Community hospitals and their services in the NHS: identifying transferable learning from international developments - scoping review, systematic review, country reports and case studies

Background: The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential. Objectives This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care. Methods A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland. Results The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented. Limitations The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth. Conclusions At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s). Funding: The National Institute for Health Research Health Services and Delivery Research programme

Principali fattori che influenzano il colore delle carni

Le decisioni di acquisto della carne sono influenzate dal colore più di qualsiasi altro fattore di qualità poichè rappresenta, per i consumatori, un indicatore di freschezza e salubrità. I consumatori desiderano un rosso attraente e mostrano una minore preferenza per la carne estremamente scura (DFD) o estremamente chiara (PSE). Il colore è determinato cromaticamente dai pigmenti presenti nelle carni e dal loro stato ossidoriduttivo oltre che dalla microstruttura della carne. Gli attributi cromatici sono principalmente determinati dalla quantità di light scattering nel muscolo, processo in cui la luce viene diffusa o deviata da collisioni con le particelle del mezzo che attraversa. Nel corso delle 48 ore post mortem (PM) i cambiamenti biochimici, ossidativi e fisici nel muscolo contribuiscono alle variazioni nel colore della carne e, quindi, nella qualità e nel valore. Si ipotizza che il light scattering provenga principalmente da: i) Contrazione trasversale del reticolo strutturale dei miofilamenti, miofibrille e fibre muscolari; ii) Mancanza di restringimento longitudinale del sarcomero; iii) Composizione proteica del mezzo circostante (sarcoplasma e spazio extracellulare). Le fibre muscolari ad alto pHu subiscono un minor restringimento trasversale, hanno diametri maggiori ed un volume minore di spazio extracellulare, che riduce la dispersione della luce e si traduce in un colore della carne più scuro. Le fibre muscolari più chiare ed a basso pHu subiscono maggiore restringimento trasversale ed hanno un volume maggiore di spazio extracellulare che consente una maggiore diffusione della luce. Per limitare gli sprechi e le perdite, l'industria deve individuare soluzioni innovative per migliorare la durata del colore e della shelf-life dei prodotti a base di carne

Primary care physicians' perspective on the management of anxiety and depressive disorders: a cross-sectional survey in Emilia Romagna Region

BACKGROUND: Evidences from literature suggest that Primary Care Physicians' (PCPs) knowledge and attitude about psychological and pharmacological treatments of anxiety and depressive disorders could influence their clinical practice. The aim of the study is double: 1) to assess PCPs' opinions about antidepressants (ADs) and psychotherapy for the management of anxiety and depressive disorders; 2) to evaluate the influence of PCPs' gender, age, duration of clinical practice, and office location on their opinions and attitudes. METHODS: This cross-sectional multicentre survey involved 816 PCPs working in four Local Health Units of the Emilia Romagna Region. Participating PCPs were asked to complete a questionnaire during educational meetings between October 2006 and December 2008. RESULTS: The response rate was 65.1%. Eighty-five percent of PCPs agreed on the effectiveness of ADs for depressive disorder whereas lower agreement emerged for anxiety disorder and on psychotherapy for both anxiety and depression. Forty percent of PCPs reported to feel "very/extremely confident" in recognizing depression and 20.0% felt equally confident in treating it with pharmacotherapy. Considering anxiety disorder, these proportions increased. Female PCPs and those located in the rural/mountain areas reported to adopt more psycho-educational support compared to male and suburban colleagues. CONCLUSIONS: Our results suggest that an effort should be made to better disseminate recent evidences about the management of anxiety and depressive disorders in Primary Care. In particular, the importance of psychological interventions and the role of drugs for anxiety disorder should be addressed

The implementation of a Community Health Centre-based primary care model in Italy. The experience of the Case della Salute in the Emilia-Romagna Region

BACKGROUND: The Comunity Health Centre (CHC) primary care model is a team-based health care delivery model intended to provide comprehensive and continuous medical care to patients within a defined community. The CHC, Case della Salute in Italian, model was introduced in the Emilia-Romagna Region in 2010.METHODS: We present updated data on the implementation on the CHC Case della Salute primary care model in the Emilia-Romagna Region.RESULTS: There are 67 operating CHCs in Emilia-Romagna (update March 2015); 26 small (39%), 24 medium (36%) and 17 large (25%). Since 2011 the number of operating CHCs has increased by 60%, reaching 55% of the target planned CHCs (n. = 122). There is, on average, one running CHC per 66.524 inhabitants. 16% of total general practitioners (GPs) and 8.4% of total family paediatricians working in Emilia-Romagna have their practice in CHCs. CHCs offer primary and specialist integrated care, prevention services, health education and social care.DISCUSSION: Although preliminary results suggest CHCs have fostered primary care's quality and efficiency, more research is needed to assess their impact on improving clinical, social and economic outcomes

A Novel KCNN2 Variant in a Family with Essential Tremor Plus: Clinical Characteristics and In Silico Analysis

Background: Essential tremor (ET) is one of the more common movement disorders. Current diagnosis is solely based on clinical findings. ET appears to be inherited in an autosomal dominant pattern. Several loci on specific chromosomes have been studied by linkage analysis, but the causes of essential tremor are still unknown in many patients. Genetic studies described the association of several genes with familial ET. However, they were found only in distinct families, suggesting that some can be private pathogenic variants. Aim of the study: to characterize the phenotype of an Italian family with ET and identify the genetic variant associated. Methods: Clinical and genetic examinations were performed. Genetic testing was done with whole-exome sequencing (WES) using the Illumina platform. Bidirectional capillary Sanger sequencing was used to investigate the presence of variant in all affected members of the family. In silico prediction of pathogenicity was used to study the effect of gene variants on protein structure. Results: The proband was a 15-year-old boy. The patient was the first of two children of a non-consanguineous couple. Family history was remarkable for tremor in the mother line. His mother suffered from bilateral upper extremity kinetic tremors (since she was 20 years old), anxiety, and depression. Other relatives referred bilateral upper extremity tremors. In the index case, WES analysis performed supposing a dominant mode of inheritance, identified a novel heterozygous missense variant in potassium calcium-activated channel subfamily N member 2 (KCNN2) (NM_021614.3: c.1145G>A, p.Gly382Asp). In the pedigree investigation, all carriers of the gene variant had ET and showed variable expressivity, the elder symptomatic relative showing cognitive impairment and hallucinations in the last decade, in addition to tremor since a young age. The amino acid residue #382 is located in a transmembrane region and in silico analysis suggested a causative role for the variant. Modelling of the mutant protein structure showed that the variant causes a clash in the protein structure. Therefore, the variant could cause a conformational change that alters the ability of the protein in the modulation of ion channels Conclusions: The KCNN2 gene variant identified could be associated with ET. The variant could modify a voltage-independent potassium channel activated by intracellular calcium