability of supplies had the best performance and the lowest coefficient of variation among the services evaluated. The indicators of assessment of human resources and coordination with other levels of care had satisfactory performance, but the latter showed the highest coefficient of variation. The performance of the indicators “training” and “access to recording instruments” was inferior to that of other indicators.CONCLUSIONS The instrument showed feasibility of application and potential to assess the structure of primary health care units for the treatment of tuberculosis.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Economic crisis and counter-reform of universal health care systems: Spanish case

The economic crisis that has been affecting Europe in the 21st century has modified social protection systems in the countries that adopted, in the 20th century, universal health care system models, such as Spain. This communication presents some recent transformations, which were caused by changes in Spanish law. Those changes relate to the access to health care services, mainly in regards to the provision of care to foreigners, to financial contribution from users for health care services, and to pharmaceutical assistance. In crisis situations, reforms are observed to follow a trend which restricts rights and deepens social inequalities.

Why and How Was Regionalization of Perinatal Care Accomplished in Portugal?

Portuguese health care system was created in 1979. It is universal and for free. Expenses are supported by the State through taxes. The modern perinatal care system started by the end of 1970. The first neonatal intensive care units were created in 1980, the Portuguese Neonatal Society in 1985 and the National Neonatal Transport System in 1987. Until the seventies of twentieth century and even during eighties there were more than 200 hospitals with deliveries, a great part without obstetrician or paediatrician, a great percentage of pregnancies had no prenatal care, there were few neonatal intensive care units and perinatal mortality rate was one of the highest in the European countries. In 1987 an Experts Committee was nominated by the Health Ministry aiming to collect and analyse data on perinatal care and to suggest improvements. The Report resulting from this work is the main document on which is based the reform. The reform was a 9 years program in 3 years stages aiming to close hospitals with less than 1500 deliveries/year, to reclassify hospitals, to create Coordinating Units between health centres and hospitals, to equip neonatal intensive and intermediate care units, to define needs of obstetricians, paediatricians and nurses for each centre and to promote specialised training in neonatology for paediatricians and nurses. Levels of perinatal care were defined as well as localization of each level of hospital according to the number of deliveries in one geographic area, geographic difficulties and existing routes and connections. Steps for opening and closure of different levels of hospitals were very well programmed. The organization, capacities, number of obstetricians, neonatologists and nurses as well as equipment for each level of care was defined. Rules for pregnant women and newborns transfer from level II to level III hospitals were also well described. A specific training is neonatology was created starting in 1990. This organization resulted in an impressive decrease in mortality rates at all levels and still it is the policy we have today.

Contributo para a validação da versão portuguesa do instrumento de avaliação VOICE (service users perceptions of impatient care, Views on Inpatient Care)

RESUMO: Nos últimos anos assistiu-se a um reposicionamento das pessoas portadoras de doença mental na sociedade, no sentido de viverem em pleno os seus direitos, sem restrições. Esta tendência acompanhou as transformações que se têm vivido na forma como os utentes dos serviços de saúde interagem com os mesmos e com os profissionais de saúde, de forma a permitir uma maior autonomização e responsabilização no que concerne ao tratamento da sua doença, a relação que estabelecem com o seu médico, e a participação na avaliação e monitorização da qualidade dos serviços. Mais recentemente, também no mundo científico, esta afirmação se fez sentir, com o surgimento de investigação liderada por utentes, no sentido de estudar de forma adequada questões que partem do seu ponto de vista, e que possibilitem a produção de conhecimento significativa no contexto das suas experiências. Com o presente trabalho pretende-se contribuir para a validação da versão portuguesa do VOICE (Service Users’ Perceptions of Inpatient Care, Views on Inpatient Care) (Evans et al., 2012), instrumento para a avaliação dos serviços de internamento de agudos em psiquiatria, construído a partir de um investigação liderado por utentes e partindo das suas perspectiva. O VOICE é constituído por 19 questões, agrupadas em sete domínios: admissão; cuidados e tratamento; medicação; equipa de técnicos do internamento; terapia e atividades; ambiente e diferenças. O presente estudo envolveu uma amostra de 85 utentes de um serviço de internamento de agudos de uma instituição psiquiátrica do Norte de Portugal. A versão portuguesa do VOICE apresentou boa aceitação por parte dos utentes e boas características psicométricas - a consistência interna foi alta (α = 0,87) e todos, exceto um item (item 6), apresentam elevadas correlações item-total (variando de 0,18 - item 6 a 0,71 - item 11; M = 0,54, DP = 0,15), sugerindo ser um instrumento útil na avaliação dos serviços de internamento de agudos. No futuro torna-se necessário alargar o estudo a outros contextos de internamento e envolvendo amostras mais alargadas.-------------- ABSTRACT: In recent years there has been a gradual process to help people with the experience of mental illness regaining their full rights. Following the advances in the understanding of mental health problems, and the use of medication to help patients overcome symptoms, service-users have become more autonomous and responsible in the way they deal with health professionals, and are now called to participate in assessing and monitoring mental health services and policies. In the context of these transformations we have assisted to the emergence of research led by service-users (in this case of psychiatric and mental health services) in order to emphasize their point of view, and to enable the production of significant knowledge resulting from their experiences, and perceptions. The present study aims to contribute to the dissemination of service-user led research, based on the adaptation and validation of the Portuguese version of the VOICE - Service Users' Perceptions Questionnaire, Views on Inpatient Care. (Evans et al., 2012). The VOICE is composed of 19 questions, grouped in seven domains: admissions, care and treatment, medication, team of technicians during hospitalization, therapy and activities, environment and diversity. The present study involved a sample of 85 inpatient of a psychiatric institution in Northern Portugal. The Portuguese version of the VOICE showed good psychometric properties and was well accepted by patients [high internal consistency (α = 0,87); and high correlation of each item, except item 6, with the total score (ranging from 0.18 on item 6 to 0.71 on item 11; average=0,54; SD=0,15), suggesting it to be a useful tool for assessing inpatient services. In the future there is a need to extend the study to other contexts and include larger samples.

Quality of institutional care and early childhood development

Institutional rearing adversely affects children’s development, but the extent to which specific characteristics of the institutional context and the quality of care provided contribute to problematic development remains unclear. In this study, 72 preschoolers institutionalised for at least 6 months were evaluated by their caregiver using the Child Behavior Checklist and the Disturbances of Attachment Interview. Distal and proximate indices of institutional caregiving quality were assessed using both staff reports and direct observation. Results revealed that greater caregiver sensitivity predicted reduced indiscriminate behaviour and secure-base distortions. A closer relationship with the caregiver predicted reduced inhibited attachment behaviour. Emotional and behavioural problems proved unrelated to caregiving quality. Results are discussed in terms of (non)-shared caregiving factors that influence institutionalised children’s development.

Older persons' perceptions of general practitioner or specialist primary care physicians : same point of view?

BACKGROUND: Identification of a Primary Care Physician (PCP) by older patients is considered as essential for the coordination of care, but the extent to which identified PCPs are general practitioners or specialists is unknown. This study described older patients' experiences with their PCP and tested the hypothesis of differences between patients who identify a specialist as their PCP (SP PCP) and those who turn to a general practitioner (GP PCP). METHODS: In 2012, a cross-sectional postal survey on care was conducted in the 68+ year old population of the canton of Vaud. Data was provided by 2,276 participants in the ongoing Lausanne cohort 65+ (Lc65+), a study of those born between 1934 and 1943, and by 998 persons from an additional sample drawn to include the population outside of Lausanne or born before 1934. RESULTS: Participants expressed favourable perceptions, at rates exceeding 75% for most items. However, only 38% to 51% responded positively for out-of-hours availability, easy access and at home visits, likelihood of prescribing expensive medication if needed, and doctors' awareness of over-the-counter drugs. 12.0% had an SP PCP, in 95.9% specialised in a discipline implying training in internal medicine. Bivariate and multivariate analyses did not result in significant differences between GP and SP PCPs regarding perceptions of accessibility/availability, doctor-patient relationship, information and continuity of care, prevention, spontaneous use of the emergency department or ambulatory care utilisation. CONCLUSIONS: Experiences of old patients were mostly positive despite some lack in reported hearing, memory testing, and colorectal cancer screening. We found no differences between GP and SP PCP groups.

Measuring the diffusion of palliative care in long-term care facilities - a death census

ABSTRACT: BACKGROUND: The dissemination of palliative care for patients presenting complex chronic diseases at various stages has become an important matter of public health. A death census in Swiss long-term care facilities (LTC) was set up with the aim of monitoring the frequency of selected indicators of palliative care. METHODS: The survey covered 150 LTC facilities (105 nursing homes and 45 home health services), each of which was asked to complete a questionnaire for every non-accidental death over a period of six months. The frequency of 4 selected indicators of palliative care (resort to a specialized palliative care service, the administration of opiates, use of any pain measurement scale or other symptom measurement scale) was monitored in respect of the stages of care and analysed based on gender, age, medical condition and place of residence. RESULTS: Overall, 1200 deaths were reported, 29.1% of which were related to cancer. The frequencies of each indicator varied according to the type of LTC, mostly regarding the administration of opiate. It appeared that the access to palliative care remained associated with cancer, terminal care and partly with age, whereas gender and the presence of mental disorders had no effect on the indicators. In addition, the use of drugs was much more frequent than the other indicators. CONCLUSION: The profile of patients with access to palliative care must become more diversified. Among other recommendations, equal access to opiates in nursing homes and in home health services, palliative care at an earlier stage and the systematic use of symptom management scales when resorting to opiates have to become of prime concern.

Psychosocial care for the caregivers of primary malignant brain tumor patients.

Despite clinical experience that suggests a high burden of care among relatives of individuals with a primary malignant brain tumor (PMBT), little is known about their actual needs. In this study, the caregivers' personal experiences, quality of life, burden of care, and psychological well-being were examined. Fifty-nine percent did not receive any financial aid for home care, 33% had increased risk for psychosomatic problems, 45% had anxiety, and 33% increased depression levels. The caregiver's quality of life was most strongly affected by the burden of care (p < .001) and the patient's mental state (p < .03). To improve the situation, empathetic professionals and an early implementation of palliative care and social work are required.

Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland.

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal intensive care unit no later than 23 0/7 weeks of gestation, unless emergency delivery is indicated. An experienced neonatology team should be involved in all deliveries that take place after 23 0/7 weeks of gestation to help to decide together with the parents if the initiation of intensive care measures appears to be appropriate or if preference should be given to palliative care (i.e., primary non-intervention). In doubtful situations, it can be reasonable to initiate intensive care and to admit the preterm infant to a neonatal intensive care unit (i.e., provisional intensive care). The infant's clinical evolution and additional discussions with the parents will help to clarify whether the life-sustaining therapies should be continued or withdrawn. Life support is continued as long as there is reasonable hope for survival and the infant's burden of intensive care is acceptable. If, on the other hand, the health care team and the parents have to recognise that in the light of a very poor prognosis the burden of the currently used therapies has become disproportionate, intensive care measures are no longer justified and other aspects of care (e.g., relief of pain and suffering) are the new priorities (i.e., redirection of care). If a decision is made to withhold or withdraw life-sustaining therapies, the health care team should focus on comfort care for the dying infant and support for the parents.