Impact of vertical integration on the readmission of individuals with chronic conditions

ABSTRACT - INTRODUCTION: Ageing populations and the increasing prevalence of multimorbidity are a challenge for healthcare delivery and health system design. Integrated care has been discussed as a solution to address these challenges. In Portugal, Local Health Units (LHU) promote vertical integration of healthcare, with one of the expected effects being a decrease of readmission rates in individuals with chronic conditions. Readmissions are frequently studied for its negative impacts on individuals, carers, and providers, with excessive unplanned readmission rates among hospitals being a sign of frail integrated care. Thus, we assume as the main aim of this study to assess the impact of vertical integration on the readmission of individuals with chronic conditions. METHODS: A database including administrative data from 1 679 634 inpatient episodes from years 2002-14 was considered. We identified readmissions with the hospital-wide all-cause unplanned readmission measure methodology of Centers for Medicare and Medicaid Services. The considered outcome was 30-day hospital-wide all-cause unplanned readmissions (1: readmitted), and risk-standardized readmission ratio. Chronic conditions were identified from all diagnoses coded with International Classification of Diseases – 9th version – Clinical Modification codes (1: chronic). In order to assess the impact of LHU on the readmission of individuals with chronic conditions, we compared 30-day readmissions before and after the creation of each LHU. We used difference-indifferences technique to address our main aim. In addition, to understand the associations between individuals’ risk factors and time to readmission, we developed a Cox regression model for LHU and control group. RESULTS: Difference-in-differences results suggest that vertical integration promoted a decrease on risk-standardized readmission ratio in four LHU, but significant only in LHU 1. In addition, when analysed the individual risk of readmission we observed that it was reduced for four LHU, but only significantly for LHU 3 and LHU 5. A sensitivity analysis was performed for annual evolution of odds ratio of risk of readmission, and initial results were considered stable for most years. Cox regression results suggest that for LHU and control hospitals, female individuals were less at risk of readmission than men, the risk increased with increasing age and number of comorbidities. At LHU, we observed a decreased risk of readmission with increasing number of chronic conditions. CONCLUSIONS: Individuals with chronic conditions faced higher risk of readmission, despite vertical integration phenomena. In order to promote better healthcare to these individuals, namely protecting them from readmission, healthcare organizations should develop integrated care pathways for the most prevalent chronic conditions on their catchment area, revise discharge processes, continuously evaluate health outcomes, and share best practices of integration involving community and other levels of care (namely palliative care)

A minha experiência conta!: um estudo de caso sobre o processo de RVCC

Tese de mestrado, Educação (Formação e Aprendizagem ao Longo da Vida), Universidade de Lisboa, Faculdade de Ciências, 2009A educação de adultos, em Portugal, tem vindo a ser um domínio educativo sem intervenções significativas (e de sucesso) de organismos governamentais, evidenciado pelas elevadas taxas de analfabetismo e número de cidadãos activos que não concluíram o 12º ano de escolaridade. Iniciativas como o ensino recorrente mostraram uma fraca adesão, por parte dos adultos, bem como taxas de conclusão muito aquém das expectativas. Em 1999, surge o sistema nacional de reconhecimento, validação e certificação de competências (SNRVCC), como resposta social às baixas qualificações escolares e profissionais dos cidadãos activos. Actualmente, assistimos a uma adesão ímpar à iniciativa novas oportunidades, sendo os centros novas oportunidades (CNO) o dispositivo com maior relevo social, actuando como uma porta de entrada para a (re)definição de trajectórias de qualificação escolar e/ou profissional de jovens e adultos. Nos CNO desenvolvem-se processos de RVCC onde adultos pouco escolarizados evidenciam, através de uma abordagem (auto)biográfica, aprendizagens, capacidades e competências desenvolvidas ao longo da vida, em diferentes cenários/contextos. Esta investigação assume uma abordagem interpretativa. Realizámos estudos de casos múltiplos, intrínsecos, num CNO da grande Lisboa. Seleccionámos um grupo de 10 candidatos a uma certificação de 9º ano de escolaridade. Focámo-nos na voz de duas adultas certificadas. Recolhemos dados através de conversas informais e observações, registadas em diário de bordo do investigador, do portefólio que construíram e de recolha documental. Realizámos uma análise de conteúdo, sucessiva e aprofundada, tendo emergido categorias indutivas. Os resultados iluminam que estas candidatas desenvolveram uma representação social positiva sobre o processo RVCC, apesar de evidenciarem, ao longo deste processo, dificuldades em construir sentidos sobre o processo de RVCC, bem como em distinguir os papéis dos agentes da equipa do CNO e das práticas. Os resultados iluminam também as potencialidades deste processo de certificação para capacitar estes adultos a retomarem percursos de qualificação pessoal, escolar e/ou profissional, ao longo da vida.In Portugal, adult education has become an educational domain with no meaningful (or successful) interventions from the government, giving place to high rates of illiteracy and high numbers of citizens who do not accomplish the 12th grade. Initiatives, such as the system of credit units, did not get adults’ attention and only a few of them completed their education using this kind of system. In 1999, the national system of recognition, validation and certification of competencies (NSRVCC) was created, trying to become a social answer to the low school and professional qualifications of active citizens. Nowadays, we are witnessing a never seen upholding to the new opportunities initiative. This initiative has its bases in the new opportunities centres (NOC) which are as a doorway to (re)define school and/or professional paths of youngsters and adults. The RVCC processes take place where less educated adults show, through a(n) (auto)biographic approach, their throughout life learning in different settings/contexts, in what concerns to abilities and skills. This research assumes an interpretative approach. We have done intrinsic multiple case studies in a NOC, nearby Lisbon. We selected a group of 10 candidates to a 9th grade certification. We focused on the voice of two certified adults. We collected data through informal conversations and observations, registered in the researcher’s diary, from the candidate’s portfolio and from documents. We did a successive and in-depth content analysis, from which inductive categories emerged. The results illuminate that these candidates developed a positive social representation towards the RVCC process. Although they have shown, throughout the process, some doubts about the meaning of this process, the differentiation of the roles of each team member and his/her practices. The results also illuminate the potential of this certification process to enable these adults to take over personal, school and/or professional qualification paths

Impact of vertical integration on frequency of hospital readmissions

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COVID-19 preparedness and perceived safety in nursing homes in Southern Portugal: A cross-sectional survey-based study in the initial phases of the Pandemic

(1) Background: Nursing homes’ preparedness in managing a public health emergency has been poor, with effects on safety culture. The objective of this study was to assess nursing homes’ COVID-19 preparedness in southern Portugal, including staff’s work experiences during the pandemic. (2) Methods: We used a COVID-19 preparedness checklist to be completed by management teams, followed by follow-up calls to nursing homes. Thereafter, a survey of staff was applied. Data analysis included descriptive statistics, exploratory factor analysis, and thematic analysis of open-end questions. (3) Results: In total, 71% (138/195) of eligible nursing homes returned the preparedness checklist. We conducted 83 follow-up calls and received 720 replies to the staff survey. On average, 25% of nursing homes did not have an adequate decision-making structure to respond to the pandemic. Outbreak capacity and training were areas for improvement among nursing homes’ contingency plans. We identified teamwork as an area of strength for safety culture, whereas compliance with procedures and nonpunitive response to mistakes need improvement. (4) Conclusions: To strengthen how nursing homes cope with upcoming phases of the COVID-19 pandemic or future public health emergencies, nursing homes’ preparedness and safety culture should be fostered and closely monitored.info:eu-repo/semantics/publishedVersio

Unmet medical needs in ambulatory care in Hungary: forgone visits and medications from a representative population survey

Background The objective of this paper is to explore unmet health care needs in Hungary in ambulatory care due to costs and difculties in travelling, and to analyze how unmet needs relate to socio-demographic characteristics. Methods The quantitative analysis is based on a national, representative online survey carried out in Hungary on a sample of 1000 respondents in early 2019 using a proposed set of questions developed by the OECD. We present and compare unmet medical needs in diferent socio-demographic groups, and we use multivariate logistic regression analysis to identify the main determinants of unmet medical needs. Results Among responders who had medical problems in the last 12 months, 27.3% reported forgone medical visit due to difculties in travelling, 24.2% had unflled prescription for medicine due to costs, 21.4% reported forgone medical visit or follow-up visit due to costs and 16.6% reported skipped medical test, treatment or other follow-up due to costs. These shares are much higher than presented previously in international databases. The logistic model indicates that respondents were signifcantly more likely to report unmet needs if they were women, younger or belonged to frst and second income quintiles. Conclusions Policy makers need to address the issue of high prevalence of forgone medical care among the Hungarian population to avoid deterioration of population health and inequalities in access. As a frst step, policies should try to decrease fnancial burden of vulnerable groups to improve access

Patient experiences with outpatient care in Hungary: results of an online population survey

Background Health systems are undertaking eforts to make health care more patient centered and value based. To achieve this goal, the use of patient-reported experience measures (PREMs) is increasing, especially across OECD countries. However, in Hungary, data on patients’ experiences are still lacking. Thus, our aim was twofold: frst, to collect data on outpatient experience in Hungary on patient–doctor communication and patient involvement in decision making and compare it with that of other OECD countries; second, to assess associations of outpatient experience with patients’ socioeconomic characteristics. Methods In early 2019, we conducted a cross-sectional, online, self-administered survey in a national representative sample of Hungary’s population (n=1000). The sample was weighted considering gender, age, highest education level attained, type of settlement, and region of residence. The survey questions were based on a set of recommended questions by the OECD. Results Our fndings show that the proportion of reported positive experiences is as follows: doctors providing easy-tounderstand explanations (93.1%) followed by time spent on the consultation (87.5%), opportunities to raise questions (85.8%), and doctors involving patients in decision making about care and treatment (80.1%). The share of positive experiences falls behind OECD’s average regarding patient–doctor communication and patient involvement in decision making, which signals room for improvement in these areas. Conclusions Women, younger people, people with a paid job, and patients with consultations with allied health professionals reported signifcant lesser positive care experiences and, hence, more targeted policies can be initiated based on our fndings

Patient experiences in a public primary health care clinic: A South African case study

The South African Ministry of Health has recognized experiences of care as key to strengthen patient-centred care. This case study aims to measure patient-reported experiences of care at a clinic in South Africa, and its associations with the respondents' sociodemographic characteristics. A survey was conducted in 2019 on a convenience sample of 179 respondents. Questions on experiences of care were based on a standardised set of questions by the Organization for Economic Co-operation and Development (OECD). Logistic regression was used to examine the effects of respondents' characteristics on their experiences. The proportion of respondents who reported that a nurse spent adequate time with them during consultation was significantly higher among literate respondents (92.3 vs. 79.5%). Those who reported past negative experiences were significantly more likely to report a positive experience in regard to perceiving adequate consulting time (odds ratio = 3.865, with a 95% confidence interval between 1.555 and 9.607), receiving easy-to-understand explanations (4.308; 1.665–11.145), being given the opportunity to ask questions (2.156; 1.013–4.589) and shared decision–making (3.822; 1.728–8.457). The results can spur comparisons with other clinics in a similar setting and inform key stakeholders on aspects of the care experience that need greater improvement within the national framework for quality and safety assurance and patient experience measurement

the influence of chronic conditions on inpatient readmissions

Background: In Portugal, a public policy established the Local Health Units (LHUs), merging primary and hospital care providers. LHUs are expected to provide better continuity and coordination of care, thus decreasing the number of unplanned readmissions among those with chronic conditions. This study aims to evaluate the influence of chronic conditions on the risk of readmission at LHUs. Methods: We used inpatient care administrative databases for the years 2002-2014 (n = 1,679,634). We assessed the effects of chronic conditions on the risk of readmission with a difference-in-differences technique, comparing LHUs with a control group. Multivariate Cox regression was used to evaluate time to readmission. Results: The risk of readmission decreased in four LHUs, but significantly only in two. Individuals with more chronic conditions presented a lesser risk of read-mission at LHUs, in contrast to those in the control group. Conclusions: After adjusting for the number of chronic conditions and comorbidities, we concluded that LHUs may successfully decrease unplanned readmissions. Several challenges still have to be addressed to achieve a larger and long-lasting effect. Further investigation is needed to account for contextual and organizational effects that may explain differences across LHUs.publishe

Features Constituting Actionable COVID-19 Dashboards:Descriptive Assessment and Expert Appraisal of 158 Public Web-Based COVID-19 Dashboards

Background: Since the outbreak of COVID-19, the development of dashboards as dynamic, visual tools for communicating COVID-19 data has surged worldwide. Dashboards can inform decision-making and support behavior change. To do so, they must be actionable. The features that constitute an actionable dashboard in the context of the COVID-19 pandemic have not been rigorously assessed. Objective: The aim of this study is to explore the characteristics of public web-based COVID-19 dashboards by assessing their purpose and users (“why”), content and data (“what”), and analyses and displays (“how” they communicate COVID-19 data), and ultimately to appraise the common features of highly actionable dashboards. Methods: We conducted a descriptive assessment and scoring using nominal group technique with an international panel of experts (n=17) on a global sample of COVID-19 dashboards in July 2020. The sequence of steps included multimethod sampling of dashboards; development and piloting of an assessment tool; data extraction and an initial round of actionability scoring; a workshop based on a preliminary analysis of the results; and reconsideration of actionability scores followed by joint determination of common features of highly actionable dashboards. We used descriptive statistics and thematic analysis to explore the findings by research question. Results: A total of 158 dashboards from 53 countries were assessed. Dashboards were predominately developed by government authorities (100/158, 63.0%) and were national (93/158, 58.9%) in scope. We found that only 20 of the 158 dashboards (12.7%) stated both their primary purpose and intended audience. Nearly all dashboards reported epidemiological indicators (155/158, 98.1%), followed by health system management indicators (85/158, 53.8%), whereas indicators on social and economic impact and behavioral insights were the least reported (7/158, 4.4% and 2/158, 1.3%, respectively). Approximately a quarter of the dashboards (39/158, 24.7%) did not report their data sources. The dashboards predominately reported time trends and disaggregated data by two geographic levels and by age and sex. The dashboards used an average of 2.2 types of displays (SD 0.86); these were mostly graphs and maps, followed by tables. To support data interpretation, color-coding was common (93/158, 89.4%), although only one-fifth of the dashboards (31/158, 19.6%) included text explaining the quality and meaning of the data. In total, 20/158 dashboards (12.7%) were appraised as highly actionable, and seven common features were identified between them. Actionable COVID-19 dashboards (1) know their audience and information needs; (2) manage the type, volume, and flow of displayed information; (3) report data sources and methods clearly; (4) link time trends to policy decisions; (5) provide data that are “close to home”; (6) break down the population into relevant subgroups; and (7) use storytelling and visual cues. Conclusions: COVID-19 dashboards are diverse in the why, what, and how by which they communicate insights on the pandemic and support data-driven decision-making. To leverage their full potential, dashboard developers should consider adopting the seven actionability features identified

The experiences of 33 national COVID-19 dashboard teams during the first year of the pandemic in the World Health Organization European Region: A qualitative study

Background: Governments across the World Health Organization (WHO) European Region have prioritised dashboards for reporting COVID-19 data. The ubiquitous use of dashboards for public reporting is a novel phenomenon. Objective: This study explores the development of COVID-19 dashboards during the first year of the pandemic and identifies common barriers, enablers and lessons from the experiences of teams responsible for their development. Methods: We applied multiple methods to identify and recruit COVID-19 dashboard teams, using a purposive, quota sampling approach. Semi-structured group interviews were conducted from April to June 2021. Using elaborative coding and thematic analysis, we derived descriptive and explanatory themes from the interview data. A validation workshop was held with study participants in June 2021. Results: Eighty informants participated, representing 33 national COVID-19 dashboard teams across the WHO European Region. Most dashboards were launched swiftly during the first months of the pandemic, February to May 2020. The urgency, intense workload, limited human resources, data and privacy constraints and public scrutiny were common challenges in the initial development stage. Themes related to barriers or enablers were identified, pertaining to the pre-pandemic context, pandemic itself, people and processes and software, data and users. Lessons emerged around the themes of simplicity, trust, partnership, software and data and change. Conclusions: COVID-19 dashboards were developed in a learning-by-doing approach. The experiences of teams reveal that initial underpreparedness was offset by high-level political endorsement, the professionalism of teams, accelerated data improvements and immediate support with commercial software solutions. To leverage the full potential of dashboards for health data reporting, investments are needed at the team, national and pan-European levels