Optimization of care in orthopaedics and neurosurgery

This thesis aimed to contribute to the optimal use of non-surgical treatment and timing of surgery among hip and knee OA and sciatica patients in two different ways. First, if guidelines are specific on non-surgical and (timing of) surgical treatment, the focus was on implementation strategies to improve guideline uptake in hip and knee OA and sciatica care. Across the different studies carried out in this thesis, knowledge, attitude of health care providers and organization of care seem to be relevant for any implementation of evidence based guideline recommendations in a multidisciplinary setting. Future implementation studies can start focusing on these topics. However, if guidelines are not available or not specific on e.g. optimal timing of total hip or knee arthroplasty (THA/TKA), additional evidence is needed. Therefore, the second part of this thesis focused on studying criteria and determinants to reach the best possible outcomes after THA and TKA, as information in the literature is lacking on optimal timing of surgery. Pooling multiple cohort studies in the Netherlands showed that preoperative status is the most important variable for outcome after both THA and TKA, i.e. patients with better preoperative quality of life, functioning and less pain had better postoperative outcomes

WHAT FACTORS EMPLOYERS SHOULD CONSIDER IN DESIGNING AND IMPLEMENTATING VALUE BASED INSURANCE DESIGN?

Employers would like employees to become more involved in managing their own health. This would not only benefit the employee but lead to decreased absenteeism and lower the healthcare costs for the employer. Employers and health plans have implemented various strategies to improve employee engagement. Value-based insurance designs (VBID) is one promising strategy that moves employees from being passive recipients of care to becoming active ones, willing to take more responsibility for managing their health and related costs, and making prudent and informed health care decisions. Although evidence exists that supports the positive impact of VBID and indicates strong interest from the employer community, adoption of VBID is far from universal. There is a need for research to generate an implementation reference for employers who are interested in using VBID to improve employee engagement. This study takes a two-step approach. A document review was conducted to understand barriers of VBID implementation. Key informant interviews were also conducted with benefit managers from employers who have implemented VBID and directors at vendor companies who have supported employers in implementing VBID. Findings provide a framework for successful VBID design and implementation - a checklist of best practices. Data suggests that senior leadership buy-in, appropriate alignment between VBID and business priories and effective communication of programs are among the keys to success.Doctor of Public Healt

eHealth in Chronic Diseases

This book provides a review of the management of chronic diseases (evaluation and treatment) through eHealth. Studies that examine how eHealth can help to prevent, evaluate, or treat chronic diseases and their outcomes are included

Rural Health

Rural health is the study of healthcare systems in rural settings. This book presents a comprehensive overview of rural health care and addresses such topics as human resources, maternal mortality in developing countries, safety of healthcare workers, zoonotic and veterinary diseases, and much more. Chapters include case studies and research in the field of rural health

Quality of Health Care for Medicare Beneficiaries: A Chartbook

Provides the results of a review of recently published studies and reports about the quality of health care for elderly Medicare beneficiaries. Includes examples of deficiencies and disparities in care, and some promising quality improvement initiatives

Using Law to Fight a Silent Epidemic: The Role of Healthy Literacy in Health Care Access, Quality & Cost

The dominant rhetoric in the health care policy debate about cost has assumed an inherent tension between access and quality on the one hand, and cost effectiveness on the other; but an emerging discourse has challenged this narrative by presenting a more nuanced relationship between access, quality, and cost. This is reflected in the discourse surrounding health literacy, which is viewed as an important tool for achieving all three goals. Health literacy refers to one\u27s ability to obtain, understand and use health information to make appropriate health decisions. Research shows that improving patients\u27 health literacy can help overcome access barriers and empower patients to be better health care partners, which should lead to better health outcomes. Promoting health literacy can also reduce expenditures for unnecessary or inappropriate treatment. This explains why, as a policy matter, improving health literacy is an objective that has been embraced by almost every sector of the health care system. As a legal matter, however, the role of health literacy in ensuring quality and access is not as prominent. Although the health literacy movement is relatively young, it has roots in longstanding bioethical principles of patient autonomy, beneficence, and justice as well as the corresponding legal principles of informed consent, the right to quality care, and antidiscrimination. Assumptions and concerns about health literacy seem to do important, yet subtle work in these legal doctrines - influencing conclusions about patient understanding in informed consent cases, animating decisions about patient responsibility in malpractice cases, and underlying regulatory guidance concerning the quality of language assistance services that are necessary for meaningful access to care. Nonetheless, health literacy is not explicitly treated as a legally relevant factor in these doctrines. Moreover, there is no coherent legal framework for incorporating health literacy research that challenges traditional assumptions about patient comprehension and decision-making, and that emphasizes the need for providers to improve communication and take affirmative steps to assess patient understanding. The absence of a clear and robust consideration of health literacy in these doctrines undermines core access and quality aims, and it means that such laws are of limited efficacy in promoting health literacy. Returning to the theme that the health literacy problem reflects a complementary view of access, quality and cost, it is likely that the cost implications of this problem (and not concerns about quality and access) will motivate the kind of health literacy reform that may ultimately strengthen existing quality and access standards. One recent example of this can be seen in reforms linked to government, insurer and provider attempts to reduce costly medication errors

Automated telephone communication systems for preventive healthcare and management of long-term conditions

Background Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone’s touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention. Objectives To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes. Search methods We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015. Selection criteria Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible. Data collection and analysis We used standard Cochrane methods to select and extract data and to appraise eligible studies. Main results We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty). For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening. Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data. The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use. Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/ substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers. Only four trials (3%) reported adverse events, and it was unclear whether these were related to the intervention

The role of the pharmacist in optimising prescribing in community-dwelling older adults

Background: Providing optimal care for older adults creates many challenges for healthcare providers especially general practitioners. The overarching aim of this thesis was to understand the potential role of the pharmacist in optimising prescribing for older people in primary care. Methods: A cross-sectional study was carried out to highlight the prevalence of prescribing issues in older adults across three European countries. The published literature was then systematically reviewed to evaluate studies of pharmacist-led interventions on potentially inappropriate prescribing (PIP) among community-dwelling older adults. A qualitative study was carried out to reveal the determinants of GP prescribing behaviour for older adults in primary care and to elicit GPs’ views on the potential role for broad intervention strategies involving pharmacists and/or information technology systems in general practice. These findings then informed the pharmacist-led academic detailing intervention with GPs on the topic of urinary incontinence in older people. Results: The cross-sectional study highlighted that PIP and potential prescribing omissions (PPOs) were prevalent in this cohort of European participants. The systematic review demonstrated that pharmacist-led interventions may improve prescribing appropriateness in community-dwelling older adults. The qualitative study highlighted the complexities of behavioural determinants of prescribing for older people in primary care and the need for additional supports to optimise prescribing for this growing cohort of patients. One approach that GP participants agreed could lead to a meaningful and sustained improvement in prescribing is interactive educational outreach or academic detailing. Therefore, an intervention was developed incorporating pharmacist-led academic detailing. The results of the research indicate that the intervention was well received and highly valued by GPs. Conclusion: This study has made an important contribution to the topic of prescribing for older adults in primary care by highlighting that educational interventions such as academic detailing are welcomed in the context of general practice in Ireland

Health Care for Older Adults

In recent decades, life expectancy has been increasing. This is a historical milestone in the history of humanity. We have never lived so long before. In these circumstances, giving the best care to older adults efficiently is one of the greatest challenges of developed countries. This book explores different initiatives that result in the improvement of health conditions of older adults, such as multicomponent physical exercise programs, interventions that try to avoid loneliness and social isolation, and multidisciplinary assessment, and the treatment of frailty and other geriatric syndromes, of the elderly in various settings such as the Emergency Unit, Orthogeriatrics, and Oncogeriatrics. This book offers different manuscripts to readers, each trying to improve life satisfaction, quality of life, and life expectancy in older adults in different scenarios. It is up to us to achieve these goals. We are sure that these interesting chapters will contribute to improving clinical practices. Following the completion of the Special Issue "Health Care for Older Adults" for the international Journal of Environmental Research and Public Health, the Guest Editors felt the satisfaction of having reached 18 published manuscripts and the possibility of transforming this volume into a book. This book was born from the need to show how health and social advances have increased human longevity as never before. We live longer, knowing more and more the epigenetic mechanisms of this longevity, as extended aging also coexists with the least favorable aging trajectories. Among them, a syndrome stands out from the gerontological and geriatric perspective: frailty. Due to the pandemic, a social problem has increased its presence in clinical practice: ageism. Older adults have found it difficult to access the necessary clinical resources due to the simple matter of age. However, at this moment, we are able to detect and to reverse frailty. In the same way, we should aim to prevent loneliness and social isolation, involved in social frailty. Geriatric syndromes are underdiagnosed and undertreated, but clinical and geriatric knowledge provide diagnostic tools and non-pharmacological approaches to prevent and to treat them. All health professionals working together in an interdisciplinary team could improve the clinical practices to develop a quality health care for older adults, improving their life satisfaction and quality of life perception too