Modelling the balance of care: Impact of an evidence-informed policy on a mental health ecosystem

Major efforts worldwide have been made to provide balanced Mental Health (MH) care. Any integrated MH ecosystem includes hospital and community-based care, highlighting the role of outpatient care in reducing relapses and readmissions. This study aimed (i) to identify potential expert-based causal relationships between inpatient and outpatient care variables, (ii) to assess them by using statistical procedures, and finally (iii) to assess the potential impact of a specific policy enhancing the MH care balance on real ecosystem performance. Causal relationships (Bayesian network) between inpatient and outpatient care variables were defined by expert knowledge and confirmed by using multivariate linear regression (generalized least squares). Based on the Bayesian network and regression results, a decision support system that combines data envelopment analysis, Monte Carlo simulation and fuzzy inference was used to assess the potential impact of the designed policy. As expected, there were strong statistical relationships between outpatient and inpatient care variables, which preliminarily confirmed their potential and a priori causal nature. The global impact of the proposed policy on the ecosystem was positive in terms of efficiency assessment, stability and entropy. To the best of our knowledge, this is the first study that formalized expert-based causal relationships between inpatient and outpatient care variables. These relationships, structured by a Bayesian network, can be used for designing evidence-informed policies trying to balance MH care provision. By integrating causal models and statistical analysis, decision support systems are useful tools to support evidence-informed planning and decision making, as they allow us to predict the potential impact of specific policies on the ecosystem prior to its real application, reducing the risk and considering the population’s needs and scientific findings.

Efficacy of post-inpatient aftercare treatments for anorexia nervosa: a systematic review of randomized controlled trials

Background Early relapse after inpatient treatment is a serious problem in the management of anorexia nervosa (AN). Specialized aftercare interventions have the potential to bridge the gap between inpatient and outpatient care, to prevent relapse and to improve the long-term outcome for patients with AN. Methods Following the guidelines of the PRISMA statement, we conducted a systematic review, synthesizing the evidence from randomized-controlled trials (RCTs) investigating the efficacy of post-inpatient aftercare treatments for AN. Results Our search resulted in seven RCTs and three registered ongoing trials. Pharmacotherapy and low-threshold guided self-help have limited uptake and high dropout. Novel mobile guided self-help approaches seem promising due to high patient satisfaction, but their efficacy has yet to be investigated in larger trials. Cognitive-behavior psychotherapy may be beneficial in delaying relapse, but evidence is based on a single study. Conclusion Only a limited number of RCTs investigating aftercare interventions for patients with AN is available. There is no clear evidence favoring any one specific approach for post-inpatient aftercare in adult patients with AN. The field faces many challenges which generally affect intervention research in AN. A specific issue is how to increase uptake of and reduce dropout from aftercare interventions. This calls for better tailoring of interventions to patient needs and the integration of patient perspectives into treatment. Intensified research and care efforts are needed to address the problem of recurrent relapse after intensive inpatient treatment for AN and to eventually improve prognosis for this eating disorder.

Impact of the COVID-19 Pandemic on Radiology in Inpatient and Outpatient Care in Germany: A Nationwide Survey Regarding the First and Second Wave

Objectives To find out the opinion of radiological inpatient and outpatient medical staff regarding the measures taken in relation to the COVID-19 pandemic during the first and second waves and to identify the measures that are still perceived as needing improvement. Materials and Methods We conducted an anonymous online survey among more than 10 000 radiologists/technicians in Germany from January 5 to January 31, 2021. A total of 862 responses (head physicians, n = 225 [inpatient doctors, n = 138; outpatient doctors, n = 84; N/A, n = 3]; radiologic personnel, n = 637 [inpatient doctor, n = 303; outpatient doctor, n = 50; inpatient technician, n = 217; outpatient technician, n = 26; N/A, n = 41]) were received. Questions of approximation, yes/no questions, and Likert scales were used. Results During the first/second wave, 70 % (86/123)/43 % (45/104) of inpatient and 26 % (17/66)/10 % (5/52) of outpatient head physicians agreed that they received financial support from the authorities but the majority rated the financial support as insufficient. During the first and second wave, 33 % (8/24) and 80 % (16/20) of outpatient technicians agreed that they were adequately provided with personal protective equipment. The perceived lack of personal protective equipment improved for all participants during the second wave. Inpatient [outpatient] technicians perceived an increased workload in the first and second wave: 72 % (142/198) [79 % (19/24)] and 84 % (146/174) [80 % (16/20)]. Conclusion: Technicians seem increasingly negatively affected by the COVID-19 pandemic in Germany. Financial support by the competent authorities seems to be in need of improvement. Key Points: Citation Format

Unbalanced Treatment Costs of Breast Cancer in China: Implications From the Direct Costs of Inpatient and Outpatient Care in Liaoning Province

Background: The increasing incidence of breast cancer and its financial burden highlights the need for controlling treatment costs. This study aimed to assess the direct costs of inpatient and outpatient care for breast cancer patients in Liaoning Province to provide a policy reference for cost containment. Methods: Based on the System of Health Accounts 2011 (SHA 2011), systematic data collection was conducted via multistage stratified cluster random sampling. A total of 1160 health institutions, including 83 hospitals, 16 public health institutions, 120 primary health institutions, and 941 outpatient institutions were enrolled in 2017. A database was established containing 20 035 patient-level medical records from the information system of these institutions. Curative care expenditure (CCE)was calculated, and generalized linear modeling was performed to determine cost-related factors. Results: In 2017, the CCE for breast cancer was approximately CNY 830.19 million (US$122.96 million) in Liaoning province (0.7% of the total health expenditure and 9.9% of cancer-related healthcare costs). Inpatient care costs were estimated to be CNY 617.27 million (US$91.42 million), accounting for 74.4% of the CCE for breast cancer, almost three times as large as outpatient costs (25.6%). The average inpatient and outpatient costs for breast cancer were estimated to be CNY 12 108 (US$1793) and CNY 829 (US$123) per visit. Medication cost was the main cost driver, which comprised 84.0% of the average outpatient cost and 37.2% of the mean inpatient cost. Conclusion: Breast cancer imposes a large economic burden on patients and the social health insurance system. Results show an irrational cost pattern of inpatient and outpatient services, with patients relying excessively on inpatient services for treatment. Promoting outpatient care whenever relevant is conducive to cost containment and rational utilization of resources.

Social, Legal and Economic Implications for the Implementation of an Intelligent Wound Plaster in Outpatient Care

Background: The care of chronic wounds is one of the core tasks of inpatient and outpatient care. The correct timing of changes has a significant impact on the positive course of wound healing. The VulnusMON project developed an intelligent wound plaster to determine the optimum time to change the plaster in hospital. Against the background of implementing the solution also in the outpatient sector, this article focuses on the following research questions: What is the legal framework for wound care in outpatient care? What are the differences in wound care between inpatient and outpatient care? What obstacles and barriers arise for the VulnusMON project when it is implemented in the outpatient sector? Can initial economic estimates be made for the transfer to the outpatient sector?Method: Due to the complexity of the different research questions, a mixed method design was used. The qualitative part of the study includes both focus groups and expert interviews. As part of the quantitative analysis, a data set on outpatient wound care was analyzed (n = 463).Results: In summary, it can be stated that the project VulnusMON and its intelligent wound plaster, which aims to determine the ideal time to change a wound plaster is viewed very positively by the professionals. However, there are a number of barriers that inhibit the potential transfer of the new digital solution to the outpatient setting. From an economic point of view, implementation in the outpatient sector makes sense, as travel times can be reduced. However, the study also points out important social implications, that pose several challenges for the actual transfer of the plaster to the outpatient sector.

Long-term improvement of quality of life in patients with breast cancer: supporting patient-physician communication by an electronic tool for inpatient and outpatient care

Purpose The effectiveness of a pathway with quality of life (QoL) diagnosis and therapy has been already demonstrated in an earlier randomized trial (RCT) in patients with breast cancer. We refined the pathway by developing and evaluating an electronic tool for QoL assessment in routine inpatient and outpatient care. Methods In a single-arm study, patients with breast cancer with surgical treatment in two German hospitals were enrolled. QoL (EORTC QLQ-C30, QLQ-BR23) was measured with an electronic tool after surgery and during aftercare in outpatient medical practices (3, 6, 9, 12, 18, and 24 months) so that results (QoL-profile) were available immediately. Feedback by patients and physicians was analyzed to evaluate feasibility and impact on patient-physician communication. Results Between May 2016 and July 2018, 56 patients were enrolled. Physicians evaluated the QoL pathway as feasible. Patients whose physician regularly discussed QoL-profiles with them reported significantly more often that their specific needs were cared for (p < .001) and that their physician had found the right treatment strategy for these needs (p < .001) compared with patients whose doctor never/rarely discussed QoL-profiles. The latter significantly more often had no benefit from QoL assessments (p < .001). Conclusion The QoL pathway with electronic QoL assessments is feasible for inpatient and outpatient care. QoL results should be discussed directly with the patient. Clinical trial information NCT04334096, date of registration 06.04.2020

Use of telemedicine by practising allergists before and during the SARS-CoV-2 pandemic

Summary Background The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic presented unprecedented challenges to both inpatient and outpatient care. In order to maintain good care under necessary contact restrictions, especially in the outpatient sector, the use of telemedical applications was demanded and promoted. The exploratory survey among members of the Association of German Allergists (AeDA) was intended to show how these were received among allergists in private practice. Methods The survey was restricted to actively practising members of the AeDA who had previously given their consent to receive such surveys (n = 437). They were invited by email to participate in a survey on the topic of “Telemedicine in everyday clinical practice in allergology”. The survey included quantitative and qualitative questions on the use of telemedicine services before and during the pandemic and was conducted anonymously on the SoSci Survey platform. Participation was possible in the period from June to August 2020. Results In all, 76 specialists with additional qualification in allergology took part in the survey. Of these, 71 completed the full questionnaire. Before the start of the pandemic-related contact restrictions, 46.5% (33/71) stated that they had used telemedicine in their clinical practice. This number increased to 73.2% (52/71) after 31 January 2020. The largest increase (4.3% vs. 15.6%) was seen in the area of video consultations. Furthermore, 43/76 participants can imagine integrating telemedicine services into their daily clinical routine in the future. Conclusion The use of telemedical services, especially video consultations, increased significantly during the SARS-CoV‑2 pandemic in Germany. The majority of respondents perceive the implementation as positive and can imagine continuing to use telemedical methods after the end of the pandemic.

Developing an innovative role for a clinical nurse specialist in structural heart disease services

This article explores a new advanced nursing role within interventional cardiology. The role was jointly developed by the lead consultant and clinical nurse specialist, and has received the first official centre of excellence award in the world. As a result, the service will now deliver expert training programmes taught by the consultant team and specialist nurse. This service was created for patients with mitral valve disease. It has a dedicated and structured pathway, with the patient always at the centre of care. This article introduces the role of nurse second operator in complex valvular intervention, which allows the clinical nurse specialist to be fully involved in the entire patient journey from referral to discharge. The author describes how the role was established and the developments that have been made in the first 3 years of the post. The role encompasses both inpatient and outpatient care in a bespoke, nurse-led service, as well as responsibility for maintaining accurate data collection and adherence to the patient pathway throughout the service. This has facilitated a streamlined and tailored service that strives to deliver high-quality, equitable care to patients across the UK. It is hoped that this will encourage other centres to develop such roles for specialist nurses.

Sexual Harassment by Patients, Clients, and Residents: Investigating Its Prevalence, Frequency and Associations with Impaired Well-Being among Social and Healthcare Workers in Germany

Social and healthcare workers are at high risk of experiencing sexual harassment in the workplace. Although sexual harassment is detrimental to people’s well-being, only a few studies have systematically investigated social and healthcare workers’ experiences of different forms of sexually harassing behaviors by patients, clients, and residents in Germany. This study aimed to address this gap by determining the prevalence rates and frequency of nonverbal, verbal, and physical sexual harassment by patients, clients, and residents against social and healthcare workers. In addition, we examined the associations of sexual harassment with workers’ well-being and described employees’ awareness of offers of organizational support for sexual harassment prevention and aftercare. Data were collected from N = 901 employees working in a total of 61 facilities, including inpatient and outpatient care, psychiatric facilities, hospitals, and facilities for persons with disabilities. While the prevalence, frequency, and predominant forms of sexual harassment differed across sectors, the results indicated that nonverbal, verbal and physical sexual harassment were highly prevalent in social and healthcare work, with both men and women being affected. Furthermore, we found that sexual harassment was positively related to impaired well-being (e.g., depressiveness and psychosomatic complaints). In terms of support offers for sexual harassment prevention and aftercare, we found that approximately one-third of social and healthcare workers were not aware of any offers at their facilities. In addition to highlighting the problem of sexual harassment by patients, clients, and residents in social and healthcare settings, this study provides recommendations for the development of interventions and suggests several avenues for future research.

Surgical Treatment of Early Postpartum Hemorrhage Caused by Lower Uterine Segment Atony

Purpose: Lower uterine segment atony is recently being recognized as one of the major reasons for early postpartum hemorrhage.Methods: We present our experience in surgical treatment of lower uterine segment atony patients that were delivered in our tertiary perinatal center during the 10 years period (2010-2019).Results: This particular study enrolled total number of 29 543 deliveries with 215 cases of early PPH (0,72%). LUSA was diagnosed in 44 cases or in 29,93% in all uterine atony cases. Exploration of the lower uterine segment accompanied by evacuation of the coagula was conducted in 5 cases (11,36%), haemostatic ligation procedures according to authors: Losickaja in 2 cases, Hebisch-Huch in 9 cases, Habek in 5 cases, Hebisch-Huch+Losickaja in 9 cases. Evacuation procedures were combined with ligation techniques in 7 cases, evacuation methods with ligation techniques and balloon tamponade in 2 cases, exploration combined with gauze tamponade in 1 case and ligation procedures with balloon tamponade in 3 cases. According to our results, haemostatic ligation procedures alone or combined with tamponade, have shown to be highly effective in 88,63%. Conclusion: Transvaginal approach for surgical treatment of lower uterine segment atony is accessible, feasible, successful and life saving. It can be easily performed in inpatient and outpatient care settings followed by administration of uterotonics, uterostiptics and tranexamic acid and fluid replacement. All of the above mentioned methods are of great importance in the prevention and treatment of obstetric hemorrhagic shock, development of coagulopathy, multiorgan failure, postpartum hysterectomy and finally vital for fertility preservation.