In our sample, 20.4% of deaths occurred in various child care settings, with 1.3% occurring with a nan- ny/babysitter, 4.3% in a relative’s home, and 14.7% in organized child care settings (12.1% in family child care homes and 2.6% in child care centers). The pro- portion of child care deaths did not increase during the survey, with 203 of 906 deaths (22.41%) in 1995, 130 of 692 (18.79%) in 1996, and 56 of 315 (17.78%) in 1997. The proportion of child care deaths in the in- dividual states ranged from 9.4% (Florida) to 40.2% (Minnesota; Table 2). Approximately 60% of SIDS in child care occurred in family child care homes (Table 2). The prevalence of prone as the usual sleep posi- tion was not increased in the child care cohort. Among the infants in child care, 32.0% usually slept prone, 37.7% supine, and 29.5% on the side, com- pared with 40.7% of those not in child care who usually slept prone, 23.0% supine, and 32.6% on the side. A total of .8% of those in child care and 3.7% of those not in child care had no usual sleep position.
The AIRE instrument that was used to assess the quality of the included studies is mainly focused on the indicator development process. We may underestimate the methodological quality of some studies, because the information related to the indicator development process was not always described within the articles. We tried to track down additional information in the literature about the development process of quality in- dicators, but we were able to get relevant additional information only for three sets of quality indicators. Due to time constraints, we did not contact any organization/author to elicit any additional information. The study results indicate the need for further develop- ment of quality indicators with detailed methodological specifications for monitoring and accurate assessment of the care for adults with depression in primary care settings.
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The NAMCS collects data from patient visits to ofﬁces of nonfederally employed physicians classiﬁed as “ofﬁce-based, patient care.” Data are collected by the individual physician, physician’s staff, or US Census Bureau ﬁeld representatives. Physicians are assigned a random reporting week, with the sampling procedures being designed to obtain ∼30 records from each physician. The NAMCS uses a multistage probability design using primary sampling units, physician practices within primary sampling units, and patient visits within practices. Data are collected on ∼40 000 patient visits annually, and proportional weights are applied to allow for extrapolation to national estimates. For both the NHAMCS and NAMCS, data processing occurs at a central facility with quality assurance performed by
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Nurses’ involvement was valued in episodic care as much as in chronic care. They were seen as pivotal to ensuring timely access and hence continuity of care. Any internal tensions experienced on this level were created by people who did not fully share the team care philosophy. Here, too, the external environment was often seen as interfering with the practices’ capacity to define professional roles in response to perceived needs. For example, regional and professional authori- ties believed nursing practice should be dedicated to chronic illness rather than episodic care, thus compro- mising the capacity to work with nurses to improve access. These tensions were expressed by the cases that had public governance (cases 2 and 3), but also by the FMG in the fee-for-service practice (case 5).
consultation with a group of clinical researchers. The SUGAR group’s comments led to the removal of questions which didn't adequately match the aims and objectives of the study and the inclusion of questions on staff views of service user and carer involvement in care planning. This draft schedule was piloted with two members of the dementia community team (a social worker and nurse) where the researcher worked. Their feedback helped clarify whether questions elicited the data sought to meet the study’s aims and objectives. Further changes to question wording were made to make them more open and exploratory.
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The participants’ lifestyles also remained the same after being diagnosed with hypertension. However, they claimed to have tried to lower their blood pressure by changing their lifestyle. However, their attempts have clearly failed. The participants in this study wanted to know more about how to control their diet and how to exercise correctly. However, accurate information was not given at screening and dur- ing follow-up. Seven participants stated that they were not referred to other health care providers, such as dietitian or staff nurse in charge in the resource center for counseling regarding their lifestyle changes. There is a need for dietitian referral because if the participants knew what food to eat, they might succeed in controlling their diet. Most of the participants were unaware of the existence of the resource center in the health clinics, where they can get information regarding hypertension from counseling, flyers, healthy cooking demonstration. As a result, the participants were uncertain what they should do. A study in Malaysia reported that three quarters of the subjects had unsatisfactory hyper- tensive control and it was related to food intake and eating habits, including high salt diet. 24
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Different theories have been proposed to describe inte- grative health care. Boon (2004) proposes a continuum of seven different models ranging from parallel care to inte- grative care . Placement along the continuum is deter- mined by differences in philosophy, structure, process and outcomes, implicit in this theoretical framework is that it is desirable to be further along the continuum, that is “more integrative”. Within this framework, it is possible to place each IHC centre along the Boon’s continuum but this does not reflect clinical day-to-day operations where “integrative” care does occur alongside “parallel practice”. One approach that has been developed from Boon’s con- tinuum, has been to acknowledge that more than one type of collaboration might occur at a single site, and therefore “grouping models” may be more useful . Another pos- sible theoretical framework for understanding IHC is to describe multidisciplinary care according to three tiers - linkage, coordination and integration. Each tier requires an increased level of organisational and clinical arrangements [27,28]. Different tiers are appropriate for different indi- viduals. For example, linkage is adequate for patients with mild to moderate care needs. Whereas for patients with complex care needs full integration may be required, that is, where new ‘programs’ are created from the pooling of resources. The differentiation between tiers is important as not all patients may require an integrative approach. Perhaps within the spectrum of Boon’s continuum, ‘inte- grative’ care needs to be contextualised as being the goal only for some patients, perhaps those with complex care needs . For other patients, linkage, or coordinated or collaborative structures and processes that are based on the goals of treating the whole person may be more than appropriate .
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However, it is important to note that mental models can manifest at various levels within an organization (i.e., per- son, team, organization), such as those within a primary care clinic. A facility, hospital, or organization-level men- tal model represents the beliefs and perceptions of an organization such that these influences are felt by individ- ual members of the organization. Research on clinical practice guideline (CPG) implementation has established empirical links between a hospital’s mental model of guidelines and their subsequent success at guideline im- plementation: specifically, compared to facilities who struggled with CPG implementation, facilities who were more successful at CPG implementation exhibited a clear, focused mental model of guidelines, and a tendency to use feedback as a source of learning . However, as the aforementioned study was not designed a priori to study audit-and-feedback, it lacked detail regarding the facilities ’ mental models about the utility of audit-and-feedback, which could have explained why some facilities were more likely than others to add audit-and-feedback to their arsenal of implementation tools. The present study directly addresses this gap in order to better shed light on the link between feedback and health- care facility effectiveness.
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We believe that palliative, end-of-life and bereavement care must extend far beyond hospitals and hospices. A wide range of health and social care settings can provide the backdrop for meaningful services and conversations. The IHF is proud of its long tradition of identifying gaps in services and working with care providers to create innovative and cutting-edge solutions. We strive to be an agent of change, collaborating with partners to imagine and realise creative and effective ways to bring about positive change.
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One of the most pre-disposed values to being truthful is associated with respect for the patient as a person who is able to make decision. This is because, to determine a course of action and governance of care for a patient, the patient requires nothing less than truthful information. The provision of truthful information to patients is one way to enable them to make correct decisions which benefit their overall health. Without knowledge of the truth, it would be uncertain whether patients can make informed decisions and would lead to failure of health professionals to respect them as autonomous individuals. Lying is held to be a breach of the autonomy of the person, and this contradicts concepts such as patient empowerment, shared decision-making and patient-centred care. This To cite this article: Zolkefli Y. The ethics of truth-telling in health-care settings. Malays J Med Sci. 2018;25(3):135– 139. https://doi.org/10.21315/mjms2018.25.3.14
Medically unexplained physical symptoms (MUPS) are those without relevant organic pathology and are commonplace in primary care and specialty medical care settings. MUPS disorders include fi- bromyalgia (FM), irritable bowel syndrome (IBS), multiple chemical sensitivity, chronic fatigue syn- drome, and others. The etiologies of FM and IBS are poorly understood and are likely multifactorial and complex. Common factors include symptom hypersensitivity or amplification, hypothalamic-pi- tuitary-adrenal axis perturbation, and genetic vul- nerability. A sexual abuse history may play a role as well. Significant comorbidity exists between IBS and FM. Patients with both disorders have more physical and psychiatric symptoms than those with only one disorder. FM and IBS can generally be diagnosed with a careful history and physical exam combined with judicious use of laboratory studies. Treatment is symptomatic and includes addressing psychiatric issues with medications, non-medication therapies, and supportive, caring attitudes.
4. Most research on medical errors is hospital based. It may not be appropriate to extrapolate the num- ber or types of errors found in hospitals to the number or types of errors that might be found in ambulatory health care settings. Because most health care is delivered in ambulatory care set- tings, and in pediatrics, many medications are taken outside of the home (in schools and child care settings), research on errors in ambulatory care settings should be a priority, particularly for unique patient populations, such as infants, chil- dren, adolescents, young adults, and children with special needs. The problem of drug dose calculation errors for pediatric patients, in partic- ular, should be explored.
There is limited consensus about what constitutes humanly sensitive care, or how it can be sustained in care settings. A new Humanised Care Assessment Tool may point to caring practices that are up to the task of meeting persons as humans within busy healthcare environments. This paper describes qualitative development of a tool that is conceptually sensitive to human dimensions of care informed by a lifeworld philosophical orientation. Items were generated to reflect eight theoretical dimensions that constitute what makes care feel humanly focused. An action research group process in 2014-2015 with researchers, service users, healthcare professionals in two diverse clinical settings (stroke rehabilitation and dermatology) was used. Feedback on conceptual content, transparency of meaning and readability was then gained from a panel in Sweden and third year student nurses in the UK. The tool can be applied to attune staff to human dimensions of care, offering items which point to concrete examples of humanising and dehumanising features of practice in ways that have not yet been fully captured in the caring literature. Based on theoretically-led experiential items, with dedicated focus on what makes people feel more, or less than human, it may offer improvement on available assessments of care.
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This study holds a number of implications for health system administrators. For those that are focused on qual- ity improvement, the results of this study may serve as the foundation for risk-adjusted discharge planning bench- marks, allowing for fair facility comparisons based on dis- charge planning efficacy after accounting for risk factors associated with prolonged length of stay. These risk-adjusted performance measures may be used for pro- gram evaluation and, and through public reporting, could incentivize discharge planning quality improvement across the health system. In terms of health system planning, the results of this study may be useful for optimizing patient flow along the continuum of care. Patients aged 65 years and older had lower odds of long-stay designation. Simi- larly, New et al.  found that patients aged 50 years and younger had greater odds of experiencing a discharge bar- rier from a rehabilitation facility. After accounting for clin- ical status, younger patients are likely at greater odds of long-stay designation as a result of a lack of long-term facility-based care settings that are oriented towards car- ing for younger individuals. Although advanced age is not a criterion for admission to an institutional care setting in Ontario, few LTC residents are younger than age 65 . We also found that patients requiring a feeding tube, dia- lysis, tracheostomy care, or a ventilator are at increased odds of long-stay designation. Though there are few pa- tients in CCC facilities that require these therapies, cap- acity to provide accommodations outside of hospital-based care may be limited or require extensive coordination with community care providers. For ex- ample, the discharge barriers most frequently experienced by community-bound mechanically ventilated patients re- late to public funding arrangements and a shortage of paid caregivers . These findings support the implemen- tation of alternative models of community and resi- dential care that meet the preferences and needs of both younger adult patients and those that require technically advanced medical treatments that can be provided outside of hospital settings. Examples in- clude intensive home health care [40, 41] and small-scale shared supported accommodations . Table 3 Multivariable logistic regression model predicting long-stay designation by discharge destination (Continued)
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On the other hand, formal care can be delivered either in the community in the form of home-and community- based care (HCBC), or in the institutional settings in the form of institutional care. To ease the caregiving burden on the younger generation, and to share the responsibil- ity of elderly support between government and family members, several laws and regulations related to elderly care have been promulgated in China, including a new law on social insurance, and a proposed revision of the law on protecting the rights and benefits of older people . In China, formal care is gaining ground [4, 18]. For institutional care, developed countries have already built up relatively advanced service delivery systems for older people’s institutional care, and there are also compre- hensive government policies and regulations to monitor the quality of service delivery, for example, the White Paper “Caring for Our Future: Reforming Care and Support” in England, the Act on Prevention of Elderly Abuse and Support for Attendants of Elderly Persons in Japan, the Omnibus Budget Reconciliation Act of 1987 in the US. In China, institutional care is still in short supply compared with that in the developed countries. Nursing homes can provide beds for only 2.72% of the total number of older people . For HCBC, although the lack of adequate and affordable institutional care and the weakening of traditional family care have made HCBC an appealing option, in China, HCBC is still at the early stages compared with that in developed countries. China is facing challenges regarding how to address mount- ing service needs with limited social resources in a young, developing civil society . With the more recent develop- ments in formal LTC provision, older Chinese people now have wider choices in LTC modes. In response to this situation, to optimize older people’ s arrangements for LTC services and improve the quality of later life, this study sets out to explore and make theoretical sense of older people’s LTC needs, and to clarify influencing factors.
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ity and dependency independently predicted mortality, and the need for hospitalization and institutionalization. As both comorbidity and dependency increase with age, more elderly people are living longer in more tenuous states of health. The proportion of elderly patients admitted to the hospital and intensive care is considerable compared with the general population, and data from the McDermid and Bagshaw study suggest an increasing trend in elderly admissions. A previously published study has shown that elderly patients often receive less intensive therapy and face greater support limitations when admitted to intensive care, implying that there may be a selection bias among elderly patients triaged for access to finite critical care. 1 This may be due to the consumption of
The study was conducted at the Riyadh Maternity Hospi- tal, a tertiary care facility with an average of 10,000 deliveries annually. Following departmental approval, a database was set up in April 2005 to prospectively collect information on all women with singleton pregnancies who underwent emer- gency cerclage over a six-month period. The database in- cluded antenatal/obstetrical history and perinatal/neonatal outcomes. The diagnosis of cervical incompetence relied on clinical criteria: finding of a dilated cervix and/or bulging or hour-glassing membranes in the absence of labor. The deci- sion to place a rescue cerclage, the selection of cerclage tech- nique, the method for replacing the bulging membranes, the decision to confine the women to bed rest in hospital after cerclage placement, and the use of antibiotics and tocolytics, were left at the discretion of the obstetricians, who were un- aware of the ongoing prospective data collection project. The author of this study was not involved in the care of patients with rescue cerclage; his role was limited to data collection.
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The current reimbursement for hospice and palliative care services is per diem, which uses a flat rate per day, mainly differentiated by a provider’s size (i.e. tertiary hospital, hospital, or clinic) for institutes involved with the pilot project. A few supplementary services are paid according to a fee schedule that takes into consideration the resources (i.e. nurse level) and time needed to provide a service (Table 1). Since 2008, only institutes in- volved with hospice pilot projects have been reimbursed by the National Health Insurance program, and the reimbursement coverage has been extended for 2015 for all hospice and palliative care services. Most supple- mentary services, irrelevant to medical services such as meals, music or art therapy, are not included.
and personal, they are touched by them, their feelings are moved and they become directly involved. They also expressed feeling uncertain as to whether their decisions would lead to good care. It is therefore understandable that the HDMs deal with questions that reflect both per- spectives such as "What should I do" as well as "How do I fulfil my role . This ethical theory  is useful for illus- trating the complexity of the ethical challenges and that ethics concerns everyone, caregivers as well as HDMs. Health administrators and politicians have been viewed as having little understanding for the demands expressed by staff in acute care  and have been reported as prob- ably cold and cynical . In our study, it is reasonable to believe that the HDMs' experiences of being ethically chal- lenged concerns their feelings that important issues and needs are at stake in elder care as well as for themselves. The crux of the ethical challenges seems to be related to the HDMs having a covenant with older patients and soci- ety to provide good care and that this care is governed by the limited budgets of the different health care organisa- tions. Bakken et al.  stressed that the rhetoric regard- ing the welfare state at the national level, including the health care sector can be experienced as being almost unlimited. The welfare state ambitions are executed at the local political level and the disparity between the ambi- tions and available recourses systematically creates ethical dilemmas . The HDMs, in our study requested a pub- lic debate addressing what can be expected from and offered by the national public health care systems. This underlines their uncertainty about how to deal with trou- blesome situations including reports of problems in elder care. A wish for some support for making decisions or maybe some relief by sharing these difficult issues with others might be sought. It might also reflect what Thomp- son  calls restoring responsibility in health care. The fundamental key issue of trust between individuals must be transferable into the character of the health care system or organisations. Studies have addressed the concept called "organisational ethics" in which, for example, the issues related to ethical conflicts at different levels and by different professionals in the organisation are revealed. The management is required to make sure that the neces- sary prerequisites are provided to ensure that the struc- tures and processes enable dialogues concerning ethical issues and behaviours within a health care organisation [44-46].
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zero TB deaths among children will require “ sustained advocacy, greater commitment, mobilization of increased resources, and a joint effort by all stakeholders involved in providing health care for children and in TB control. ” Ten basic steps are described (Table 2). The most crucial steps include: better training of TB program personnel and child health workers in TB-related skills and techniques; engaging key stake- holders and fostering local expertise and leadership through coalitions and partnerships; integrating child TB ser- vices into existing health programs, especially those dealing with HIV infec-