Organisational innovations and health care decentralisation: A perspective from Spain

Recent policy developments in public health care systems lead to a greater diversity in health care. Decentralisation, either geographically or at an institutional level, is the key force, because it encourages innovation and local initiatives in health care provision. The devolution of responsibilities allows for a sort of de-construction of the status quo by changing both organizational forms and service provision. The new organizations enjoy greater freedom in the way they pay their staff, and are judged according to their results. These organizations may retain financial surpluses, develop spin-off companies and commission a range of specialised services (such as Diagnostic and Treatment Centres in UK) from providers outside the institutional setting in order to have more access to capital markets. However this diversity may generate a feeling of lack of commitment to a national health service and ultimately a loss of social cohesion. By fiscal decentralisation to regional authorities or planned delegation of financial agreements to the providers, financial incentives are more explicit and may seem to place profit-making above a commitment to better health care. An evaluation of the myths and realities of the decentralization process is needed. Here, I offer an assessment pros and cons of the decentralization process of health care in Spain, drawing on the experience of regional reforms from the pioneering organisational innovations implemented in Catalonia in 1981, up to the observed dispersion of health care spending per capita among regions at present.

Candida bloodstream infections in intensive care units: analysis of the extended prevalence of infection in intensive care unit study.

OBJECTIVES: To provide a global, up-to-date picture of the prevalence, treatment, and outcomes of Candida bloodstream infections in intensive care unit patients and compare Candida with bacterial bloodstream infection. DESIGN: A retrospective analysis of the Extended Prevalence of Infection in the ICU Study (EPIC II). Demographic, physiological, infection-related and therapeutic data were collected. Patients were grouped as having Candida, Gram-positive, Gram-negative, and combined Candida/bacterial bloodstream infection. Outcome data were assessed at intensive care unit and hospital discharge. SETTING: EPIC II included 1265 intensive care units in 76 countries. PATIENTS: Patients in participating intensive care units on study day. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of the 14,414 patients in EPIC II, 99 patients had Candida bloodstream infections for a prevalence of 6.9 per 1000 patients. Sixty-one patients had candidemia alone and 38 patients had combined bloodstream infections. Candida albicans (n = 70) was the predominant species. Primary therapy included monotherapy with fluconazole (n = 39), caspofungin (n = 16), and a polyene-based product (n = 12). Combination therapy was infrequently used (n = 10). Compared with patients with Gram-positive (n = 420) and Gram-negative (n = 264) bloodstream infections, patients with candidemia were more likely to have solid tumors (p < .05) and appeared to have been in an intensive care unit longer (14 days [range, 5-25 days], 8 days [range, 3-20 days], and 10 days [range, 2-23 days], respectively), but this difference was not statistically significant. Severity of illness and organ dysfunction scores were similar between groups. Patients with Candida bloodstream infections, compared with patients with Gram-positive and Gram-negative bloodstream infections, had the greatest crude intensive care unit mortality rates (42.6%, 25.3%, and 29.1%, respectively) and longer intensive care unit lengths of stay (median [interquartile range]) (33 days [18-44], 20 days [9-43], and 21 days [8-46], respectively); however, these differences were not statistically significant. CONCLUSION: Candidemia remains a significant problem in intensive care units patients. In the EPIC II population, Candida albicans was the most common organism and fluconazole remained the predominant antifungal agent used. Candida bloodstream infections are associated with high intensive care unit and hospital mortality rates and resource use.

Home care: a safe and attractive alternative to inpatient administration of intensive chemotherapies.

OBJECTIVE: The objective of this study was to evaluate feasibility, safety, perception, and costs of home care for the administration of intensive chemotherapies. METHODS: Patients receiving sequential chemotherapy in an inpatient setting, living within 30 km of the hospital, and having a relative to care for them were offered home care treatment. Chemotherapy was administered by a portable, programmable pump via an implantable catheter. The main endpoints were safety, patient's quality of life [Functional Living Index-Cancer (FLIC)], satisfaction of patients and relatives, and costs. RESULTS: Two hundred days of home care were analysed, representing a total of 46 treatment cycles of intensive chemotherapy in 17 patients. Two cycles were complicated by technical problems that required hospitalisation for a total of 5 days. Three major medical complications (heart failure, angina pectoris, and major allergic reaction) could be managed at home. Grades 1 and 2 nausea and vomiting occurring in 36% of patients could be treated at home. FLIC scores remained constant throughout the study. All patients rated home care as very satisfactory or satisfactory. Patient benefits of home care included increased comfort and freedom. Relatives acknowledged better tolerance and less asthenia of the patient. Home care resulted in a 53% cost benefit compared to hospital treatment (420 ± 120/day vs. 896 ± 165/day). CONCLUSION: Administration of intensive chemotherapy regimens at home was feasible and safe. Quality of life was not affected; satisfaction of patients and relatives was very high. A psychosocial benefit was observed for patients and relatives. Furthermore, a cost-benefit of home care compared to hospital treatment was demonstrated.

Medical appropriateness of hospital utilization: an overview of the Swiss experience.

We present here the principal results of four concurrent hospital utilization reviews conducted in Switzerland in 1990 and 1991, based on an adapted Appropriateness Evaluation Protocol. The studies were performed on all the hospital days from a sample of patients admitted over a 6 month period. The level of inappropriate use ranged between 8 and 15% in terms of days and was consistently higher in medicine than in surgery. In comparison with other published studies, the low proportion of observed inappropriate days is probably due, at least partly, to differences in study design.

Emergency Department use by patients aged 85 years and over, between 2005 and 2010 in a Swiss university hospital

Introduction: Population ageing challenges Emergency Departments (ED) with a population shift toward higher age groups. People over 65 years are heterogenous with respect to polymorbidity and functional capacity. Complex situations become more prevalent among patients aged 85+, the fastest growing segment of the elderly population (+72% between 2010 and 2030). Objectives: To identify the trend of ED admission rates for patients aged 85+ and to compare the characteristics of their ED visits with the one of patients aged 65-84. Method: Retrospective analysis of 56162 ED admissions of patients aged 65+ at the University of Lausanne Medical Center (CHUV), from 2005 to 2010. All visits of patients aged 65+ at the time of admission were considered. Analyses focus on demographic characteristics, living arrangement, hospital admission, and median Length of Stay (LOS) in the ED. Data from 2010 were examined for the degree of emergency (DE), the main reason for visiting the ED (Swiss triage scale) and readmission at 30 days. Results: Between 2005 and 2010, ED visits of patients aged 65 years and over increased from 8228 to 10390/year (with a slight decrease of women from 56% to 54%). This is an increment of +26% i.e. 5.9 patients/day more. Patients aged 85+ increased by +46% vs +20% for the 65-84. ED visits of people aged 18-64 years raised by +20%. Among patients over 65 years, the proportion of patients aged 85 and more increased from 23% in 2005 to 27% in 2010. In 2010, 85+ patients were more likely than 65-84 patients to come from a NH setting (13% vs 4%), to be hospitalised (70% vs 59%) and to stay longer in the ED (median LOS 9 hours vs 7 hours). Readmission to ED within 30 days after discharge did not differ (85+: 14% vs 65-84: 12%) (similar proportions in 2005). In 2010, the first reason for patients 85+ to visit ED was fall/injury (27% vs 18% by 65-84), whereas the main cause for patients aged 65-84 years was a cardiovascular disorder (18% vs 16% by 85+). The part of high emergency cases was similar for patients 85+ and 65-84 (42%). Conclusion: Among aged patients those aged 85 and over are the fastest growing group admitted to ED. Compared to their younger counterparts, their reason to visit ED and their pattern of health services utilization differ due to specific epidemiological conditions. ED addressing specific needs of geriatric patients would improve their care and lead to a better use of available resources.

TRENDS IN HOSPITAL MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION IN SWITZERLAND, 1998 TO 2008 THE REGION MAKES THE DIFFERENCE: DISPARITIES IN MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION WITHIN SWITZERLAND

The aim of this master's thesis was to assess the ten- year trends and regional differences in management and outcome of acute myocardial infarction (AMI) within Switzerland. The thesis is composed of two articles. First, in the article "Trends in hospital management of acute myocardial infarction in Switzerland, 1998 to 2008" over 102,700 cases of AMI with corresponding management and revascularization procedures were assessed. The results showed a considerable increase in the numbers of hospital discharges for AMI, namely due to the increase of between- hospital transfers. Rates of intensive care unit admissions remained stable. All types of revascularization procedures showed an increase. In particular, overall stenting rates increased with drug-eluting stents partly replacing bare stents. Second, in the article "The region makes the difference: disparities in management of acute myocardial infarction within Switzerland" around 25,600 cases of AMI with corresponding management were assessed for the period of 2007-2008 and according to seven Swiss regions. As reported by our results, considerable regional differences in AMI management were stated within Switzerland. Although each region showed different trends regarding revascularization interventions, Leman and Ticino contrast significantly by presenting the minimum and maximum rates in almost all assessed parameters. As a consequence these two regions differ the most from the Swiss average. The impact of the changes in trends and the regional differences in AMI management on Swiss patient's outcome and economics remains to be assessed. Purpose: To assess ten-year trends in management and outcome of acute myocardial infarction (AMI) in Switzerland. Methods: Swiss hospital discharge database for the 1998 to 2008 period. AMI was defined as a primary discharge diagnosis code I21 according to the CIM-10 classification of the World Health Organization. Management and revascularization procedures were assessed. Results: Overall, 102,729 hospital discharges with a diagnosis of AMI were analyzed. The number of hospital discharges increased almost three-fold from 5530 in 1998 to 13,834 in 2008, namely due to a considerable increase in between-hospital transfers (1352 in 1998, 6494 in 2008). Relative to all hospital discharges, Intensive Care Unit admission rate was 38.0% in 1998 and remained stable (36.2%) in 2008 (p for trend=0.25). Percutaneous revascularization rates increased from 6.0% to 39.9% (p for trend<0.001). Non-drug-eluting stent use increased from 1.3% to 16.6% (p for trend<0.05). Drug eluting stents appeared in 2004 and increased to 23.5% of hospital discharges in 2008 (p for trend=0.07). Coronary artery bypass graft increased from 1.0% to 3.0% (p for trend<0.001). Circulatory assistance increased from 0.2% to 1.7% (p for trend<0.001). Thrombolysis showed no significant changes, from 0.5% to 1.9% (p for trend=0.64). Most of these trends were confirmed after multivariate adjustment. Conclusion: Between 1998 and 2008 the number of hospital discharges for AMI increased considerably in Switzerland, namely due to between-hospital transfers. Overall stenting rates increased, drug-eluting stents partly replacing bare stents. The impact of these changes on outcome and economics remains to be assessed.

Can smaller-scale comprehensive cancer centers provide outstanding care in abdominal and thoracic pediatric solid tumor surgery? Results of a 14-year retrospective single-center analysis.

PURPOSE: Quality of care and its measurement represent a considerable challenge for pediatric smaller-scale comprehensive cancer centers (pSSCC) providing surgical oncology services. It remains unclear whether center size and/or yearly case-flow numbers influence the quality of care, and therefore impact outcomes for this population of patients. PATIENTS AND METHODS: We performed a 14-year, retrospective, single-center analysis, assessing adherence to treatment protocols and surgical adverse events as quality indicators in abdominal and thoracic pediatric solid tumor surgery. RESULTS: Forty-eight patients, enrolled in a research-associated treatment protocol, underwent 51 cancer-oriented surgical procedures. All the protocols contain precise technical criteria, indications, and instructions for tumor surgery. Overall, compliance with such items was very high, with 997/1,035 items (95 %) meeting protocol requirements. There was no surgical mortality. Twenty-one patients (43 %) had one or more complications, for a total of 34 complications (66 % of procedures). Overall, 85 % of complications were grade 1 or 2 according to Clavien-Dindo classification requiring observation or minor medical treatment. Case-sample and outcome/effectiveness data were comparable to published series. Overall, our data suggest that even with the modest caseload of a pSSCC within a Swiss tertiary academic hospital, compliance with international standards can be very high, and the incidence of adverse events can be kept minimal. CONCLUSION: Open and objective data sharing, and discussion between pSSCCs, will ultimately benefit our patient populations. Our study is an initial step towards the enhancement of critical self-review and quality-of-care measurements in this setting.

Assessing psychosocial vulnerability and care needs of pretransplant patients by means of the INTERMED.

OBJECTIVE: We investigated whether the INTERMED, a generic instrument for assessing biopsychosocial case complexity and direct care, identifies organ transplant patients at risk of unfavourable post-transplant development by comparing it to the Transplant Evaluation Rating Scale (TERS), the established measure for pretransplant psychosocial evaluation. METHOD: One hundred nineteen kidney, liver, and heart transplant candidates were evaluated using the INTERMED, TERS, SF-36, EuroQol, Montgomery-Åsberg Depression Rating Scale (MADRS), and Hospital Anxiety & Depression Scale (HADS). RESULTS: We found significant relationships between the INTERMED and the TERS scores. The INTERMED highly correlated with the HADS,MADRS, and mental and physical health scores of the SF-36 Health Survey. CONCLUSIONS: The results demonstrate the validity and usefulness of the INTERMED instrument for pretransplant evaluation. Furthermore, our findings demonstrate the different qualities of INTERMED and TERS in clinical practice. The advantages of the psychiatric focus of the TERS and the biopsychosocial perspective of the INTERMED are discussed in the context of current literature on integrated care.

Hospital disaster preparedness in Switzerland.

STUDY OBJECTIVE: Hospital preparedness is an essential component of any developed health care system. However, there is no national legislation in Switzerland. The objective of this inquiry was to establish the geographic distribution, availability and characteristics of hospital preparedness across Switzerland. METHODS: A questionnaire regarding hospital preparedness in 2006 was addressed to all heads responsible for emergency departments (ED). The survey was initiated in 2007 and finalised in 2012. RESULTS: Of the 138 ED, 122 (88%) returned the survey. Eighty nine EDs (82%) had a disaster plan. CONCLUSIONS: Our study identified an insufficient rate of hospitals in which emergency physicians reported a disaster plan. The lack of national or cantonal legislation regulating disaster preparedness may be partially responsible for this.

Un modèle de soins adapté aux hospitalisations psychiatriques brèves [A care model adapted to brief psychiatric hospitalizations]

Practice of psychiatric hospitalization has considerably changed: deinstitutionnalization, brief hospitalizations, opened units, partnership with patients and complementarity with community mental health services. These changes appear simultaneously in most of industrialized countries. They are the result of social changes, evolution of mental health care, and a sharper perception of deinsertion risks through long term hospitalizations. Values of psychiatric hospital were based on a closed and protective place, where community life prepared to life in the community; they are now founded on an opened place where care aims at resolving crisis and keeping closely in touch with the community. These modifications imply to rethink hospital psychiatric care and their connections with environment. This paper describe a model of care developed in a first admission psychiatric unit.

Quality of care and survival of haemodialysed patients in western Switzerland.

BACKGROUND: Many factors affect survival in haemodialysis (HD) patients. Our aim was to study whether quality of clinical care may affect survival in this population, when adjusted for demographic characteristics and co-morbidities. METHODS: We studied survival in 553 patients treated by chronic HD during March 2001 in 21 dialysis facilities in western Switzerland. Indicators of quality of care were established for anaemia control, calcium and phosphate product, serum albumin, pre-dialysis blood pressure (BP), type of vascular access and dialysis adequacy (spKt/V) and their baseline values were related to 3-year survival. The modified Charlson co-morbidity index (including age) and transplantation status were also considered as a predictor of survival. RESULTS: Three-year survival was obtained for 96% of the patients; 39% (211/541) of these patients had died. The 3-year survival was 50, 62 and 69%, respectively, in patients who had 0-2, 3 and >or=4 fulfilled indicators of quality of care (test for linear trend, P < 0.001). In a Cox multivariate analysis model, the absence of transplantation, a higher modified Charlson's score, decreased fulfilment of indicators of good clinical care and low pre-dialysis systolic BP were independent predictors of death. CONCLUSION: Good clinical care improves survival in HD patients, even after adjustment for availability of transplantation and co-morbidities.

Delirium in elderly patients hospitalized in an acute care unit.

Introduction: Delirium is frequent in hospitalized older people, with incidence rate up to 40% in acute care. Delirium is associated with several adverse consequences, including increased mortality and institutionalization. This study aims to investigate the prevalence, incidence, and consequences of delirium in patients hospitalized in an acute care unit for elderly (ACE unit). Methods: Over a 3 months period, every patient (N = 93, mean age 84.1 ± 7.8 years, 66/93(71%) women) admitted to a 28-bed ACE unit were systematically assessed for delirium. Trained nurses used the Confusion Assessment Method (CAM) instrument to determine the presence of delirium at admission and on each subsequent day over patients' stay. Delirium prevalence rate was defined as the proportion of patients with a positive CAM within 24 hours of admission to the ACE unit. Delirium incidence rate was defined as the proportion of patients with a negative CAM at admission whose CAM became positive at least once during their stay. This evaluation was part of a functional assessment, including Basic Activities of Daily Life (Katz BADL, from 0 to 6, higher score indicating better function). Delirium prevention interventions and specific treatment was provided if needed. Results: Overall,25/93(27%)patients had delirium during their stay. Prevalence of delirium at admission was 10/93 (11%), with an incidence of 15/83(18%). Compared with non-delirious patients, those with delirium were more frequently men (10/25(40%) vs 17/68(25%), p <.001) and had reduced functional status at admission(BADL 2.0 ± 1.9 vs 3.6 ± 2.1, p = .004). They tended to be older (86.0 ± 6.7 vs 83.3 ± 8.1 years, p = .110). At discharge, delirium was associated with reduced functional status (BADL 2.0 ± 2.1 vs 4.3 ± 1.9, p <.001), lower rate of home discharge (6/20(30%) vs 28/65 (43%), p = .009) and increased mortality (5/25 (20%) vs 3/68 (5%), p <.001). On average, patients with delirium stayed 5.7 days longer (17.0 ± 9.8 vs 11.31 ± 6.3, p = .011). Conclusion: Delirium occurred in almost a third of these older patients, even though its incidence was relatively low in this frail population. Despite specific management, delirium remained associated with higher risk for adverse outcomes at discharge. These results suggest that early preventive interventions, implemented as soon as possible after hospital admission, might be needed in similar population to achieve better outcomes. Effectiveness of such interventions will be evaluated in future studies.

Changes in the use of broad-spectrum antibiotics after withdrawal of cefepime from the market: an interrupted time series analysis

Background and objective: Cefepime was one of the most used broad-spectrum antibiotics in Swiss public acute care hospitals. The drug was withdrawn from market in January 2007, and then replaced by a generic since October 2007. The goal of the study was to evaluate changes in the use of broad-spectrum antibiotics after the withdrawal of the cefepime original product. Design: A generalized regression-based interrupted time series model incorporating autocorrelated errors assessed how much the withdrawal changed the monthly use of other broad-spectrum antibiotics (ceftazidime, imipenem/cilastin, meropenem, piperacillin/ tazobactam) in defined daily doses (DDD)/100 bed-days from January 2004 to December 2008 [1, 2]. Setting: 10 Swiss public acute care hospitals (7 with\200 beds, 3 with 200-500 beds). Nine hospitals (group A) had a shortage of cefepime and 1 hospital had no shortage thanks to importation of cefepime from abroad. Main outcome measures: Underlying trend of use before the withdrawal, and changes in the level and in the trend of use after the withdrawal. Results: Before the withdrawal, the average estimated underlying trend (coefficient b1) for cefepime was decreasing by -0.047 (95% CI -0.086, -0.009) DDD/100 bed-days per month and was significant in three hospitals (group A, P\0.01). Cefepime withdrawal was associated with a significant increase in level of use (b2) of piperacillin/tazobactam and imipenem/cilastin in, respectively, one and five hospitals from group A. After the withdrawal, the average estimated trend (b3) was greatest for piperacillin/tazobactam (+0.043 DDD/100 bed-days per month; 95% CI -0.001, 0.089) and was significant in four hospitals from group A (P\0.05). The hospital without drug shortage showed no significant change in the trend and the level of use. The hypothesis of seasonality was rejected in all hospitals. Conclusions: The decreased use of cefepime already observed before its withdrawal from the market could be explained by pre-existing difficulty in drug supply. The withdrawal of cefepime resulted in change in level for piperacillin/tazobactam and imipenem/cilastin. Moreover, an increase in trend was found for piperacillin/tazobactam thereafter. As these changes generally occur at the price of lower bacterial susceptibility, a manufacturers' commitment to avoid shortages in the supply of their products would be important. As perspectives, we will measure the impact of the changes in cost and sensitivity rates of these antibiotics.