Determining appropriateness for rehabilitation or other subacute care: is there a role for utilisation review?

BACKGROUND: Rehabilitation and other forms of subacute care play an important role in the Australian health care system, yet there is ambiguity around clinical definitions of subacute care, how it differs from acute care, where it is best done and what resources are required. This leads to inconsistent and often poorly defined patient selection criteria as well as a lack of research into efficient models of care. METHODS: A literature review on the potential role of utilisation review in defining levels of care and in facilitating appropriate care, with a focus on the interface between acute care and rehabilitation. RESULTS: In studies using standardised utilisation review tools there is consistent reporting of high levels of 'inappropriate' bed days in acute care settings. These inappropriate bed days include both inappropriate admissions to acute care and inappropriate continuing days of stay. While predominantly an instrument of payers in the United States, concurrent utilisation review programs have also been used outside of the US, where they help in the facilitation of appropriate care. Some utilisation review tools also have specific criteria for determining patient appropriateness for rehabilitation and other subacute care. CONCLUSION: The high levels of 'inappropriate' care demonstrated repeatedly in international studies using formal programs of utilisation review should not be ignored in Australia. Utilisation review tools, while predominantly developed in the US, may complement other Australian patient flow initiatives to improve efficiency while maintaining patient safety. They could also play a role in the identification of patients who may benefit from transfer from acute care to another type of care and thus be an adjunct to physician assessment. Testing of the available utilisation review tools in the Australian context is now required

Cost Models for mHealth Intervention in Aged Care Diabetes Management

Governments across the globe are facing the challenges posed by ageing population. Diabetes is one of the leading causes of disease burden to the economies. A proactive management of diabetes for the elderly can offer benefits to all the stakeholders. Mobile Health (mHealth) can play a vital role to tackle the complexities associated with aged people who are living independently. While there have been several pilot studies of mHealth interventions in diabetes management, they have not made inroads into operational reality. The significant factors appear to be lack of comprehensive cost models and business case for mHealth interventions. The paper reviews some of the related research work and argues for the development of cost models for mHealth interventions in aged care diabetes management. It also presents the work-in-progress of creation of cost models and envisages that such a development will help the operational adoption of mHealth benefiting all the stakeholders

Determining level of care appropriateness in the patient journey from acute care to rehabilitation

Background: The selection of patients for rehabilitation, and the timing of transfer from acute care, are important clinical decisions that impact on care quality and patient flow. This paper reports utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation. It examines reasons why acute level of care criteria are not met and explores differences in decision making between acute care and rehabilitation teams around patient appropriateness and readiness for transfer. Methods: Cohort study of patients in a large acute referral hospital in Australia followed with the InterQual utilization review tool, modified to also include reasons why utilization criteria are not met. Additional data on team decision making about appropriateness for rehabilitation, and readiness for transfer, were collected on a subset of patients. Results: There were 696 episodes of care (7189 bed days). Days meeting acute level of care criteria were 56% (stroke, hip fracture and joint replacement patients) and 33% (other patients, from the time of referral). Most inappropriate days in acute care were due to delays in processes/scheduling (45%) or being more appropriate for rehabilitation or lower level of care (30%). On the subset of patients, the acute care team and the utilization review tool deemed patients ready for rehabilitation transfer earlier than the rehabilitation team (means of 1.4, 1.3 and 4.0 days from the date of referral, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients became unstable. From when deemed stable by the rehabilitation team or utilization review, 9% and 11%, respectively, became unstable. Conclusions: A high proportion of patient days did not meet acute level of care criteria, due predominantly to inefficiencies in care processes, or to patients being more appropriate for an alternative level of care, including rehabilitation. The rehabilitation team was the most accurate in determining ongoing medical stability, but at the cost of a longer acute stay. To avoid inpatients remaining in acute care in a state of \u27terra nullius\u27, clinical models which provide rehabilitation within acute care, and more efficient movement to a rehabilitation setting, is required. Utilization review could have a decision support role in the determination of medical stability

Collaborative Autoethnographic Writing as Communal Curative

This collaborative autoethnography reflects on how each author experienced COVID-19 and associated precarity. We explore the ways in which this experience relates to our identities (both particular and plural), and our positionalities in terms of privilege and marginality. As a collective of diverse collaborators, we confront dialectical questions of self and society. Our contributions reveal our advantage/disadvantage, mobility/immobility, and the borders and boundedness before/during/after COVID-19. We show the power of curative writing in collaborative autoethnography and how the sharing of our experiences of vulnerability represents an invitation to human connection

Stan praktyk publikacyjnych polskich czasopism naukowych w 2017 roku

Celem raportu jest prezentacja informacji o polskich czasopismach naukowych. Uwzględnione zostały czasopisma ze wszystkich obszarów nauki, które – według źródeł je indeksujących – uznawane są za czasopisma naukowe. Dane na temat wydawanych czasopism naukowych w Polsce są rozproszone i niepełne. Jednocześnie wiele gromadzonych informacji nie jest publicznie dostępna bądź odpowiednio eksponowana. Dlatego istotne jest pokazanie tego, co wiemy o polskich czasopismach oraz wskazanie, czego nie wiemy, a powinniśmy wiedzieć, aby prowadzić efektywną politykę wydawniczą: zarówno na poziomie pojedynczego czasopisma i wydawnictwa, jak i na poziomie kraju.Publikacja finansowana jest w ramach projektu „Badanie wzorców doskonałości w nauce i sztuce” w ramach programu Ministra Nauki i Szkolnictwa Wyższego pod nazwą „DIALOG” w latach 2017-2019

The Cosmos of a Public Sector Township: Democracy as an Intellectual Culture

The public sector plays an important role in responding to the rights of citizens and evolving norms of social interest (Qu 2015). Qu argues that the nature of public enterprise is never final and there is a constant negotiation between the private and the public emergence of life and rights. One such space where the tension between the private and the public manifests itself is the public sector township or the residential colony in India. The sociality of hierarchy in public sector organizations manifest itself in the public sector township and may nurture everyday aspirations, angsts and divides. The officer lives in a bigger hone, in a bungalow, and the clerk lives in a smaller home, many times with a larger family. [excerpt

Enantioselective, intermolecular benzylic C–H amination catalysed by an engineered iron-haem enzyme

C–H bonds are ubiquitous structural units of organic molecules. Although these bonds are generally considered to be chemically inert, the recent emergence of methods for C–H functionalization promises to transform the way synthetic chemistry is performed. The intermolecular amination of C–H bonds represents a particularly desirable and challenging transformation for which no efficient, highly selective, and renewable catalysts exist. Here we report the directed evolution of an iron-containing enzymatic catalyst—based on a cytochrome P450 monooxygenase—for the highly enantioselective intermolecular amination of benzylic C–H bonds. The biocatalyst is capable of up to 1,300 turnovers, exhibits excellent enantioselectivities, and provides access to valuable benzylic amines. Iron complexes are generally poor catalysts for C–H amination: in this catalyst, the enzyme's protein framework confers activity on an otherwise unreactive iron-haem cofactor

The North American tree-ring fire-scar network

Fire regimes in North American forests are diverse and modern fire records are often too short to capture important patterns, trends, feedbacks, and drivers of variability. Tree-ring fire scars provide valuable perspectives on fire regimes, including centuries-long records of fire year, season, frequency, severity, and size. Here, we introduce the newly compiled North American tree-ring fire-scar network (NAFSN), which contains 2562 sites, >37,000 fire-scarred trees, and covers large parts of North America. We investigate the NAFSN in terms of geography, sample depth, vegetation, topography, climate, and human land use. Fire scars are found in most ecoregions, from boreal forests in northern Alaska and Canada to subtropical forests in southern Florida and Mexico. The network includes 91 tree species, but is dominated by gymnosperms in the genus Pinus. Fire scars are found from sea level to >4000-m elevation and across a range of topographic settings that vary by ecoregion. Multiple regions are densely sampled (e.g., >1000 fire-scarred trees), enabling new spatial analyses such as reconstructions of area burned. To demonstrate the potential of the network, we compared the climate space of the NAFSN to those of modern fires and forests; the NAFSN spans a climate space largely representative of the forested areas in North America, with notable gaps in warmer tropical climates. Modern fires are burning in similar climate spaces as historical fires, but disproportionately in warmer regions compared to the historical record, possibly related to under-sampling of warm subtropical forests or supporting observations of changing fire regimes. The historical influence of Indigenous and non-Indigenous human land use on fire regimes varies in space and time. A 20th century fire deficit associated with human activities is evident in many regions, yet fire regimes characterized by frequent surface fires are still active in some areas (e.g., Mexico and the southeastern United States). These analyses provide a foundation and framework for future studies using the hundreds of thousands of annually- to sub-annually-resolved tree-ring records of fire spanning centuries, which will further advance our understanding of the interactions among fire, climate, topography, vegetation, and humans across North America