no stati presi in considerazione tutti gli studi presenti su Medline (Medical Literature Analysis and Retrieval Sy- stem Online), utilizzando il motore di ricerca PUBMED, selezionati in base alle seguenti keywords: mixed state(s) treatment/therapy o mixed episode(s) treatment/the- rapy. Considerando i pur pochi dati esistenti, lo scritto che segue cerca di tracciarne le conclusioni in modo critico nel tentativo di dare qualche elemento di utilità clinico-pratica. Verrà considerata prima la gestione e la cura degli episodi maniacali con elementi misti e suc- cessivamente la gestione e la cura degli episodi depres- sivi con elementi misti.
Another case study that illustrates the importance of human resources management to the health care system is that of The University of Nebraska Medical Center in 1995. During this period, the hospital administrative staff recognized a variety of new challenges that were necessi- tating organizational change. Some of these challenges included intense price competition and payment reform in health care, reduced state and federal funding for edu- cation and research, and changing workforce and popula- tion demographics . The organizational administrators recognized that a cultural reformation was needed to meet these new challenges. A repositioning process was enacted, resulting in a human resources strat- egy that supported the organization's continued success . This strategy consisted of five major objectives, each with a vision statement and series of action steps. • Staffing: Here, the vision was to integrate a series of organization-wide staffing strategies that would anticipate and meet changing workforce requirements pertaining to staff, faculty and students. To achieve this vision, corpo- rate profiles were developed for each position to articulate the core competences and skills required .
Management of patients with complex disease is one cor- nerstone of delaying and preventing complications and thus improving delivery of medical care, clinical outcomes, and appropriate utilization of health care resources. Although published evidence-based guidelines exist, care often fails to meet these guidelines due to barriers such as lack of time during office visits, patient adherence, and the struggle to stay current with new information and to recall specific instructions that are relevant to each patient. After previously re-designing their approach to managing patients with dia- betes which includes a nine part all-or-none diabetes bundle, Geisinger Health System has demonstrated improvement not only in process measures and overall adherence to the bundle, but also clinical metrics such as HbA 1c ,7%, LDL ,100 mg/ dL, and blood pressure ,130/80 mmHg that have proven to be effective downstream in the management of diabetic complications. 21,22 With over 146 distinct measures in diabetes
The purpose of this focus group and survey was to ex- plore the challenges and possible solutions for conduct- ing more effective pediatric obesity management in the primary care setting. The physicians and nurse practi- tioners in San Diego County reiterated many of the commonly recognized challenges, namely the lack of time, poor communication skills, and limited resources to effectively conduct this management within the struc- ture of the current well-child visit. These sentiments echo those from previous reports [16, 17] and highlight the continued difficulty providers have with conducting obesity management in the office setting. Providers also commented on the need to increase families’ motivation to engage in treatment and identify trusted local referral resources that families could easily access. This issue of access has not been frequently highlighted in previous studies and underscores the need to develop effective programs that can be implemented in the primary care setting or other community settings that families from underserved communities can easily access.
The final model evaluated the association between the outcome of medical readmission rates and the condi- tions of case management staffing ratios, hospitalist pro- gram effectiveness, urgent care availability after hours, and the frequency of PO medical director hospital rounds. All four capabilities appear to contribute in vari- ous combinations to lower medical readmissions. Com- munities with readily available urgent care after hours and effective hospitalist programs have low medical re- admission rates despite low case management staffing. Where hospitalist resources are weak, high case manage- ment staffing is associated with low medical readmission rates. Finally, some POs achieved low medical readmis- sion rates by combining medical director rounding and high case management staffing. High case management staffing was a component of the two configurations with the highest coverage, with a total coverage of 0.581, sug- gesting that it is an important contributor to low med- ical readmissions.
Regarding the use, the internet and intranets available, for improvement of the quality of information on disease or treatment associated with or about patients’ previous hospitalization history, only 23.1% of the nurses believed computer systems help them in this regard (retrieval of evidence in the care process). Despite the limited amount of internet traffic for the hospital nurses (almost 20 hours, monthly), 46% of the respondents did not know enough about it, and 28% of nurses, despite being aware, did not use it. In general, the findings indicate that the most common use of the computer in the caremanagement process is the admission and discharge of the patient, as well as support in the provision of drugs and equipment, and the least was related to the recovery of evidence in the care process.
The strength of this review stems from the focused clinical question and comprehensive literature search. We were more interested in the recent trend over the past decade in diabetes caremanagement programs and therefore did not evaluate prior publications. We attempted to synthe- size the evidence on outcomes that matter to patients although meta-analyses were only possible on surrogate laboratory outcomes. The likelihood of reporting bias and publication bias threatens the validity of this review and its presence is suggested by the selective reporting of out- comes (only a small numbers of studies reported each out- come). This review focuses on the last decade because we aimed at providing a contemporary evaluation of the cur- rent trends in these care models. Therefore, our conclu- sions may be biased since relevant older publications, summarized elsewhere, are not presented in this report. The evaluation of publication bias was not statistically fea- sible due to the small number of studies and the signifi- cant heterogeneity in results across trials . Lastly, we used a consensus process to categorize study intervention methods to allow comparisons across these methods. However, assigning intervention methods to mutually exclusive categories could have biased the observed effects toward the null.
Strong leadership was also raised by several members as a key element to the success of the multidisciplinary team: coordinating and chairing regular meetings, encouraging involvement of all participants in case discussions and decision-making and, at the conclusion of case discussions, summarizing the discussion and inviting any further input before moving to the next case. Motivational factors for attending meetings included, 1) perceived benefits of the meetings for both meeting participants and patients, 2) an opportunity to interact with other members of the multidis- ciplinary team in an inclusive atmosphere, 3) an opportunity for educational interaction and professional development, and 4) streamlining of referral pathways. Meetings may also serve as a resource of identifying patients suitable for clinical trial participation. An established center for managing disease also allows for the collection of registry data on patient presentations, patterns of care and treatment outcomes. This provides a comprehensive set of information available to guide future management, clinical research and treatment practices.
Methods: Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped- wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content. Results: From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89. 1% overall (range: 70.1 – 100%), but decreased to 62.1% (range: 0 – 100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance. Conclusions: Our findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes.
Abstract: Chronic obstructive pulmonary disease (COPD) is a multicomponent disorder that leads to substantial disability, impaired quality of life, and increased mortality. Although the majority of COPD patients are first diagnosed and treated in primary care practices, there is comparatively little information on the management of COPD patients in primary care. A web-based pilot survey was conducted to evaluate the primary care physician’s, or general practitioner’s (GP’s), knowledge, understanding, and management of COPD in twelve territories across the Asia-Pacific region, Africa, eastern Europe, and Latin America, using a 10-minute questionnaire comprising 20 questions and translated into the native language of each participating territory. The questionnaire was administered to a total of 600 GPs (50 from each territory) involved in the management of COPD patients and all data were collated and analyzed by an independent health care research consultant. This survey demonstrated that the GPs’ understanding of COPD was variable across the territories, with large numbers of GPs having very limited knowledge of COPD and its management. A consistent finding across all territories was the underutilization of spirometry (median 26%; range 10%–48%) and reliance on X-rays (median 14%; range 5%–22%) for COPD diagnosis, whereas overuse of blood tests (unspecified) was particularly high in Russia and South Africa. Similarly, there was considerable underrecognition of the importance of exacerbation history as an important factor of COPD and its initial management in most territories (median 4%; range 0%–22%). Management of COPD was well below guideline-recommended levels in most of the regions investigated. The findings of this survey suggest there is a need for more ongoing education and information, specifically directed towards GPs outside of Europe and North America, and that global COPD guidelines appear to have limited reach and application in most of the areas studied.
reduced the administrative burden associated with ap- pointment booking and may have reduced the non-attendance rate at hospital clinics [2, 25]. However, this system may not be appropriate for all specialties and in all contexts. Prior to and following the introduction of this UK NHS national system, independent electronic referral management systems were developed with mixed success. For example Maddison et al.  evalu- ated electronic referral management with triage and an adjunct advanced primary care service for uncompli- cated musculoskeletal conditions. They found that, al- though the number of referrals greatly increased following the introduction of referral management, wait- ing times fell. In addition, duplicate referrals disap- peared, and a high degree of patient satisfaction was reported. However Kim et al.  found that, although electronic referral management improved access to care there were some barriers to implementation. Some refer- ring clinics reported IT issues, specifically multi step computer login procedures, a lack of computer access and reliable internet connection. Consequently, elec- tronic referrals were reported as taking longer to complete that traditional letter writing (which was often delegated to administrators following dictation), which was associated with lower satisfaction with overall clin- ical care. This finding highlights the importance of con- sidering the context in which referral management interventions are implemented.
effective manner. Taking this proactive approach offered an opportunity to lessen the need for more costly treatments and reduce the negative impact of the condition on the patient. Information on recommended tests and services was shared by the all members of the health team and included educa- tion of patients about the rationale and timing for tests and the impact of test results on their health management. In fact, care managers were commended by the some of the doctors as the “guardians” of the testing schedule since it was common for the care manager to provide this type of monitoring, and this helped keep patients informed as well served to remind doctors when the patient needed additional tests. Lessening the gap between the recommendations of clinical guidelines and the care patients actually received throughout the Project can be regarded as one of the major achievements of Leonardo.
Another major challenge and at the same time relevant strategy of self-management is the “merging of treatment data”. Patients with a long treatment history – often combined with different care settings – have to handle a significant amount of data over the course of their illness. Considering the complexity of the treatment, disease- and care-related data are collected from many different service providers. Our participants had the impression that they often had responsibility to bring all their data together. It became appar- ent with our focus groups that much time and commitment were needed for patients to merge all of their treatment data. The patients in our focus groups often knew exactly how they receive their treatment data from different health care providers (eg, format of data, contact person, etc.).
Previous research has not demon- strated any statistically significant differences between in-person visits and telemedicine modalities with respect to A1C outcomes (8–10). A majority of these studies primarily involved visits centered around diabe- tes education and rarely evaluated the use of telemedicine for medication management. Medication manage- ment encompasses the addition or removal of a medication or a dosage adjustment. Additionally, previous studies have not focused on glyce- mic control in patients who receive telephone care alone compared to telephone care plus face-to-face visits, which include in-person and video- conferencing modalities of care.
Abstract: Self-management is becoming increasingly important in COPD health care although it remains difficult to embed self-management into routine clinical care. The implementation of self-management is understood as a complex interaction at the level of patient, health care provider (HCP), and health system. Nonetheless there is still a poor understanding of the barriers and effective facilitators. Comprehension of these determinants can have significant implications in optimizing self-management implementation and give further directions for the development of self-management interventions. Data were collected among COPD patients (N=46) and their HCPs (N=11) in three general practices and their collaborating affiliated hospitals. Mixed methods exploration of the data was conducted and collected by interviews, video-recorded consultations (N=50), and questionnaires on consultation skills. Influencing determinants were monitored by 1) interaction and communication between the patient and HCP, 2) visible and invisible competencies of both the patient and the HCP, and 3) degree of embed- ding self-management into the health care system. Video observations showed little emphasis on effective behavioral change and follow-up of given lifestyle advice during consultation. A strong presence of COPD assessment and monitoring negatively affects the patient-centered communication. Both patients and HCPs experience difficulties in defining personalized goals. The satisfaction of both patients and HCPs concerning patient centeredness during consultation was measured by the patient feedback questionnaire on consultation skills. The patients scored high (84.3% maximum score) and differed from the HCPs (26.5% maximum score). Although the patient-centered approach accentuating self-management is one of the dominant paradigms in modern medicine, our observations show several influencing determinants causing difficulties in daily practice implementation. This research is a first step unravelling the determinants of self-management leading to a better understanding.
32. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
Individual adoption depends on communication between health care professionals, case managers and patient- caregiver dyads and their interpersonal influence. One of the factors associated with CM implementation was insuf- ficient collaboration between local health care professionals (eg, general practitioner, geriatrician, and case manager, ie, nurse or social worker). 41,43,45–48,50,51,54 For example, 52% of
In Bangladesh, the demand for and supply of UAPs is growing rapidly. Cockcroft et al. found that the propor- tion of outpatient visits conducted by unqualified practi- tioners rose from 52% in 2000 to 60% in 2004 . In 2004, there were 110,000 UAPs in Bangladesh , while in 2007, there were 12 village doctors and 11 drug sellers per 10,000 population . Along with the increased number of UAPs, their areas of practice are also expanding. Results of recent studies have showed that UAPs provide treatment for simple to more serious conditions, ranging from diarrhea and fever to repro- ductive health and maternity care. In a rural area of Bangladesh, almost half of the women in the study reported receiving treatment from UAPs for complica- tions of pregnancy, delivery and the postpartum . Another study in the urban slums of Bangladesh demonstrated that families preferred seeking care from unqualified allopathic practitioners for perceived post- partum complications compared to other sources . UAPs have poor knowledge about pregnancy-related complications ; however, they are the preferred pro- viders for complications during home delivery. UAPs also manage postpartum complications. One study found that UAPs incorrectly managed postpartum bleeding with ergometrine. They also play an important role in referring women to health facilities, even when traditional birth attendants (TBAs) prefer to manage the complications at home [12,20].
One approach taken to improve the management of care provided to this population is the allocation of a health or social care professional to assume the responsi- bility of coordinating all aspects of care for the individual. These are organisational interventions which have been under development over recent decades and have been applied to a number of long-term conditions including dementia. The organisation and implementation of such interventions varies widely, but the primary focus is to de- velop a collaborative process of planning, facilitating and coordinating care and providing a proactive support base for both the patient and their informal caregiver/families. In the literature, the variations in these interventions have taken a number of different titles which are often used loosely and interchangeably including care/case manage- ment, collaborative care and care coordination.
Our data on the use of lithium in clinical practice, in monotherapy or in combination with valproate, showed that more than 50% of the sample was treated with the combination of the two drugs. Most patients receiving lithium plus valproate were male and rapid cyclers; fur- thermore, combination treatment was associated with a higher severity of psychotic symptoms at baseline. This is consistent with the common practice to administer poly- pharmacotherapy for the management of more severe forms of BD 9 11 14 .