This document summarizes a project using the SPARRA tool and Gold Standards Framework approach to identify and manage complex patients at risk of hospital admission in Angus, Scotland. Key findings include:
- SPARRA identified some at-risk patients but missed others known to professionals and 40% of the SPARRA list were already identified in preliminary studies.
- A pilot project at one practice used SPARRA and a "top ten" list to implement Gold Standards Framework care planning which improved communication between professionals and reduced emergency care contacts.
- Further work cross-referenced SPARRA lists with existing case management services to better identify and share information on complex patients.
Jesús de Los Milagros, Templo de San José 2010Claudio Obregón
El documento describe la procesión del Domingo de Ramos en el Templo de San José en Guatemala. Las calles se preparan con alfombras para dar la bienvenida a Jesús. La procesión incluye "romanos", cucuruchos, Jesús de los Milagros y la Virgen de Dolores. La procesión dura 18 horas y concluye entrada a la iglesia a la 1 de la mañana.
complication of myocardial infarction,There are some complications in myocardial infarction , a disease resulting from complications of myocardial infarction can be very dangerous because it can lead to cardiogenic shock
Bahco is launching a complete range of hydraulic lifting equipment for vehicles and heavy parts. The range includes a foldable crane, engine slings, stands, and transmission jacks. It also offers trolley jacks, air hydraulic jacks, jack stands, and other important equipment such as a hydraulic wheel dolly and ram sets. The Bahco tools enable quick, comfortable, and safe working.
This document summarizes government spending by department from 2007-2008, with the largest allocations going to social security (27%) and health (16%). Planned spending increases from 2008-2011 are also shown, with the largest increases for health, social security, and education. The document then discusses reasons for optimism in the NHS, including improved quality of services, but also reasons for concern like increasing demand, a tighter financial regime, and rising prescription drug costs. Areas for scrutiny of the NHS are identified as budget areas, productivity, and outcomes. The document argues for actions that motivate at multiple levels from individual practitioners to centralized policy through guidance, financial incentives, and infrastructure like IT.
Professor Peter Littlejohns: NICE current practice and future directionNuffield Trust
NICE currently provides national guidance on health promotion and disease prevention and treatment. It issues guidance in public health, health technologies, and clinical practice based on comprehensive evidence reviews and expert input. NICE will take on responsibility for social care guidance in 2012. Quality standards are being developed to define high quality care and will include 150 topics over 5 years. NICE's guidance and quality standards will play a key role in the new NHS Outcomes Framework and in determining provider payment mechanisms. This expanded role may impact national and local priority setting.
The document summarizes the Trafford Integration Story, which details the progress and challenges of integrating health services in Trafford, England over 15 months. It describes three phases: 1) planning from 2008-2010, 2) implementation from 2010-2011, and 3) future challenges. Key accomplishments include developing an integrated care strategy, establishing governance structures like the clinical board and multi-disciplinary panels, and implementing work streams like one focused on end of life care. Ongoing challenges include engaging stakeholders, developing the integrated care organization business plan, and continuing system redesign.
Peter Smith: Allocating health care budgets to general practicesNuffield Trust
The document discusses the development of the Person-based Resource Allocation (PBRA) model for allocating healthcare budgets to general practices in England based on individual patient data and characteristics. It outlines the principles and variables used in the PBRA models to predict individual and practice healthcare expenditures. The document also examines issues around implementing hard budget constraints for practices and potential risk management strategies.
Jesús de Los Milagros, Templo de San José 2010Claudio Obregón
El documento describe la procesión del Domingo de Ramos en el Templo de San José en Guatemala. Las calles se preparan con alfombras para dar la bienvenida a Jesús. La procesión incluye "romanos", cucuruchos, Jesús de los Milagros y la Virgen de Dolores. La procesión dura 18 horas y concluye entrada a la iglesia a la 1 de la mañana.
complication of myocardial infarction,There are some complications in myocardial infarction , a disease resulting from complications of myocardial infarction can be very dangerous because it can lead to cardiogenic shock
Bahco is launching a complete range of hydraulic lifting equipment for vehicles and heavy parts. The range includes a foldable crane, engine slings, stands, and transmission jacks. It also offers trolley jacks, air hydraulic jacks, jack stands, and other important equipment such as a hydraulic wheel dolly and ram sets. The Bahco tools enable quick, comfortable, and safe working.
This document summarizes government spending by department from 2007-2008, with the largest allocations going to social security (27%) and health (16%). Planned spending increases from 2008-2011 are also shown, with the largest increases for health, social security, and education. The document then discusses reasons for optimism in the NHS, including improved quality of services, but also reasons for concern like increasing demand, a tighter financial regime, and rising prescription drug costs. Areas for scrutiny of the NHS are identified as budget areas, productivity, and outcomes. The document argues for actions that motivate at multiple levels from individual practitioners to centralized policy through guidance, financial incentives, and infrastructure like IT.
Professor Peter Littlejohns: NICE current practice and future directionNuffield Trust
NICE currently provides national guidance on health promotion and disease prevention and treatment. It issues guidance in public health, health technologies, and clinical practice based on comprehensive evidence reviews and expert input. NICE will take on responsibility for social care guidance in 2012. Quality standards are being developed to define high quality care and will include 150 topics over 5 years. NICE's guidance and quality standards will play a key role in the new NHS Outcomes Framework and in determining provider payment mechanisms. This expanded role may impact national and local priority setting.
The document summarizes the Trafford Integration Story, which details the progress and challenges of integrating health services in Trafford, England over 15 months. It describes three phases: 1) planning from 2008-2010, 2) implementation from 2010-2011, and 3) future challenges. Key accomplishments include developing an integrated care strategy, establishing governance structures like the clinical board and multi-disciplinary panels, and implementing work streams like one focused on end of life care. Ongoing challenges include engaging stakeholders, developing the integrated care organization business plan, and continuing system redesign.
Peter Smith: Allocating health care budgets to general practicesNuffield Trust
The document discusses the development of the Person-based Resource Allocation (PBRA) model for allocating healthcare budgets to general practices in England based on individual patient data and characteristics. It outlines the principles and variables used in the PBRA models to predict individual and practice healthcare expenditures. The document also examines issues around implementing hard budget constraints for practices and potential risk management strategies.
Dr Jennifer Dixon: Competition between providersNuffield Trust
Competition in healthcare provision in England has increased through policies introducing market mechanisms since 2002. While independent sector activity makes up a small percentage of overall NHS care, research finds competition is associated with reduced mortality, especially for heart attacks. Competition may also reduce waiting times. Primary and community care is seeing more competitive tendering, with many contracts awarded to independent providers. Further evidence is still needed on the impacts of competition and potential mergers on quality, costs and regulation of different provider models.
Professor Enthoven: Integrated delivery systemsNuffield Trust
The document discusses integrated delivery systems and their key characteristics. Integrated systems have shared values and goals, aligned financial incentives through a common revenue stream, physician leadership, and a management structure. They provide comprehensive medical records, shared practice guidelines, and seek to provide most or all of a patient's care within the system in a patient-centered, team-based approach. The benefits of integrated systems include improved health outcomes, more efficient resource use, better coordination of care across settings, and a focus on preventive health. However, integrated systems remain relatively uncommon in the U.S. due to historical resistance and lack of incentives within the traditional fragmented system.
Anita Charlesworth: Spending on Health 2011-2015Nuffield Trust
The document summarizes government spending plans and health spending in the UK from 2010-2015. It finds that overall health funding is increasing by an average of 0.1% per year over this period. However, it also notes that annual real terms growth in public health spending needs to be around 2% just to maintain current services, representing a significant efficiency challenge. It outlines some strategies for improving efficiency in the NHS, including the Quality, Innovation, Productivity and Prevention program which aims to achieve over £3 billion in annual productivity savings through various means.
Dr Jennifer Dixon: Commissioning and integrated careNuffield Trust
Commissioning and integrated care aims to improve coordination and alignment of incentives across health and social care. Integrated care organizations bring together providers from different sectors to provide seamless, patient-centered care. Emerging models in the UK include integrated primary, community, and secondary care organizations, as well as partnerships between health and social care providers. While evidence on outcomes is still limited, integrated models show promise for improving efficiency and care for patients with complex needs. National policies on payment systems, provider competition, and performance measurement will influence how integrated care continues to evolve in the UK.
1) The study prospectively evaluated women's sexual function and behavior over 24 weeks postpartum based on their delivery method (vaginal without episiotomy, vaginal with episiotomy, instrumental delivery, elective c-section, emergency c-section).
2) Women who delivered vaginally without episiotomy resumed sexual activity sooner (average 4.5 weeks) than those with an episiotomy or instrumental delivery (averages 7.9 and 7.3 weeks).
3) Overall sexual function scores (based on the FSFI questionnaire) improved from 6 to 24 weeks postpartum for all groups but did not significantly differ based on delivery method.
Jo Ellins: Priority setting is everyone’s businessNuffield Trust
- The document discusses different levels of involvement from information to consultation to participation. More complex decisions that require trade-offs may be better suited to participation methods like citizens' juries.
- Factors that can enhance involvement include clear communication, selecting appropriate methods, building trust and relationships, and providing feedback on how views influenced decisions.
- While the public wants their needs met, they prefer participating at a system level rather than decisions affecting individual patients.
Kirk Stapleton: How performance data can influence clinical behaviourNuffield Trust
1) There is significant unexplained variation in Medicare costs per enrollee between different geographic markets, with costs in some markets nearly 300% higher than others.
2) UnitedHealthGroup reviews various programs aimed at influencing clinical behavior through the use of performance data, including organ transplant networks, cardiac data sharing initiatives, and gainsharing programs between providers and hospitals.
3) The organ transplant Centers of Excellence program designates certain medical centers as specialized transplant providers based on meeting quality criteria and economic criteria. This program has led to a 22% reduction in hospital length of stay and a 21% reduction in unnecessary transplants.
David Carson: Primary care in emergency departments (A&E)Nuffield Trust
- Primary care clinicians like GPs can see 10-30% of emergency department cases depending on the setup, with more ambitious targets likely leading to underutilized emergency staff.
- There is variation in how primary care is integrated into emergency departments, with four main models including separate or integrated reception and operations.
- Objectives for including primary care include reducing admissions and wait times, but the emphasis should be on collaboration and providing prompt care to all patients.
- Responsibilities like clinical governance and auditing are sometimes unclear when primary care clinicians see patients in emergency departments.
Helen parker and Naresh Rati: Creating a GP led integrated care organisationNuffield Trust
The document discusses the creation of a "Super Partnership" which would integrate primary and secondary care services within one organization. Key features include a patient list size over 100k served across multiple sites, long term business planning, and integrated specialist services delivered through a central hub. The partnership has grown to include 38k patients currently and aims to expand to 50k by November and 70k by December 2012. Specialist services like rheumatology and dermatology are already being provided. Both opportunities and tensions around further integrating specialist community services through this model are discussed.
Social care and hospital use at the end of lifeNuffield Trust
This document analyzes social care and hospital use at the end of life using data from 3 PCT/LA areas in England. It looks at 16,479 people who died within a one year period, linking their health and social care records. The analysis finds that over 50% of people accessed social care in their last year of life, with rates varying by location and health condition. Social care use, especially low intensity services, increased significantly in the last few months before death. The average cost of services was highest in the last 3-6 months, with inpatient costs inversely related to social care costs.
Leo Lewis & Gareth John: Prism: Predictive risk stratification modelNuffield Trust
Prism is a predictive risk stratification model that uses data from GP practices and hospitals to identify patients at risk of emergency admission. It was piloted in 25 GP practices to evaluate its functionality, usability, usefulness, and accuracy. The evaluation found Prism could help identify at-risk patients, map services, and support workforce and service planning. Next steps include rolling Prism out nationally, further developing the tool based on pilot feedback, and including additional data sources like A&E data. Prism uses a split-file methodology and data flows to pseudonymously link and share individual-level data while protecting patient confidentiality.
La deformación incremental de chapa es un proceso automatizado para fabricar prototipos y series cortas de piezas de chapa sin necesidad de utillajes caros. Se basa en deformar el metal aplicando presión localizada con una herramienta esférica móvil guiada por un sistema CAD/CAM. Esto permite fabricar piezas directamente a partir de diseños 3D para aplicaciones en sectores como aeronáutica, automoción y metalmecánica.
This document discusses the potential impacts of automation on healthcare employment and discusses alternative views beyond job loss. It notes that automation may lead to reconfiguring of healthcare work rather than outright job loss. Examples of existing technologies that have automated tasks in healthcare like pharmacy automation and emerging technologies like decision support systems and personal health tracking are provided. The document advocates that automation could lead to a virtuous cycle in healthcare if it allows workers to focus on tasks that require human skills and judgment.
Evaluation of the Integrated Care and Support Pioneers ProgrammeNuffield Trust
This document summarizes the findings of evaluations of the Integrated Care and Support Pioneers Programme in the UK. The evaluations found that while Pioneers aspired to comprehensive system change, their activities focused more narrowly on initiatives like risk stratification and care coordination teams. Progress was difficult to measure against indicators and Pioneers faced challenges from financial pressures and competing priorities. The evaluations concluded that further integration will be challenging under increasing demands on the health system.
The document discusses lessons learned from the Southwark and Lambeth Integrated Care (SLIC) program in London. Key points:
- SLIC aimed to reduce hospital admissions and care home placements for older adults through risk stratification, holistic assessments, and care management.
- Success required agreement on the problem, dedicated teams, funding shifts to support community care, and leadership development.
- Future programs need a strong business case, co-design with citizens, and a dedicated "engine room" team to drive local transformation.
Effectiveness of the current dominant approach to integrated care in the NHSNuffield Trust
Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
Dr Jennifer Dixon: Competition between providersNuffield Trust
Competition in healthcare provision in England has increased through policies introducing market mechanisms since 2002. While independent sector activity makes up a small percentage of overall NHS care, research finds competition is associated with reduced mortality, especially for heart attacks. Competition may also reduce waiting times. Primary and community care is seeing more competitive tendering, with many contracts awarded to independent providers. Further evidence is still needed on the impacts of competition and potential mergers on quality, costs and regulation of different provider models.
Professor Enthoven: Integrated delivery systemsNuffield Trust
The document discusses integrated delivery systems and their key characteristics. Integrated systems have shared values and goals, aligned financial incentives through a common revenue stream, physician leadership, and a management structure. They provide comprehensive medical records, shared practice guidelines, and seek to provide most or all of a patient's care within the system in a patient-centered, team-based approach. The benefits of integrated systems include improved health outcomes, more efficient resource use, better coordination of care across settings, and a focus on preventive health. However, integrated systems remain relatively uncommon in the U.S. due to historical resistance and lack of incentives within the traditional fragmented system.
Anita Charlesworth: Spending on Health 2011-2015Nuffield Trust
The document summarizes government spending plans and health spending in the UK from 2010-2015. It finds that overall health funding is increasing by an average of 0.1% per year over this period. However, it also notes that annual real terms growth in public health spending needs to be around 2% just to maintain current services, representing a significant efficiency challenge. It outlines some strategies for improving efficiency in the NHS, including the Quality, Innovation, Productivity and Prevention program which aims to achieve over £3 billion in annual productivity savings through various means.
Dr Jennifer Dixon: Commissioning and integrated careNuffield Trust
Commissioning and integrated care aims to improve coordination and alignment of incentives across health and social care. Integrated care organizations bring together providers from different sectors to provide seamless, patient-centered care. Emerging models in the UK include integrated primary, community, and secondary care organizations, as well as partnerships between health and social care providers. While evidence on outcomes is still limited, integrated models show promise for improving efficiency and care for patients with complex needs. National policies on payment systems, provider competition, and performance measurement will influence how integrated care continues to evolve in the UK.
1) The study prospectively evaluated women's sexual function and behavior over 24 weeks postpartum based on their delivery method (vaginal without episiotomy, vaginal with episiotomy, instrumental delivery, elective c-section, emergency c-section).
2) Women who delivered vaginally without episiotomy resumed sexual activity sooner (average 4.5 weeks) than those with an episiotomy or instrumental delivery (averages 7.9 and 7.3 weeks).
3) Overall sexual function scores (based on the FSFI questionnaire) improved from 6 to 24 weeks postpartum for all groups but did not significantly differ based on delivery method.
Jo Ellins: Priority setting is everyone’s businessNuffield Trust
- The document discusses different levels of involvement from information to consultation to participation. More complex decisions that require trade-offs may be better suited to participation methods like citizens' juries.
- Factors that can enhance involvement include clear communication, selecting appropriate methods, building trust and relationships, and providing feedback on how views influenced decisions.
- While the public wants their needs met, they prefer participating at a system level rather than decisions affecting individual patients.
Kirk Stapleton: How performance data can influence clinical behaviourNuffield Trust
1) There is significant unexplained variation in Medicare costs per enrollee between different geographic markets, with costs in some markets nearly 300% higher than others.
2) UnitedHealthGroup reviews various programs aimed at influencing clinical behavior through the use of performance data, including organ transplant networks, cardiac data sharing initiatives, and gainsharing programs between providers and hospitals.
3) The organ transplant Centers of Excellence program designates certain medical centers as specialized transplant providers based on meeting quality criteria and economic criteria. This program has led to a 22% reduction in hospital length of stay and a 21% reduction in unnecessary transplants.
David Carson: Primary care in emergency departments (A&E)Nuffield Trust
- Primary care clinicians like GPs can see 10-30% of emergency department cases depending on the setup, with more ambitious targets likely leading to underutilized emergency staff.
- There is variation in how primary care is integrated into emergency departments, with four main models including separate or integrated reception and operations.
- Objectives for including primary care include reducing admissions and wait times, but the emphasis should be on collaboration and providing prompt care to all patients.
- Responsibilities like clinical governance and auditing are sometimes unclear when primary care clinicians see patients in emergency departments.
Helen parker and Naresh Rati: Creating a GP led integrated care organisationNuffield Trust
The document discusses the creation of a "Super Partnership" which would integrate primary and secondary care services within one organization. Key features include a patient list size over 100k served across multiple sites, long term business planning, and integrated specialist services delivered through a central hub. The partnership has grown to include 38k patients currently and aims to expand to 50k by November and 70k by December 2012. Specialist services like rheumatology and dermatology are already being provided. Both opportunities and tensions around further integrating specialist community services through this model are discussed.
Social care and hospital use at the end of lifeNuffield Trust
This document analyzes social care and hospital use at the end of life using data from 3 PCT/LA areas in England. It looks at 16,479 people who died within a one year period, linking their health and social care records. The analysis finds that over 50% of people accessed social care in their last year of life, with rates varying by location and health condition. Social care use, especially low intensity services, increased significantly in the last few months before death. The average cost of services was highest in the last 3-6 months, with inpatient costs inversely related to social care costs.
Leo Lewis & Gareth John: Prism: Predictive risk stratification modelNuffield Trust
Prism is a predictive risk stratification model that uses data from GP practices and hospitals to identify patients at risk of emergency admission. It was piloted in 25 GP practices to evaluate its functionality, usability, usefulness, and accuracy. The evaluation found Prism could help identify at-risk patients, map services, and support workforce and service planning. Next steps include rolling Prism out nationally, further developing the tool based on pilot feedback, and including additional data sources like A&E data. Prism uses a split-file methodology and data flows to pseudonymously link and share individual-level data while protecting patient confidentiality.
La deformación incremental de chapa es un proceso automatizado para fabricar prototipos y series cortas de piezas de chapa sin necesidad de utillajes caros. Se basa en deformar el metal aplicando presión localizada con una herramienta esférica móvil guiada por un sistema CAD/CAM. Esto permite fabricar piezas directamente a partir de diseños 3D para aplicaciones en sectores como aeronáutica, automoción y metalmecánica.
This document discusses the potential impacts of automation on healthcare employment and discusses alternative views beyond job loss. It notes that automation may lead to reconfiguring of healthcare work rather than outright job loss. Examples of existing technologies that have automated tasks in healthcare like pharmacy automation and emerging technologies like decision support systems and personal health tracking are provided. The document advocates that automation could lead to a virtuous cycle in healthcare if it allows workers to focus on tasks that require human skills and judgment.
Evaluation of the Integrated Care and Support Pioneers ProgrammeNuffield Trust
This document summarizes the findings of evaluations of the Integrated Care and Support Pioneers Programme in the UK. The evaluations found that while Pioneers aspired to comprehensive system change, their activities focused more narrowly on initiatives like risk stratification and care coordination teams. Progress was difficult to measure against indicators and Pioneers faced challenges from financial pressures and competing priorities. The evaluations concluded that further integration will be challenging under increasing demands on the health system.
The document discusses lessons learned from the Southwark and Lambeth Integrated Care (SLIC) program in London. Key points:
- SLIC aimed to reduce hospital admissions and care home placements for older adults through risk stratification, holistic assessments, and care management.
- Success required agreement on the problem, dedicated teams, funding shifts to support community care, and leadership development.
- Future programs need a strong business case, co-design with citizens, and a dedicated "engine room" team to drive local transformation.
Effectiveness of the current dominant approach to integrated care in the NHSNuffield Trust
Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
Ramani Moonesinghe, Associate National Clinical Director for Elective Care at NHS England, discusses the use of data for monitoring care quality at various levels within the system.
This document discusses using statistical process control (CUSUM) charts to monitor mortality rates at the level of individual general practitioners and health authorities. It describes how CUSUM charts could potentially have detected Harold Shipman, a GP who murdered over 200 patients, by spotting outliers in the routine mortality data. The document also discusses challenges in risk adjusting outcomes to account for differences in patient characteristics and casemix between providers. Accurately adjusting for factors like age, comorbidities, and emergency status is important for fair comparisons but difficult using only administrative data.
Martin Utley, Director of the Clinical Operational Research Unit at University College London, reflects upon his involvement in the launch of specific tools to monitor care quality for paediatric cardiac surgery.
Evaluating new models of care: Improvement Analytics UnitNuffield Trust
Martin Caunt, Improvement Analytics Unit Project Director and NHS England and Adam Steventon, Director of Data Analytics at The Health Foundation share insights into how they have approached evaluating new models of care.
Lisa Annaly, Head of Provider Analytics at the Care Quality Commission, discusses lessons learned from the CQC as they have worked to monitor care quality over time.
- Real-time monitoring of healthcare services requires defining both a reporting window and data window to accurately capture demand, activity, and wait times.
- Using only a reporting window (e.g. a single month) to request data can result in invalid or misleading performance metrics, as it does not account for patients with long wait times.
- Defining a larger data window that includes all patients requested before the end of the reporting window and reported after the start avoids this problem, but requires a counterintuitive data request.
- Without properly defining both windows, real-time monitoring can provide an inaccurate picture of service performance and falsely suggest the need for more resources.
Monitoring quality of care: making the most of dataNuffield Trust
Chris Sherlaw-Johnson, Senior Research Analyst at the Nuffield Trust, introduced the Monitoring quality of care conference and gives an overview of some of the approaches that we've been using at the Trust to identify where care quality has been improving, especially for frail and older people.
Providing actionable healthcare analytics at scale: Insights from the Nationa...Nuffield Trust
Christopher Boulton, Falls and Fragility Fracture Audit Programme Manager at the Royal College of Physicians and Rob Wakeman, Clinical Lead for Orthopaedic Surgery at the National Hip Fracture Database talk about what they have learned by analysing the national hip fracture database.
Providing actionable healthcare analytics at scale: A perspective from stroke...Nuffield Trust
Benjamin Bray, Research Director and the Sentinel Stroke National Audit Programme, presents at the Monitoring quality of care conference about stroke care analytics.
New Models of General Practice: Practical and policy lessonsNuffield Trust
Nuffield Trust policy researchers Rebecca Rosen and Stephanie Kumpunen present findings from our upcoming report on large scale general practice models.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
4. Angus Demographics
• Total population 109,320
• Lower than Scottish average population
of working age
• Higher life expectancy in both men and
women
• 0.8% ethnic minority population
• All cause mortality and heart disease
mortality lower that Scottish average and
cancer mortality amongst lowest in
Scotland.
5. Demographics (continued)
• Proportion of population hospitalised
for alcohol or drug related causes
amongst lowest in Scotland
• Significantly lower rate of acute
admissions
• Lower levels of homelessness
• Lower levels of deprivation
(Source: Scot PHO Health & Wellbeing Profile, 2008)
8. The Angus Journey in Complex Care
Management: Step One
•Preliminary studies
within general
practices in 2006,
reviewing complex
care pts on basis of
Uniquecare criteria
9. Key Findings from Preliminary
Studies
• Patients identified through this process all
deemed as complex by professionals
involved
• Patients were not high users of
unscheduled care
• All patients proactively managed within
general practice, with impact of QoF
evident
10. • Recurring themes in those who did
have > unscheduled care ( COPD,
mental health and/or alcohol issues)
• Issues in entire adult population, not
particular to older age groups
• Key issues related to coordination of
services between primary and
secondary care
11. Uniquecare Criteria vs SPARRA
• Scottish Patients at Risk of Readmission
and Admission identified fewer pts than
Uniquecare approach (focussed on >65’s)
• 40% pts on SPARRA list had been
identified by initial approach
• 27% pts on SPARRA but not in initial
approach had died
• Of remaining 33% pts on SPARRA but
not in initial approach, renal issues was a
predominant feature. Implications of QoF
coding also noted
12. Uniquecare vs LA Care
Management
• Small numbers receiving complex care
packages within LA
• 17% pts with complex care packages <65
yrs, 73% >65 years.
• Many had just one long term condition,
with an impact on ability to self manage
• Stroke a predominant feature
13. Heart Disease
Mental Health
Circulatory
Ill Defined
Digestive
Cancer
Injuries
COPD
Other
Resp
Townhead Practice
Patients with 70-90% Risk of Admission
Springfield MC - West
Springfield MC - East
Ravenswood Surgery
Monifieth HC
Lour Rd Gp Practice
Kirriemuir HC
Friockheim HC
Edzell HC
Castlegait Surgery
Parkview
The Angus Journey: Step 2
Brechin HC
Arbroath MC
Annat Bank Practice
Academy MC
Abbey HC
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Patient Numbers
Early SPARRA
Total Number of Patients at Risk of Admission
Townhead Practice
Springfield MC - West
Springfield MC - East
Ravenswood Surgery
Monifieth HC
Lour Rd Gp Practice
Kirriemuir HC
Friockheim HC
Edzell HC
Castlegait Surgery
Parkview
Brechin HC
Arbroath MC
Annat Bank Practice
Academy MC
Abbey HC
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Pop
As a % of Practice
14. The Angus Journey: Step 3
Gold Standards Framework for LTC’s
in General Practice
•The Gold Standards Framework (GSF) is a
‘systematic evidence based approach to
optimising the care for patients nearing the end
of life in the community’.
•The focus of GSF is to improve care in the
community by optimising the local primary care
team’s provision, so that more patients are
enabled to live and die where they choose, and
un-needed hospital admissions are avoided.
15. 3 processes of GSF include:
• Identification of patients in need of
palliative/supportive care
• Assessment of needs, symptoms,
preferences etc
• Care planning and delivery.
16. 5 GSF Goals:
• Good symptom control.
• Patients enabled to live and die well in
their place of choice.
• Better advanced care, planning,
information, less fear, fewer crisis/hospital
admissions.
• Well supported and informed carers.
• Staff confidence, communication and co-
working.
17. Aims of GSF Project for LTC’s
•To explore the impact
introduction of the Gold
Standards Framework (GSF)
in the management of
complex Long Term
Conditions Management,
within primary care, had on
patient outcomes and staff
satisfaction
18. Pilot Details
• Based in Academy Medical Centre,
Forfar
• Large teaching practice
• Practice population 10990
• 81% being under the age of 65
• 19% over the age of 65.
• Multi-agency participation
• 2008-9
19. ‘Top Ten’: Identification
• Identified through SPARRA and Tayside
Predictive Tool
Or
• Recommendation of patients by core team
member and approval by others
• Any adult eligible for inclusion and the
project did not focus exclusively on any
given areas of priority from a disease, multi-
disease or age perspective
20. Project Plan
• Education of staff re aims of complex care
management, & GSF
• Core list of ‘top ten’ agreed by core team
• Inclusion in supportive care register
• Monthly meets aimed to improve the flow of
information, advance care planning and
measurement/audit of outcomes
• Shared care planning
21. Our Top Ten!
Pati Age Long Term How Services at New Emergency Emergency
ent Conditions Identified? Outset of services or Care Care
No (List all) Sparra/PEONY Project changes to Contacts Contacts
/ eg GP, DN care as a 6/12 pre-pilot 6/12 during
Team/Other result of pilot
pilot
Eg 85 CHD District Nurse DN Care 10 5
Diabetes Not on GP management
SPARRA
1 69 DIABETIC PN PN 3 0
HYPERTENSI
ON
2 61 CHD CM CM+DN 0 0 and no
MS GP visits
3 79 COPD SPARRA PRACTICE 2 2
CKD
4 68 COPD DN ALL DIED DIED DIED
CKD
5 74 DIABETIC DN DN + CM 2 2
HYPERTENSI
ON
COPD
6 83 HYPERTENSI DN DN 0 0 and 0
ON OOH
CHD callouts
COPD
CKD
22. Patie Ag Long Term How Identified? Services at New services Emergency Emergency
nt e Conditions Sparra/PEONY/ Outset of or changes to Care Contacts Care
No (List all) Team/Other Project care as a result 6/12 pre-pilot Contacts
eg GP, DN of pilot 6/12 during
pilot
7 59 DIABETIC DN DN PN 0 0 and 0 OOH
CHD callouts
CKD
8 82 HYPERTENSION CM CM + DN 1 0 and 0 OOH
CHD callouts
9 67 HYPERTENSION CM CM 3 0
MS
10 78 CHD SPARRA CM + 2 0 and 0 OOH
PRACTICE callouts
TOTALS 13 4
23. Q1. In your opinion, has this project improved
communication between the professionals involved
in the care of the patients included?
0%
Yes
No
DNA Q2. Has your understanding of the roles
100% performed by other professionals involved in the
project improved as a result of this project?
14%
Yes
14%
No
DNA
72%
Q11. Do you feel that this project has been a
success?
0%
Yes
No
DNA
100%
24. Staff Views on Most Effective Means
of Pt Identification
• ‘Case discussion. SPARRA chose patients that were
deceased or had very little input from both social work and
health’
• ‘I decided to use the SPARRA data as a tool for identifying my
patient. This proved ineffective due to its basis on
retrospective data and in fact my patient had no admissions or
GP contacts during the duration of the pilot despite multiple
co-morbidities and numerous preceding issues, which required
MDT work.’
• ‘SPARRA search and individual proposal of suitable patients.
Some patients we felt who would be suitable for inclusion did
not appear on the electronic search’
• ‘Individual/team knowledge’
• ‘Best “mechanism” for patient identification was without doubt
the DNs!’
25. The Angus Journey: Step 4
• Cross reference of SPARRA lists with
existing care/case management
services, to aid dissemination of
information/use of data
• General Practice : Quality &
Outcomes Framework +
• COPD Anticipatory Care Project
26. COPD Anticipatory Care Project
All COPD patients All COPD patients Clinical agreement
registered with registered with Montrose of suitability of any
Montrose practice practice with COPD other COPD
with COPD related
identified by SPARRA as patient registered
admission during
period of pilot being at risk of recurrent with Montrose
admission practice
Agreement of inclusion of patient in anticipatory care project by
clinicians with links with Palliative Care DES and advice from other
agencies where appropriate.
(Maximum caseload to be agreed, approx 15 patients at any given
time)
1. Holistic assessment by COPD nurses offered to all patients identified
through SPARRA or team, who have not had a COPD assessment by
housebound service within last 6 months.
2. In addition to normal care, all COPD related discharges will receive a
joint assessment visit by DN and COPD housebound nurse on the
next working day after discharge (even where ESD in place).
1Care plans to be developed, with a focus on patient goal setting and self management
education, using the BLF COPD Self-Management Plan in all cases, and Palliative Care
DES information if appropriate.
2 Anticipatory care planning for all patients, including recording of information in OOH
systems.
3 Urgent referral to pulmonary rehabilitation if appropriate.
4 Standardised community and COPD housebound nursing documentation to be used.
5 Ongoing implementation of care plan, with minimum of 3/12 review.
27. Criteria Pt1* Pt2 Pt3* Pt4* Pt5*
Smoking status
Smoker Smoker Smoker
Immunisation status
Assessment of MRC 3 3 2 2 3
dyspnoea score
Medication review
Inhaler technique
Education
Self-management
BLF booklet BLF booklet BLF booklet BLF booklet BLF booklet
Co-morbidities
Assessment of
psychological co-
morbidity
Anticipatory care
planning on Taycare on Taycare on Taycare on Taycare on Taycare
Others Taxicard Referral for anxiety mgt OT referral Meds changes Smoking cessation
Rescue meds New devices Exercises Devices changes advice
Exercise advice Referral to pulmonary Rescue meds New devices
rehab CMT referral Meds changes
Exercise on referral
Referral to pulmonary
rehab
Status at end of On DN service books Admitted onto DN Admitted onto DN Discharged Discharged back to PN
project prior to project. Care caseload & COPD caseload & COPD
ongoing Housebound service Housebound service
28. Pt6* Pt7 Pt8* Pt9
Smoking status
Smoker
Immunisation Status
Assessment of MRC 4/5 3 5 4
Dyspnoea Score
Medication Review
Inhaler Technique
Education
Self Management
BLF booklet BLF booklet BLF booklet BLF booklet
Co-morbidities
Assessment of
Psychological Co-
morbidity
Anticipatory Care
Planning on Taycare on Taycare on Taycare on Taycare
Others Rescue meds Rescue meds Meds changed Flu vac
Continence assessment Flu vac Rescue meds Referral to pulmonary
Oral thrush identified and tx, Inhaler technique rehabilitation
and oral hygiene taught Dental referral Rescue meds
Commenced antidepressants Referral to pulmonary rehab
Reliant of nebulisers
Taught re use of
aerochamber
Portable O2 arranged for
holidays
Status at End of Project On DN service books prior to Discharged back to PN On DN service books prior to Admitted onto DN caseload
project. Care ongoing project. Care ongoing & COPD
Housebound service
29. General Observations Regarding
SPARRA
•Accuracy of data sources
•1/4rly report limiting
•? Finding patients too late?
•? Disadvantaged by lack of GP data feed?
•Variable use of SPARRA data
To effectively implement and evaluate systems
for complex care, we need a tool to effectively
identify those who we can effectively make a
quantitative as well as qualitative impact