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Background: Most chronic patients receive some level of care and support by their families. The burden of family caregivers comprises any factor that disrupts their lives and affects their health, interpersonal relationships, work, finances, social life and leisure. The burden is related to the experience as a result of the patient's daily care, possibly dependent on the feeling of family support. Aim: To investigate the relationship between burden and family support in family caregivers of older adults with chronic diseases. Methods: A cross sectional study was carried out involving 150 family caregivers of patients with chronic diseases. A questionnaire of socio-demographic and other data was used as well as the Zarit Burden Interview (ZBI) and the Family Support Scale (FSS). Results: The sample consisted of 150 people, with a mean age of 57, with the majority being women (70.7%). Most caregivers were married (48.7%) with 21.3% having a child-father relationship and with 22% having a child-mother relationship. Regarding the score on the ZBI Charge Rating Scale, the caregivers of the sample recorded high caregiver burden rates from the lowest (not at all to mild 25.3%) to the moderate and severe rating (mild to moderate 38.7% and moderate to severe 33.7%). Women appeared to experience higher levels of burden than men, while caregivers with reported health problems suffered more burden. On the Family Support Scale (FSS), women reported an increased sense of family support compared to male caregivers (75 ± 19 vs. 29 ± 7, p = 0.001). Finally, scores of the ZBI scale were found to be negatively related to the scores of FSS scale (r=-0.288, p=0.008). These findings supported the main research hypothesis since carers who received higher levels of family support, were experiencing lower levels of burden. Conclusions: The positive correlation found between the burden of caregivers of patients with chronic diseases and the family support they receive indicates that health professionals ought to provide all necessary educative and counselling measures of relief for caregivers indicating the importance of asking and receiving support by other family members so as to be able to carry out the difficult and burdensome task of care. [ABSTRACT FROM AUTHOR]

Various care processes have been affected by COVID-19. One of the most dramatic has been the care of chronic patients under medical supervision. According to the World Health Organization (WHO), a chronic patient has one or more long-term illnesses, and must be permanently monitored by the health team.. In fact, and according to the Chilean Ministry of Health (MINSAL), 7 out of 10 chronic patients have suspended their medical check-ups, generating critical situations, such as a more significant number of visits to emergency units, expired prescriptions, and a higher incidence in hospitalization rates. For this problem, health services in Chile have had to reschedule their scarce medical resources to provide care in all health processes. One element that has been considered is caring through telemedicine and patient prioritization. In the latter case, the aim was to provide timely care to those critical patients with high severity and who require immediate clinical attention. For this reason, in this work, we present the following methodological contributions: first, an unsupervised algorithm that analyzes information from anonymous patients to classify them according to priority levels; and second, rules that allow health teams to understand which variable(s) determine the classification of patients. The results of the proposed methodology allow classifying new patients with 99.96% certainty using a three-level decision tree and five classification rules. [ABSTRACT FROM AUTHOR]

We describe the technological development of a web platform named CHRONIC-PHARMA that integrates three prescription support tools for patients with chronic diseases: Anticholinergic Burden Calculator (ABC), LESS-CHRON criteria and TRIGGER-CHRON. They focus on the optimization and evaluation of pharmacotherapy in patients with chronic diseases, resulting in a useful, single platform that can facilitate the review of pharmacotherapy and improve the safety of chronically ill patients. This is achieved by estimating and reducing the anticholinergic risk (ABC), detecting opportunities for deprescribing drugs and monitoring its success (LESS-CHRON criteria), as well as calculating the risk of adverse drug events (TRIGGER-CHRON). The platform is freely accessible online (https://chronic-pharma.com/) as well as through a mobile application, and therefore easily accessible among the healthcare community. [ABSTRACT FROM AUTHOR]

A major concern in the management of Inflammatory Bowel Disease (IBD) is the absence of accurate and specific biomarkers to drive diagnosis and monitor disease status timely and non-invasively. Fibroblast activation protein (FAP) represents a hallmark of IBD bowel strictures, being overexpressed in stenotic intestinal myofibroblasts. The present study aimed at evaluating the potential of circulating FAP (cFAP) as an accessible blood biomarker of IBD. Quantitative determination of cFAP was performed by enzyme-linked immunosorbent assay on plasma samples prospectively collected from patients with IBD and control subjects. A discrimination model was established on a training set of 50% patients and validated on independent samples. Results showed that cFAP concentration was reduced in patients with IBD when compared to controls (p < 0.0001). Age, sex, smoking, disease location and behavior, disease duration and therapy were not associated with cFAP. The sensitivity and specificity of cFAP in discriminating IBD from controls were 70 and 84%, respectively, based on the optimal cutoff (57.6 ng mL−1, AUC = 0.78). Predictions on the test set had 57% sensitivity, 65% specificity, and 61% accuracy. There was no strong correlation between cFAP and routine inflammatory markers in the patients' population. A subgroup analysis was performed on patients with Crohn's disease undergoing surgery and revealed that cFAP correlates with endoscopic mucosal healing. In conclusion, cFAP deserves attention as a promising blood biomarker to triage patients with suspected IBD. Moreover, it might function as a biomarker of post-operative remission in patients with Crohn's disease.

Various care processes have been affected by COVID-19. One of the most dramatic has been the care of chronic patients under medical supervision. According to the World Health Organization (WHO), a chronic patient has one or more long-term illnesses, and must be permanently monitored by the health team.. In fact, and according to the Chilean Ministry of Health (MINSAL), 7 out of 10 chronic patients have suspended their medical check-ups, generating critical situations, such as a more significant number of visits to emergency units, expired prescriptions, and a higher incidence in hospitalization rates. For this problem, health services in Chile have had to reschedule their scarce medical resources to provide care in all health processes. One element that has been considered is caring through telemedicine and patient prioritization. In the latter case, the aim was to provide timely care to those critical patients with high severity and who require immediate clinical attention. For this reason, in this work, we present the following methodological contributions: first, an unsupervised algorithm that analyzes information from anonymous patients to classify them according to priority levels; and second, rules that allow health teams to understand which variable(s) determine the classification of patients. The results of the proposed methodology allow classifying new patients with 99.96% certainty using a three-level decision tree and five classification rules.

Copyright of Journal of Anatolia Nursing & Health Sciences / Anadolu Hemsirelik Ve Saglik Bilimleri Dergisi is the property of Ataturk University Coordinatorship of Scientific Journals and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Because of the high demand and costs of care, chronic diseases have shown an increasing number of caregivers who develop their role without the required training and skill. Objective: To describe the capacity for home care of caregivers of patients with chronic illness in a service provider institution of San José de Cúcuta. Materials and methods: Descriptive quantitative cross-sectional study, developed in the fi rst half of 2017. The sample was composed by 360 caregivers of patients with chronic disease. We used the instruments developed by the Chronic Patient Care Group of the Faculty of Nursing of the National University of Colombia called: GCPC-UN-C © - technical characterization chart for family caregivers of patients with chronic non-transferable disease and the instrument “Caring” - short version to measure the competence of care at home. Results: In the study, low and medium levels of competence of the caregivers were reported in the exercise of their role, and the categories Knowledge and Enjoyment (Welfare) were more affected. It is important to note that caregivers with a high level of competence were not reported. Conclusion: The results show that the need for nursing intervention in strengthening the competence of caregivers remains an important constant of professional performance.

Introduction: High-need, high-cost (HNHC) patients can over-use acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased U.S. healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care. We targeted HNHC patients and identified root causes of frequent healthcare utilization. We developed a crosscontinuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services. Methods: Using a pre-/post-test design in which each subject served as his/her own historical control, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients. We conducted the analysis between November 2012 and December 2015 at Mercy Health Saint Mary’s, a Midwestern urban hospital with greater than 80,000 annual emergency department (ED) visits. All referred patients with three or more hospital visits (ED or inpatient [IP]) in the 12 months prior to initiation of a CCM© (n=339) were included in the study. Individualized CCMs© were created and made available in the electronic medical record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost-accounting system for 12 months before and after CCMs© implementation. We used both descriptive and limited inferential statistics. Results: ED mean visits decreased 43% (p

Hypothyroidism affects up to 5% of the general population, with a further estimated 5% being undiagnosed. Over 99% of affected patients suffer from primary hypothyroidism. Worldwide, environmental iodine deficiency is the most common cause of all thyroid disorders, including hypothyroidism, but in areas of iodine sufficiency, Hashimoto's disease (chronic autoimmune thyroiditis) is the most common cause of thyroid failure. Hypothyroidism is diagnosed biochemically, being overt primary hypothyroidism defined as serum thyroid-stimulating hormone (TSH) concentrations above and thyroxine concentrations below the normal reference range. Symptoms of hypothyroidism are non-specific and include mild to moderate weight gain, fatigue, poor concentration, depression, and menstrual irregularities, while the consequences of untreated or under-treated hypothyroidism include cardiovascular disease and increased mortality. Levothyroxine has long been the main tool for treating hypothyroidism and is one of the world's most widely prescribed medicines. In adults with overt hypothyroidism, levothyroxine is usually prescribed at a starting dose of 1.6 µg/kg/day, which is then titrated to achieve optimal TSH levels (0.4-4.0 mIU/L), according to the therapeutic target. We here summarise the history of levothyroxine and discuss future issues regarding the optimal treatment of hypothyroidism. Because nearly one-third of patients with treated hypothyroidism still exhibit symptoms, it is important that levothyroxine is used more appropriately to achieve maximum benefit for patients. In order to ensure this, further research should include more accurate assessments of the true prevalence of hypothyroidism in the community, optimisation of the levothyroxine substitution dose, proper duration of treatment, and identification of patients who may benefit from combination therapy with levothyroxine plus levotriiodothyronine.Funding: Merck.Plain Language Summary: Plain language summary available for this article. [ABSTRACT FROM AUTHOR]

Mortality rates among pluripathological patients are significantly higher in the hospital setting, with advanced age and dependence on certain vital functions the main clinical aspects. Other features involved in the care, such as the loss of autonomy and social problems, have important ethical implications. The aim of this article is to analyze the health problems and the functional and social situation of chronic patients after hospital admission in order to determine their care needs and the ethical implications these might have. For this, a cross-sectional descriptive study is being carried out with a sample of 111 chronic pluripathological patients admitted to the internal medicine service and discharged later. Overall, 96.6% of the patients in the sample were dependent, 91.7% had social problems or were at social risk and 36.9% had cognitive impairment. Among dependent patients, 59.4% had social problems (p = 0.029), 19.2% lived alone (p = 0.13), and in 73.3% of cases the housing was inadequate (p = 0.47). Among those with cognitive impairment, 79.5% of patients had social problems (p = 0.001), and 10.3% lived alone (p = 0.038). The results of the study confirm the presence of dependence and social problems at hospital discharge in a high proportion of chronic patients. Planning their care can lead to ethical conflicts related to the use of information technologies, which are destined to promote the patients’ autonomy, and to the social problems associated with the illness.

Palliative care in Romania is a relatively new emerging field. Challenges of this specialty, its uniqueness and the several problems posed by a particular category of patients, the chronically ill patients, make this medical specialty a particularly complex one in certain situations, requiring a multidisciplinary team well-prepared in terms of theory and practice. Unlike in the case of most medical specialties, particular emphasis is laid on the “human” side of medical care, this specialty introducing the concept of “total pain”.

Management of chronic diseases in a progressively aging population is a major issue in western industrialized countries and telehealth is one way to ensure the continuity of care in chronic illness. We describe here our personal experience in a telehealth and telecare centre in Italy. Between January 2000 and December 2015, 1635 elderly patients (71% male) with one or more comorbidities have undergone a telehealth program tailored to their specific disease: chronic obstructive pulmonary disease (COPD)/chronic respiratory insufficiency; amyotrophic lateral sclerosis/neuromuscular diseases; chronic heart failure (CHF); post-stroke; and post-cardiac surgery patients discharged from hospital after an acute event. COPD and CHF represent the majority of patients treated (accounting for 80%). Interventions performed by the nurse tutor account for 39-82% of all activities in the five different programs. Specialist second opinion represents 12-27% of the health staff activities. Previously reported results show a reduction of the re-hospitalization rate and costs, and increase in quality of life and patient satisfaction with the service. A multidisciplinary telehealth and telecare integrated approach can provide efficient management for the growing number of complex patients. [ABSTRACT FROM AUTHOR]

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity.

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity. [ABSTRACT FROM AUTHOR]

The autonomy of chronic patients in Iranian hospitals is challenged by impaired functioning resulting from chronic illness, a negative image in society, and effects related to hospitalization. Comprehensive interviews and observations of 34 patients, nurses, and physicians were performed to assess the autonomy of chronic patients in Iran. Conceptualization, constant comparison, and the combination of data resulted in the identification of 5 main categories related to autonomy: welcoming paternalism, self-expression, self-proof, shared decision making, and self-determination. Authority scrambling was a central category describing chronic patients’ perceptions of their autonomy during hospitalization. These patients sought to maintain their independence despite serious threats to their autonomy. [ABSTRACT FROM PUBLISHER]

Background: Studies assessing the quality of life of patients with multiple sclerosis (MS) seek to determine which quality of life dimensions are the most significantly decreased as a result of the illness. For MS patients the broad term "the quality of life" is not exclusively associated with the degree of physical disability or the progress of the illness. It is also affected by cultural and socio-economic factors. Aim of the study: An assessment of the impact of the chronic disease a multiple sclerosis is which, is a main purpose to the quality of life of persons being dying for it. Material and methods: The study was conducted between 2013 and 2014 on a population of 50 members of the Association of Multiple Sclerosis Patients in Głogów. The study method of choice was a diagnostic survey, including the standardized questionnaire Ferrans and Powers' Quality of Life Index for Multiple Sclerosis (version II). Results: The highest quality of life satisfaction among MS patients was recorded for the Family subscale and the lowest in the Health/functioning subscale. Conclusions: The general assessment of the quality of life made by the participants rates on an average level (mean 4.34). The result can be considered good and focus may turn on the elements which require additional support. [ABSTRACT FROM AUTHOR]

Copyright of Scientific Annals of the 'Al. I. Cuza' University, Iasi. Sociology & Social Work / Analele Stiintifice ale Universitatii 'Al. I. Cuza' Iasi Sociologie si Asistenta Sociala is the property of Alexandru Ioan Cuza University and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Personal health devices (PHDs) are rapidly developing and getting smarter. But little is known about chronic patients’ acceptance of such PHDs. Objective The objective of this study is to explore how chronic patients accept PHDs and what are the main factors that predict use intention of PHDs. The results will provide suggestions for the design of PHDs and e-health services. Method A questionnaire survey was conducted to identify the main factors that affect chronic patients’ acceptance of PHDs. Three hundred and forty-six valid responses from chronic patients were collected and the data were analyzed using exploratory factor analysis and regression analysis method. The questionnaire also included questions about respondents’ experience of PHDs and preference of PHD functions. These questions help to understand lived experience of PHD users and to explain the factors that influence their use intention. Result Five influencing factors that predict use intention of PHDs were identified: attitude toward technology, perceived usefulness, ease of learning and availability, social support, and perceived pressure. An acceptance model of PHDs was proposed based on these factors, and suggestions for PHD designers and e-health service designers were discussed. The exploration of PHD experience indicated that ease of learning and social norm significantly influenced PHD use intention, and many respondents expressed negative opinions on the accuracy, durability and maintenance service of PHDs. Besides, people generally expressed positive attitude toward future functions of a PHD. [ABSTRACT FROM AUTHOR]

Background Patients with chronic diseases often receive multiple medications and are associated with increased vulnerability to medication errors. Identifying high-alert medications for them would help to prioritize the interventions with greatest impact for improving medication safety. The aim of this study was to develop a list of high-alert medications for patients with chronic illnesses (HAMC list) that would prove useful to the Spanish National Health Service strategies on chronicity. Methods The RAND/UCLA appropriateness method was used. Drug classes/drugs candidates to be included on the HAMC list were identified from a literature search in MedLine, bulletins issued by patient safety organizations, incidents recorded in Spanish incident reporting systems, and previous lists. Eighteen experts in patient/medication safety or in chronic diseases scored candidate drugs for appropriateness according to three criteria (evidence, benefit and feasibility of implementing safety practices). Additionally they rated their priority of inclusion on a Likert scale. Results The final HAMC list includes 14 drug classes (oral anticoagulants, narrow therapeutic range antiepileptics, antiplatelets – including aspirin –, antipsychotics, β-blockers, benzodiazepines and analogues, corticosteroids long-term use, oral cytostatics, oral hypoglycemic drugs, immunosuppressants, insulins, loop diuretics, nonsteroidal anti-inflammatory drugs, and opioid analgesics), and 4 drugs or pairs of drugs (amiodarone/ dronedarone, digoxin, oral methotrexate and spironolactone/eplerenone). Conclusions An initial list of high-alert medications for patients with chronic diseases has been developed, which can be built into the medication management strategies for chronicity to guide the implementation of efficient safety strategies and to identify those patients at greater risk for preventable adverse drug events. [ABSTRACT FROM AUTHOR]

Purpose Many European countries have been undertaking measures to promote integration of health and social care. The purpose of this study is to identify different approaches to integrated care and retrieve a number of experiences and approaches of working in some European countries. Methods A systematic review of the integrated care literature was conducted in a 3-month period. The Pubmed, Embase, and BioMed Central databases were searched for articles from 2002 through 2008. The articles were selected according to inclusion and exclusion criteria. A standard form was used for data extraction. Findings A total of 24 studies that conformed to the criteria were found. The analysed articles describe integrated care in 16 European countries: UK, Germany, Finland, Sweden, Austria, Spain, Netherlands, Ireland, Portugal, Denmark, France, Greece, Italy, Norway, Poland, and Switzerland. The studies' setting was primary care, social care, home care, or a combination of these. In majority of the studies similar challenges to health care systems were identified: advances in health care, ageing population, multi-system nature of chronic diseases, hospital-based care system, insufficient provision of community care services, lack of cooperation among health and social care providers, fragmentation of the health and social care systems, and rurality. These challenges are seen as a stimulus to the integration of care. The articles also mentioned some integration strategies that were categorized according to: changes in organizational structure, workforce reconfiguring, and changes in the financing system. Integrated care definitions were also derived from the articles, and from the verbatim text when possible. Definitions were grouped according to their sectorial focus: community-based care, combined health and social care, combined acute and primary care, the providers, and in a more comprehensive approach the whole health system. Conclusion Despite integrated care being implemented in some European countries since the beginning of the millennium, it is a relatively new concept in health management discourse. There is room for more studies on the need for integrated care and the effectiveness of the implemented strategies. Despite integration models having a similar background there is no European consensus about the definition of integrated care. The data collected are useful for debate on the topic within the international health management and marketing community. [ABSTRACT FROM AUTHOR]

Previous studies have discussed the effectiveness or ineffectiveness of prism adaptation for neglect patients. Purpose: The aim of present study was to determine the long-term effect of prism adaptation with activity performance instead of pointing performance on chronic neglect patients. Subjects: Seven patients with chronic unilateral spatial neglect were recruited. Methods: We performed an 8-week intervention using prismatic glasses. Changes in eye movement before and after intervention were measured using an eye mark recorder system. We also assessed intentional spatial bias in terms of center of gravity in the standing position using a tactile sensor scan system. Additionally, regional cerebral blood flow was measured using SPECT (IMP) before and after intervention. Results: Eye movements significantly improved on the neglected side (p<0.01), and the effects were sustained for up to 6 weeks after the removal of the prism. The center of gravity significantly moved to the left and forward. Furthermore, rCBF showed a significant increase at the parietal cortex, pericalleosal area of the left hemisphere (P<0.05). Conclusion: These results suggest that intervention using prismatic glasses could improve eye movement on the neglected side and correct intentional spatial bias. Prism intervention might be one valuable method for the activation of the important areas of the brain in neglect patients. [ABSTRACT FROM AUTHOR]

Mortality rates among pluripathological patients are significantly higher in the hospital setting, with advanced age and dependence on certain vital functions the main clinical aspects. Other features involved in the care, such as the loss of autonomy and social problems, have important ethical implications. The aim of this article is to analyze the health problems and the functional and social situation of chronic patients after hospital admission in order to determine their care needs and the ethical implications these might have. For this, a cross-sectional descriptive study is being carried out with a sample of 111 chronic pluripathological patients admitted to the internal medicine service and discharged later. Overall, 96.6% of the patients in the sample were dependent, 91.7% had social problems or were at social risk and 36.9% had cognitive impairment. Among dependent patients, 59.4% had social problems (p = 0.029), 19.2% lived alone (p = 0.13), and in 73.3% of cases the housing was inadequate (p = 0.47). Among those with cognitive impairment, 79.5% of patients had social problems (p = 0.001), and 10.3% lived alone (p = 0.038). The results of the study confirm the presence of dependence and social problems at hospital discharge in a high proportion of chronic patients. Planning their care can lead to ethical conflicts related to the use of information technologies, which are destined to promote the patients' autonomy, and to the social problems associated with the illness. [ABSTRACT FROM AUTHOR]

Background: Proper planning of Palliative Care in nursing homes requires advanced knowledge of the care needs that residents show. The aim of the study was to evaluate Palliative Needs and other conditions such as fragility, complexity, and prognosis and also to suggest new indicators for the establishment of the resident's advanced chronic condition., Methods: Cross-sectional study conducted in 149 nursing homes Complex Chronic residents evaluated by trained professionals. Palliative Care Needs, assessed by the NECPAL ICO-CCOMS© tool, and fragility, case and palliative complexity and prognosis were evaluate through a comprehensive assessment. Descriptive analyses and association measures were performed setting the statistical significance at 0.05., Results: More than 50% of the residents had positive Surprise Question and other Palliative Needs and were classified as Advanced Chronic Patients. Distress and/or Severe Adaptative Disorder was the most frequent need shown by the residents and significant differences in levels of frailty and other characteristics, were found between the Positive and the Negative Surprise Question Groups. Statistically significant correlations were also found between aspects of both groups., Conclusions: Nursing homes residents show Palliative Needs regardless of the response to the Surprise Question of the NECPAL tool. Other characteristics such as presence of an intermediate level of frailty are suggested as a new perspective to identify advanced chronic patients among nursing homes residents.

Introduction: In the past few years, healthcare systems are facing a growing demand related to high prevalence of chronic diseases. Case Management (CM) programs have emerged as a new approach for the management of chronic disease focused on improving individual's health and serving social needs. Nevertheless, there is no great scientific evidence about the impact on healthcare of using generic CM program for high-complexity chronic patients. Methodology: We evaluated a CM model based on a reengineering care process that has aligned the health care levels implied, providing the attention from a patient centred perspective and promoting the patient empowerment through education and self-care. A retrospective cohort study has been carried out using a sample of 714 adult chronic patients admitted at the Valencia-La Fe Health Department Chronic CM program between January 2012 and January 2015. Results: The results of the one-tailed matched Wilcoxon's hypothesis test (a=5%), show statistically significant differences for the rate of unplanned admissions and for the rate of emergency room (ER) visits. The rate of admissions in Hospital at Home (HaH) did not show a significant difference. The results showed statistically significant differences for the rate of unplanned hospitalization Length of Stay (LoS) and for HaH. The results of the RR of admission show that the risk of unplanned admission decreases to a 58.4%, and the risk of visits to the ER decreases to a 73.5%. However, the HaH admission relative risk increases in 50.2%. Discussion: The positive results can be based on two facts. Firstly, the proactive character of the intervention through Primary Health scheduled intervention; and secondly, the support of the CM nurses from the Telemedicine Unit and the advanced care at home, developed by the HaH unit when needed. Self-management educational interventions have positive effects on hospital consumption, such as hospital admission. Two studies evaluated a home-based educational intervention on patients with heart failure achieving fewer emergency department visits and unplanned readmissions, improving quality of life and reducing mortality. We may expect that the induction program in our model empowers patients for self-care interventions and early identification of risk situations. Additionally, the close follow-up of patients and families by primary healthcare team could explain our results. The possibility of scheduled home visits and/or consultations performed by general practitioner, staff nurse and community case manager nurse facilitates the accessibility to medical attention. This may explain the relationship between complex chronic CM and the decrease of Hospital admissions, LoS and ER visits. Our model had also the support of the Telemedicine unit led by case manager nurses. Their aim is to promote self-care, early risk identification and an appropriate management of sources when social and clinical needs appear. Studies reflect that the benefit of telephone follow-up is observed regardless of home visits and consultations, concluding that a positive effect could exist between the role of the telemedicine unit and the results. Also, the increase in the number of HaH admissions once the patient is included in the program is a good indicator of appropriate use of Hospital-based home care as an alternative to conventional hospitalization. From the institutional perspective, we can estimate a global bed savings per year. We expect to save around 5 days of a bed per patient. Taking into account that we manage around 243 patients per year in the CM intervention, this may imply a number of around 1,215 bed savings per year. Conclusion: Our CM intervention has a significant hospital resource savings in average with a positive impact on patient admissions and LoS. We suggest that policies and strategies should keep promoting CM interventions both for healthcare network for patients and families and for research. Whether the CM intervention is profitable for reducing the use of hospital resources for other clinical profiles is still a question under study. It seems clear that the CM intervention reduces hospital resources, which of course leads to economic savings. However, the CM intervention also entails new economic costs that should be analyzed. A future step is to carry out a costeffectiveness analysis to compare if the CM intervention implies economic savings apart from the observed hospital resources savings. The adoption of this type of intervention to a different health center may require a careful implementation according to the characteristics of chronic patients. In elderly patients, the assessment of social environment is an aspect of relevance as well as the cultural aspects and organizational issues. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between sense of coherence (SOC) and physical health-related quality of life in patients with chronic illnesses by focusing on the mediating role of the mental component of quality of life., Design: Cross-sectional survey design., Setting: Secondary care; three departments of an Italian university hospital., Methods: The participants (n=209) in the study were adult (≥18 years) outpatients with a chronic pathology (eg, diabetes, thyroid disorders or cancer) at any phase in the care trajectory (eg, pre-treatment, undergoing treatment, follow-up care). They agreed to participate in the study after providing their informed consent. Data were collected using a structured self-reporting questionnaire. Data analysis was carried out using SPSS, and mediation analysis was performed via PROCESS macro., Results: The SOC score of the study sample was equivalent to that of the general population (mean difference=-2.50, 95% CI -4.57 to 0.00). Correlation analysis showed that SOC was mainly correlated to the mental component (MCS) (r=0.51, p<0.01) of quality of life and then to the physical component (PCS) (r=0.35, p<0.01). Mediation analysis showed that SOC was directly related to MCS (p<0.001, 95% CI 0.62 to 0.99) but not to PCS (p=0.42, 95% CI -0.27 to 0.12). In turn, MCS was directly related to PCS (p<0.001, 95% CI 0.76 to 1.01). The indirect effect of SOC on PCS through MCS was significant (0.71, p<0.001, bootstrap 95% CI 0.54 to 0.91), thus supporting the mediating role of the mental component of quality of life., Conclusion: The indirect effect suggests that SOC is a marker of quality of life, especially of the mental component. The findings show that SOC is a psychological process that impacts patients' mental health status, which in turn affects physical health. Better knowledge of a person's SOC and how it affects his/her quality of life may help to plan tailoring interventions to strengthen SOC and improve health-related quality of life., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)