Brandon Regional Health Authority

Abstract Background Mental health (MH) care often exhibits uneven quality and poor coordination of physical and MH needs, especially for patients with severe mental disorders. This study tests a Population Health Management (PHM) approach to identify patients with severe mental disorders using administrative health databases in Italy and evaluate, manage and monitor care pathways and costs. A second objective explores the feasibility of changing the payment system from fee-for-service to a value-based system (e.g., increased care integration, bundled payments) to introduce performance measures and guide improvement in outcomes. Methods Since diagnosis alone may poorly predict condition severity and needs, we conducted a retrospective observational study on a 9,019-patient cohort assessed in 2018 (30.5% of 29,570 patients with SMDs from three Italian regions) using the Mental Health Clustering Tool (MHCT), developed in the United Kingdom, to stratify patients according to severity and needs, providing a basis for payment for episode of care. Patients were linked (blinded) with retrospective (2014–2017) physical and MH databases to map resource use, care pathways, and assess costs globally and by cluster. Two regions (3,525 patients) provided data for generalized linear model regression to explore determinants of cost variation among clusters and regions. Results Substantial heterogeneity was observed in care organization, resource use and costs across and within 3 Italian regions and 20 clusters. Annual mean costs per patient across regions was €3,925, ranging from €3,101 to €6,501 in the three regions. Some 70% of total costs were for MH services and medications, 37% incurred in dedicated mental health facilities, 33% for MH services and medications noted in physical healthcare databases, and 30% for other conditions. Regression analysis showed comorbidities, resident psychiatric services, and consumption noted in physical health databases have considerable impact on total costs. Conclusions The current MH care system in Italy lacks evidence of coordination of physical and mental health and matching services to patient needs, with high variation between regions. Using available assessment tools and administrative data, implementation of an episodic approach to funding MH could account for differences in disease phase and physical health for patients with SMDs and introduce performance measurement to improve outcomes and provide oversight.

Background: There is a tendency to decrease the intensity of breast cancer treatments, e.g. omitting adjuvant chemotherapy in endocrine-sensitive and HER-2 negative patients. The purpose of this study was to analyse changes in the frequency of the indication of adjuvant chemotherapy and the differences in survival over time for this subtype of breast cancer, with 1–3 positive nodes. Methods: The study was based on descriptive, observational, retrospective, single-institution research between 2004–10 and 2011–18, on endocrine-sensitive, HER-2 negative breast cancer, stage pN1 (1–3 nodes). The analytical tests carried out for a comparison of the frequency of chemotherapy use the chi-square test with Fisher's exact test. Survival data in both periods are presented. Results: A total of 236 patients were included, 66 for the period 2004–10, and 170 for 2011–18. More patients were treated with hormone therapy alone in 2011–18: hormone therapy alone 10/66 (15.20%) for 2004–10, and 83/169 (49.10%) for 2011–18; chemotherapy-hormone therapy 56/66 (84.80%) for 2004–10, and 86/169 (50.90%) for 2011–18 (P = 0.0001). For 2004–10, the 5-year overall survival probability was 100%. For 2011–18 it was 98.20% (95% CI 95.65–100). For 2004-10, 5-year disease free survival (DFS) was 96.9% (95% CI 92.7–101). For 2011–18 it was 87.7% (95% CI 81.8–93.5) (P=0,040). For 2004–10 the 5 year distant relapse free interval was 96.9% (95% CI 92.5–101.2). For 2011–18 it was 93% (95% CI 88.1–97.9) (P=0.312). Conclusion: A decrease in the indication of adjuvant chemotherapy according to the clinical risk is confirmed in endocrine-sensitive, HER-2 negative breast cancer, with 1-3 positive nodes, over the period 2011–18 compared to 2004–10. Based on the results, 5-year DFS is slightly worse in the 2011–18 period.

INTRODUCTION:The systematic evaluation of the quality of medical records is crucial. Nevertheless, even if the improvement of medical records quality represents a priority for every health organization, it might be difficult to realize.This is the first study to assess the efficacy of internal audit as a tool to improve the quality of medical records in hospital setting.METHODS:The program was carried out in a third level teaching hospital. Trained ad hoc evaluation teams carried out two retrospective assessments of quality of medical records using a random sampling strategy. The quality assessment was performed using a 48-items evaluation grid divided into 9 domains: General; Patient Medical History and Physical Examination; Daily Clinical Progress Notes; Daily Nursing Progress Notes; Drug Therapy Chart; Pain Chart; Discharge Summary; Surgery Register; Informed Consent. After the first evaluation of 1.460 medical records, an audit departmental program was set up. The second evaluation was carried out after the internal auditing for 1.402 medical records.RESULTS:Compared to the first analysis, a significant quality amelioration in all the sections of the medical chart was shown with the second analysis, with an increase of all the scores above 50%. The differences found for each section of medical records between the first and second analysis are all significant (p<0.01).CONCLUSIONS:Internal audits are not just measurement activities but a necessary activity to support the organization in achieving its objectives and assessing the quality of clinical care and maintaining high quality professional performance.

Umbilical hernia presents as a bulge at the site of the umbilicus. It is a common finding during routine well-baby visits for the first few months of life. New parents who are not very familiar with this anomaly tend to be very worried when they see the bulge in their infant’s belly button. On the one hand, parents might be concerned with the idea that their child will suffer serious complications from an umbilical hernia, and they wonder if there are be any measures that they should take to avoid complications. It is important to understand the normal embryology and etiology of the umbilical hernia in order to answer these questions and when it is time to refer the patient for surgical evaluation.