1,720,965 research outputs found
The Role of Cardiologists in the Management of Patients with Heart Failure
No full textHeart failure is a complex clinical syndrome with a remarkable impact on health care systems in terms of patients' morbidity and mortality, as well as direct and indirect costs. It is essential to redesign models of care for patients with heart failure that are tailored on personalized health care needs and carried out in the most appropriate setting. There is some debate about the role of cardiologists in the management of patients with heart failure. Indeed, results regarding the inclination of cardiologists' patients to achieve better outcomes are controversial, given the heterogeneity of studies in terms of study design, population, setting and variables considered. The aim of this chapter is to describe and synthesize the current state of knowledge about the role of specialists in the management of patient with heart failure, and to assess whether there is a type of patients for which cardiologists demonstrate the greatest value or a setting of care where they add more benefit
Burden of multimorbidity in relation to age, gender and immigrant status: A cross-sectional study based on administrative data
Full text linkObjectives Many studies have investigated multimorbidity, whose prevalence varies according to settings and data sources. However, few studies on this topic have been conducted in Italy, a country with universal healthcare and one of the most aged populations in the world. The aim of this study was to estimate the prevalence of multimorbidity in a Northern Italian region, to investigate its distribution by age, gender and citizenship and to analyse the correlations of diseases. Design Cross-sectional study based on administrative data. Setting Emilia-Romagna, an Italian region with-1/44.4 million inhabitants, of which almost one-fourth are aged ≥65 years. Participants All adults residing in Emilia-Romagna on 31 December 2012. Hospitalisations, drug prescriptions and contacts with community mental health services from 2003 to 2012 were traced to identify the presence of 17 physical and 9 mental health disorders. Primary and secondary outcome measures Descriptive analysis of differences in the prevalence of multimorbidity in relation to age, gender and citizenship. The correlations of diseases were analysed using exploratory factor analysis. Results The study population included 622 026 men and 751 011women, with a mean age of 66.4 years. Patients with multimorbidity were 33.5% in 75 years and >60% among patients aged ≥90 years; among patients aged ≥65 years, the proportion of multimorbidity was 39.9%. After standardisation by age and gender, multimorbidity was significantly more frequent among Italian citizens than among immigrants. Factor analysis identified 5 multimorbidity patterns: (1) psychiatric disorders, (2) cardiovascular, renal, pulmonary and cerebrovascular diseases, (3) neurological diseases, (4) liver diseases, AIDS/HIV and substance abuse and (5) tumours. Conclusions Multimorbidity was highly prevalent in Emilia-Romagna and strongly associated with age. This finding highlights the need for healthcare providers to adopt individualised care plans and ensure continuity of care
Organisational determinants of adherence to secondary prevention medications after acute myocardial infarction
No full textOBJECTIVES:
to identify organisational determinants of adherence to evidence-based drug treatments after acute myocardial infarction (AMI), under the hypothesis that low adherence is associated with higher mortality and risk of reinfarction. In particular, we investigated the effect of group vs. single handed practice and multi-professional practice characteristics on patients' adherence to polytherapy after AMI.
DESIGN:
retrospective cohort study.
SETTING AND PARTICIPANTS:
residents in the Local Health Authority of Bologna (Italy) who were discharged from any Italian hospital between 2008 and 2011 with a diagnosis of AMI, and followed-up for a year.
MAIN OUTCOME MEASURES:
adherence to at least three out of the four drug therapies recommended for secondary prevention of AMI (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, antiplatelet agents, statins). Patients who had at least 80% of days of follow-up covered by drug doses were considered adherent.
RESULTS:
of the 4,828 post-AMI patients, 31.6% were adherent to polytherapy. General practice characteristics were unrelated to adherence, whereas discharge from cardiology hospital wards was significantly associated with higher patients' adherence (OR 1.97; 95%CI 1.56-2.48).
CONCLUSION:
general practice organisational models are not associated with higher adherence to evidence-based medications after AMI, whereas cardiologists seem to play a key role in improving patient adherence to polytherapy. Healthcare delivery models should be designed; in them, general practitioners are responsible for the provision of patient-centred care pathways and for care co-ordination with other primary care professionals and specialists, and take an advocacy role for the patient when needed
Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis
Full text linkBackground and objectives Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients’ heterogeneity is rarely taken into account. The aim of this study is to stratify patients with type-2 diabetes into homogeneous cost groups based on demographic and clinical characteristics. Methods We conducted a retrospective cost of illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis. Results The study population consists of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified 10 patient subgroups with different costs, ranging from a median of € 483 to € 39,578. The 2 subgroups with highest costs comprised dialysis patients and the largest subgroup (57.9%) comprised patients aged ≥65 years without renal, cardiovascular and cerebrovascular complications. Conclusions Patients’ classification into homogeneous cost subgroups can be used to improve the management and budget allocation for patients with type 2 diabetes
Caratteristiche ed esiti della sindrome coronarica acuta nella popolazione italiana e migrante: uno studio osservazionale basato su dati amministrativi sanitari nella Regione Emilia-Romagna
No full textRAZIONALE. Lo scopo dello studio è analizzare le caratteristiche e gli esiti dei pazienti con sindrome coronarica acuta (SCA) in relazione al paese di origine. MATERIALI E METODI. La popolazione in studio comprende i residenti in Emilia-Romagna con un ricovero per infarto miocardico acuto (con [STEMI] e senza sopraslivellamento del tratto ST) tra il 2012 e il 2014. Sono stati indagati cinque esiti: procedura coronarica percutanea (PCI) entro 2 giorni dallo STEMI, mortalità a 30 giorni, mortalità a 1 anno, eventi cardio-cerebrovascolari avversi maggiori a 1 anno (MACCE) e aderenza alla terapia post-infarto. Gli esiti sono stati valutati in funzione della cittadinanza, al netto di potenziali confondenti (rilevati al ricovero indice e nelle ospedalizzazioni dei 2 anni precedenti) con modelli di regressione multipla. RISULTATI. Dei 23 884 soggetti in studio, 647 (2.7%) sono migranti. L’età media di insorgenza della SCA è più bassa tra i migranti (56 anni) rispetto agli italiani (73 anni). La mortalità a 30 giorni dal ricovero per SCA è pari al 9.6% mentre le percentuali di mortalità e MACCE a 1 anno sono rispettivamente del 19.8% e 20.8%. Il 63.2% dei soggetti con STEMI viene sottoposto a PCI e i pazienti aderenti alla terapia post-infarto sono il 31.0%. Rispetto agli italiani, gli africani e gli asiatici hanno una probabilità inferiore di essere sottoposti a PCI e sono significativamente meno aderenti alla terapia. Non si rilevano differenze significative nei tassi di mortalità, mentre gli asiatici hanno un rischio più alto del 62% di incorrere in un MACCE. CONCLUSIONI. I cittadini migranti con SCA sono molto più giovani, vengono sottoposti meno frequentemente a procedure invasive e sono meno aderenti alle terapie farmacologiche rispetto agli italiani. Sono necessari ulteriori studi per valutare i determinanti di tali differenze e sviluppare modelli organizzativi che tengano conto delle esigenze specifiche di questi pazienti.Background. The aim of this study was to analyze the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. Methods. The study population included patients living in the Emilia-Romagna Region and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (with [STEMI] and without ST-elevation). The study outcomes were: percutaneous coronary intervention (PCI) within 48 hours of admission for STEMI, 30-day all-cause mortality, 1-year all-cause mortality, 1-year major adverse cardiac and cerebrovascular events (MACCE), and adherence to post-infarction medications. The relationship between outcomes and citizenship was investigated using multiple regression analysis. Potential confounders were identified among diagnoses recorded in the index hospitalization and in all hospitalizations occurring 2 years prior to the index hospitalization. Results. Of the 23 884 study patients, 647 (2.7%) were non-Italians. The mean age of onset of ACS was lower among immigrants (56 years) than among Italians (73 years). Thirty-day mortality was 9.6% while 1-year mortality and MACCE were 19.8% and 20.8%, respectively. The proportion of PCI within 48 hours was 63.2%, while patients adherent to medications were 31.0%. Compared with Italians, patients from Africa and Asia had a reduced probability of undergoing PCI and were less adherent to medications. Adjusted mortality rates were similar between Italians and immigrants, while patients from Asia had a 62% increased probability of experiencing a MACCE during follow-up. Conclusions. Compared with Italians, immigrant citizens with ACS were younger, less likely to undergo PCI, and less adherent to drug treatment after discharge. Further studies are warranted to identify the determinants of these disparities and to develop organizational models tailored to the specific needs of immigrant patients
Risk-adjustment models for heart failure patients' 30-day mortality and readmission rates: The incremental value of clinical data abstracted from medical charts beyond hospital discharge record
Full text linkBackground: Hospital discharge records (HDRs) are routinely used to assess outcomes of care and to compare hospital performance for heart failure. The advantages of using clinical data from medical charts to improve risk-adjustment models remain controversial. The aim of the present study was to evaluate the additional contribution of clinical variables to HDR-based 30-day mortality and readmission models in patients with heart failure. Methods: This retrospective observational study included all patients residing in the Local Healthcare Authority of Bologna (about 1 million inhabitants) who were discharged in 2012 from one of three hospitals in the area with a diagnosis of heart failure. For each study outcome, we compared the discrimination of the two risk-adjustment models (i.e., HDR-only model and HDR-clinical model) through the area under the ROC curve (AUC). Results: A total of 1145 and 1025 patients were included in the mortality and readmission analyses, respectively. Adding clinical data significantly improved the discrimination of the mortality model (AUC = 0.84 vs. 0.73, p < 0.001), but not the discrimination of the readmission model (AUC = 0.65 vs. 0.63, p = 0.08). Conclusions: We identified clinical variables that significantly improved the discrimination of the HDR-only model for 30-day mortality following heart failure. By contrast, clinical variables made little contribution to the discrimination of the HDR-only model for 30-day readmission
Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: Results from an observational study based on administrative data
Full text linkObjectives To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). Design Retrospective observational study based on administrative data. Setting Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. Participants All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. Primary and secondary outcome measures Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. Results The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/ angiotensin receptor blockers (ACEIs/ARBs), Î2-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or Î2-blockers (â53% and â28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (â28%). Conclusions Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
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