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The definition of the role of hospitals and communities in terms of the response to patients’ health care needs is essential in the Lombardy region health-care reform development (LR. 23/2015). The stratification of patients according to clinical severity and care complexity for adequate clinical health care, is achieved by delineating care settings, staff standards, required technical equipment and crucial aspects of clinical pathways. An observational and retrospective study at Manerbio Hospital Internal Medicine Unit (IMU) was carried out to define: i) characteristics of IMU patients; ii) role of IMU physician in management of poly-pathological patients; iii) alternative organizational models. After a Literature review, clinical severity was defined by modifying early warning score, complexity and co-morbidities by cumulative illness rating scale (CIRS) and by intensity of care through care intensity index (IIA). All medical records of patients admitted in the first quarter of 2016 were analyzed. A total of 393 medical records were examined: 199 M/194 F, median age 81 years. Critical patients (requiring continuous monitoring using advanced equipment): 27% of the sample (10% with intensive care transfer criteria). Co-morbidity: between 5 and 6 active diseases for most of the sample; 53% with CIRS between 7 and 12. Elevated care intensity (IIA) was found in 46% of the sample, remaining constant throughout hospital stay. Medium stay: 9.35 days. 27% of IMU patients needs subintensive care. About a quarter of patients has unresolved social problems contributing to acute presentations in the emergency room. Agreement on appropriate links between hospital and community care structures is advisable to reduce hospital stay, adequately responding to patients’ needs.

Background Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. Objective Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. Methods Systematic searches were conducted in five major electronic databases—MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)—to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. Results The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. Conclusions Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.

Despite recommendations from German public health authorities for seasonal influenza immunization, vaccination coverage rates (VCRs) fall short of targets. This study explores gaps in influenza VCRs, focusing on the intensity of outpatient care of adults for whom vaccination is recommended. We conducted a retrospective study based on a large German statutory health insurance claims database provided by GWQ ServicePlus AG. For influenza seasons 2016–2017 to 2022–2023, we examined seasonal VCRs in the adult population differentiated by age, prevalence of chronic conditions, and participation in disease management programs (DMP) or GP-centered care programs. We also explored the relationship between VCRs and physician contact frequency during the vaccination-relevant period from September to February. Seasonal VCRs of individuals aged 60+, for whom influenza vaccination is generally recommended, varied between 34.8 % (2016–2017) and 47.0 % (2020–2021). We observed higher VCRs among individuals with chronic conditions and among individuals who participated in GP-centered care in all age groups. Among adults with DMP-relevant chronic conditions, VCRs were higher for participants than for individuals not participating in 4 out of 5 examined DMPs. VCRs consistently increased with number of GP contacts. In the 60+ group, cross-seasonal average VCRs increased from 24.0 % for individuals with one GP contact to 52.7 % for individuals with five or more GP contacts. However, most unvaccinated individuals with chronic conditions in this age group had 5 or more GP contacts during the vaccination-relevant period. VCRs remain below targets for all investigated groups. Higher VCRs among DMP and GP-centered care participants and patients with multiple GP contacts emphasize the relevance of outpatient care intensity for the vaccination process. However, most unvaccinated individuals with prevalent chronic conditions have frequent contacts with care providers, underlining the need for care providers to routinely assess and discuss the vaccination status of their patients. •Influenza vaccination coverage rates (VCRs) in Germany stay below targets.•Patients with chronic illness and structured care enrollment show highest VCRs.•VCRs increase consistently with more GP and specialist contacts.•Many high-risk patients remain unvaccinated despite frequent physician visits.•Missed opportunities underline need for routine vaccination checks in outpatient care.

Background Early diagnosis of low ejection fraction (EF) remains challenging despite being a treatable condition. This study aimed to evaluate the effectiveness of an electrocardiogram (ECG)-based artificial intelligence (AI)-assisted clinical decision support tool in improving the early diagnosis of low EF among inpatient patients under non-cardiologist care. Methods We conducted a pragmatic randomized controlled trial at an academic medical center in Taiwan. 13,631 inpatient patients were randomized to either the intervention group ( n  = 6,840) receiving AI-generated ECG results or the control group ( n  = 6,791) following standard care. The primary outcome was the incidence of newly diagnosed low EF (≤ 50%) within 30 days following the ECG. Secondary outcomes included echocardiogram utilization rates, positive predictive value for low EF detection, and cardiology consultation rates. Statistical analysis included hazard ratios (HR) with 95% confidence intervals (CI) for time-to-event outcomes and chi-square tests for categorical variables. Results The intervention significantly increased the detection of newly diagnosed low EF in the overall cohort (1.5% vs. 1.1%, HR 1.50, 95% CI: 1.11–2.03, P  = 0.023), with a more pronounced effect among AI-identified high-risk patients (13.0% vs. 8.9%, HR 1.55, 95% CI: 1.08–2.21). While overall echocardiogram utilization remained similar between groups (17.1% vs. 17.3%, HR 1.00, 95% CI: 0.92–1.09), the intervention group demonstrated higher positive predictive value for identifying low EF among patients receiving echocardiogram (34.2% vs. 20.2%, p  < 0.001). Post-hoc analysis revealed increased cardiology consultation rates among high-risk patients in the intervention group (29.3% vs. 23.5%, p  = 0.027). Conclusions Implementation of an AI-ECG algorithm enhanced the early diagnosis of low EF in the inpatient setting, primarily by improving diagnostic efficiency rather than increasing overall healthcare utilization. The tool was particularly effective in identifying high-risk patients who benefited from increased specialist consultation and more targeted diagnostic testing. Trial registration ClinicalTrials.gov Identifier: NCT05117970.

Providing unpaid informal care to someone who is ill or disabled is a common experience in later life. While a supportive and potentially rewarding role, informal care can become a time and emotionally demanding activity, which may hinder older adults’ quality of life. In a context of rising demand for informal carers, we investigated how caregiving states and transitions are linked to overall levels and changes in quality of life, and how the relationship varies according to care intensity and burden. We used fixed effects and change analyses to examine six-wave panel data (2008–2018) from the Swedish Longitudinal Occupational Survey of Health (SLOSH, n = 5076; ages 50–74). The CASP-19 scale is used to assess both positive and negative aspects of older adults’ quality of life. Caregiving was related with lower levels of quality of life in a graded manner, with those providing more weekly hours and reporting greater burden experiencing larger declines. Two-year transitions corresponding to starting, ceasing and continuing care provision were associated with lower levels of quality of life, compared to continuously not caregiving. Starting and ceasing caregiving were associated with negative and positive changes in quality of life score, respectively, suggesting that cessation of care leads to improvements despite persistent lower overall levels of quality of life. Measures to reduce care burden or time spent providing informal care are likely to improve the quality of life of older people.

Background We aimed to study the mortality and intensity of health care in patients with advanced lung cancer who received systemic anti-cancer treatment (SACT) compared with patients who were not eligible for SACT (no-SACT). Methods A retrospective cohort of patients with lung cancer, who were treated at the North Estonia Medical Centre from 2015 to 2017, was linked to population-based health care data from the Estonian Health Insurance Fund. We calculated 14- and 30-day mortality after SACT and used a composite measure of intensity of care, comprised from the following: emergency department visit, admission to hospital, admission to intensive care unit, receipt of radiotherapy or systemic treatment. Results The median overall survival (OS) of patients who received at least one cycle of SACT ( n  = 489) was 9.1 months and in patients with no-SACT ( n  = 289) 1.3 months (hazard ratio [HR] = 4.23, 95% CI = 3.60–5.00). During the final 30 days of life, intensive EOL care was received by 69.9% of the SACT patients and 43.7% of the no-SACT patients. Intensive EOL care in the last 30 days of life is more probable among patients in the SACT group (odds ratio [OR] = 3.58, 95% CI = 2.54–5.04, p  <  0.001), especially in those with a stage IV disease (OR = 1.89, 95% CI = 1.31–2.71, p  = 0.001). In the SACT group 6.7 and 14.7% of patients died within 14 days and 30 days after the last cycle, respectively. Conclusions Significant proportion of patients with advanced lung cancer continue to receive intensive care near death. Our results reflect current patterns of EOL care for patients with lung cancer in Estonia. Availability of palliative care and hospice services must be increased to improve resource use and patient-oriented care.

•The Critical Care Resuscitation Unit provides high care intensity.•The Critical Care Resuscitation Unit further reduces patients' blood pressure variability.•Older age, higher GCS, and mechanical ventilation prior to transfer are associated with need for higher care intensity.•Increased age and high acuity based on the Emergency Severity Index during ED stay are associated with high mortality.•High maximum systolic blood pressures, history of hypertension, and male gender are factors associated with AKI.

Background Long-term weight loss effect of bariatric surgeries for patients with Prader-Willi Syndrome (PWS) remains controversial since factors like postoperative home care intensity may impact the outcome. The aim of this study was to evaluate the role of home care intensity on long-term weight loss effect of bariatric surgery in patients with PWS. Methods This was a prospective observational study on patients with PWS undergoing bariatric surgery and patients were enrolled from July 2015 to December 2016. Detailed information of patients’ weight and behaviors was recorded by caregivers postoperatively. The intensities of home care applied to patients were classified into four categories (high, moderate, low, and very low) according to the records. Results Six cases (3 males, 3 females) were enrolled in this study with LSG ( n  = 2), RYGB ( n  = 3), and LSG-DJB ( n  = 1) as their primary operation. The mean BMI of these participants was 46.78 ± 11.63 kg/m 2 , and the mean age was 17.66 ± 6.59 years. All patients had at least 5 years of follow-ups, and the %EWL were 51.57 ± 23.36%, 64.54 ± 18.97%, 35.34 ± 36.53%, 19.45 ± 41.78%, and − 4.74 ± 71.50% in the half, first, second, third, and fifth year after surgery respectively. Two patients with high-intensity home care achieved a %EWL of 70.57 ± 8.86% in the fifth year after surgery. Conclusions Overall long-term weight loss of bariatric surgery for patients with PWS was not found through the follow-ups. Two patients with high-intensity home care maintained weight loss at the fifth-year follow-up, suggesting a pivotal role of high-intensity home care in long-term outcomes of bariatric surgery in patients with PWS. Graphical Abstract

We analysed whether care time, burden and range of caregiving tasks were associated with informal caregivers’ subjective views of ageing (measured as attitudes towards own age (ATOA), subjective age (SA), and onset of old age (OOA)), and whether these associations differed as a function of the caregivers’ age and gender. Adjusted cluster-robust fixed effects regression analyses were conducted with gender and age as moderators using data of informal caregivers (≥ 40 years) of the population-based German Ageing Survey (2014, 2017). All three aspect of care intensity were associated with changes in subjective views of ageing and this pattern was a function of the caregiver’s age and gender. Care time was significantly associated with higher SA. Care tasks were significantly associated with more positive ATOA and earlier OOA. Age moderated the association between burden and ATOA, with older adults reporting more positive ATOA. Gender moderated the association between care time and ATOA; women reported less positive ATOA than men with increasing care time, but also felt subjectively younger than men with a broader range of care tasks. Age- and gender-stratified analysis indicated further differences. Our findings suggest to reduce care time, especially among older and female caregivers, to prevent a worsening of views of ageing, while being involved in a broad range of care tasks seems to (only) benefit female caregivers.

This article investigates gender inequalities in care provision across European long-term care (LTC) public spending systems using data from the European Health Interview Survey (2013–19). Women are more likely than men to provide care (OR = 1.41) and intensive care (OR = 1.50), particularly in countries with lower LTC public spending. Higher LTC expenditure appears to reduce intensive care but does not eliminate gender disparities, suggesting persistent inequalities despite greater state support. The findings highlight the need for policies addressing structural barriers to equitable care provision and expanding LTC resources to reduce gendered care burdens and promote fairness in care responsibilities across Europe.