No / The establishment of a correct diagnosis links care to established guidelines and underpins all subsequent therapeutic activity. Problems can arise when definitions of disease overlap, as is the case with diabetic foot ulceration and pressure ulcers on the foot occurring in people with diabetes. In such cases, clinicians must ensure that patients receive a care bundle that recognises both the wound causation (pressure and shear) and the underlying pathology (diabetic neuropathy, potential foot architecture disruption and ischaemia). All patients with diabetes that have foot ulceration, irrespective of wound aetiology should, therefore, be seen by the multidisciplinary diabetic foot team. Care can then be optimised to include appropriate assessments, including assessment of peripheral perfusion, correct offloading, appropriate diabetic management, and general foot and skin care.

No / Purpose: The European Academy of Allergy and Clinical Immunology (EAACI) has produced Guidelines on Allergen Immunotherapy (AIT). We sought to gauge the preparedness of primary care to participate in the delivery of AIT in Europe. Methods: We undertook a mixed‐methods, situational analysis. This involved a purposeful literature search and two surveys: one to primary care clinicians and the other to a wider group of stakeholders across Europe. Results: The 10 papers identified all pointed out gaps or deficiencies in allergy care provision in primary care. The surveys also highlighted similar concerns, particularly in relation to concerns about lack of knowledge, skills, infrastructural weaknesses, reimbursement policies and communication with specialists as barriers to evidence‐based care. Almost all countries (92%) reported the availability of AIT. In spite of that, only 28% and 44% of the countries reported the availability of guidelines for primary care physicians and specialists, respectively. Agreed pathways between specialists and primary care physicians were reported as existing in 32%‐48% of countries. Reimbursement appeared to be an important barrier as AIT was only fully reimbursed in 32% of countries. Additionally, 44% of respondents considered accessibility to AIT and 36% stating patient costs were barriers. Conclusions: Successful working with primary care providers is essential to scaling‐up AIT provision in Europe, but to achieve this, the identified barriers must be overcome. Development of primary care interpretation of guidelines to aid patient selection, establishment of disease management pathways and collaboration with specialist groups are required as a matter of urgency.

No description available.

<p>Standardvårdplaner är vanligt förekommande inom hälso- och sjukvård och är under ständig utveckling. Standardvårdplaner är i olika grad evidensbaserade och framtagna med skiftande kvalitet. Standardvårdplaner används som ett hjälpmedel för effektivisering och kvalitetshöjning av vården för en specifik patientgrupp och är en på förhand formulerad vårdplan. Behov av ytterligare forskning efterfrågas om standardvårdplaner faktiskt minskar mängden dubbeldokumentation, leder till ökad tidsvinst och ökad vårdkvalitet. Syftet med föreliggande litteraturstudie var att göra en beskrivning av de effekter som användande av standardvårdplaner leder till. I litteraturstudien bearbetades 10 vetenskapliga artiklar som grund för resultatredovisningen. Resultatet visar att standardvårdplaner kan höja vårdkvaliteten, minska mängden dubbeldokumentation och leda till att tid frigörs till patientnära arbete. Det finns emellertid studier som visar på det motsatta. Standardvårdplanen kan ses som ett verktyg som underlättar en jämlik, högkvalitativ vård till alla patienter oavsett vem som vårdar. Utveckling av standardvårdplaner i vården bör ske på ett strukturerat och vetenskapligt sätt och tid till detta bör prioriteras. Litteraturstudien redovisar motstridiga resultat vilket indikerar behovet av fortsatt forskning av vilka effekter standardvårdplaner har för vården, både sett ur patientperspektiv, personalperspektiv samt ur ett organisatoriskt perspektiv.</p> / <p>Standardized care plans are commonly used in health care and are under constant development. Standardized care plans are to varying degrees evidence-based and designed with varying quality. Standardized care plans are used as a tool for improving the quality of care and are seen as a pre-formulated treatment plan. Research is needed into whether standardized care plans reduce the amount of redundant documentation, save time and increase quality of care. The aim of this literature study was to describe the situation regarding effects of using standardized care plans. In this study 10 scientific articles were analyzed. Results show that standardized care plans can improve quality of care, reduce redundant documentation and decrease time spent on documentation. However, there are studies that demonstrate the opposite.<strong> </strong>Standardized care plans can be seen as a tool for providing high-quality basic care for all patients. Scientific evidence should be used for development of standardized care plans and therefore priority should be given to making resources for this work available. There is a need for further research to validate the effects of standardized care plans as the results from this literature study are ambiguous. It would also be interesting to compare the views from patients, staff and management on the effects of using standardized care plans.</p>

Standardvårdplaner är vanligt förekommande inom hälso- och sjukvård och är under ständig utveckling. Standardvårdplaner är i olika grad evidensbaserade och framtagna med skiftande kvalitet. Standardvårdplaner används som ett hjälpmedel för effektivisering och kvalitetshöjning av vården för en specifik patientgrupp och är en på förhand formulerad vårdplan. Behov av ytterligare forskning efterfrågas om standardvårdplaner faktiskt minskar mängden dubbeldokumentation, leder till ökad tidsvinst och ökad vårdkvalitet. Syftet med föreliggande litteraturstudie var att göra en beskrivning av de effekter som användande av standardvårdplaner leder till. I litteraturstudien bearbetades 10 vetenskapliga artiklar som grund för resultatredovisningen. Resultatet visar att standardvårdplaner kan höja vårdkvaliteten, minska mängden dubbeldokumentation och leda till att tid frigörs till patientnära arbete. Det finns emellertid studier som visar på det motsatta. Standardvårdplanen kan ses som ett verktyg som underlättar en jämlik, högkvalitativ vård till alla patienter oavsett vem som vårdar. Utveckling av standardvårdplaner i vården bör ske på ett strukturerat och vetenskapligt sätt och tid till detta bör prioriteras. Litteraturstudien redovisar motstridiga resultat vilket indikerar behovet av fortsatt forskning av vilka effekter standardvårdplaner har för vården, både sett ur patientperspektiv, personalperspektiv samt ur ett organisatoriskt perspektiv. / Standardized care plans are commonly used in health care and are under constant development. Standardized care plans are to varying degrees evidence-based and designed with varying quality. Standardized care plans are used as a tool for improving the quality of care and are seen as a pre-formulated treatment plan. Research is needed into whether standardized care plans reduce the amount of redundant documentation, save time and increase quality of care. The aim of this literature study was to describe the situation regarding effects of using standardized care plans. In this study 10 scientific articles were analyzed. Results show that standardized care plans can improve quality of care, reduce redundant documentation and decrease time spent on documentation. However, there are studies that demonstrate the opposite. Standardized care plans can be seen as a tool for providing high-quality basic care for all patients. Scientific evidence should be used for development of standardized care plans and therefore priority should be given to making resources for this work available. There is a need for further research to validate the effects of standardized care plans as the results from this literature study are ambiguous. It would also be interesting to compare the views from patients, staff and management on the effects of using standardized care plans.

No description available.

Yes / Objectives: Young onset dementia is associated with distinctive support needs but existing research on service provision has been largely small scale and qualitative. Our objective was to explore service use, cost and satisfaction across the UK. Methods: Information about socio‐demographic characteristics, service use and satisfaction were gathered from people with young onset dementia (YOD) and/or a family member/supporter via a national survey. Results: Two hundred and thirty‐three responses were analysed. Diagnosis was most commonly received through a Memory Clinic or Neurology. The type of service delivering diagnosis impacted on post‐diagnostic care. Those diagnosed in specialist YOD services were more likely to receive support within the first 6 weeks and receive ongoing care in the service where they were diagnosed. Ongoing care management arrangements varied but generally care was lacking. Around 42% reported no follow‐up during 6‐weeks after diagnosis; over a third reported seeing no health professional within the previous 3 months; just over a third had a key worker and just under a third had a care plan. Satisfaction and quality of care were highest in specialist services. Almost 60% of family members spent over 5 h per day caring; median costs of health and social care, 3 months, 2018, were £394 (interquartile range £389 to 640). Conclusions: Variation across diagnostic and post‐diagnostic care pathways for YOD leads to disparate experiences, with specialist young onset services being associated with better continuity, quality and satisfaction. More specialist services are needed so all with YOD can access age‐appropriate care. / Alzheimer's Society. Grant Number: 278 AS-PG-15b-034

Comme dans la plupart des pays développés, l’hôpital public français fait face à de nombreux défis : démographie médicale défavorable, évolution des modes de prise en charge des patients, accumulation de réformes introduisant de nouvelles règles de financement ou de gouvernance, etc. L’organisation encore très éclatée du maillage hospitalier, qui compte près d’un millier d’établissements publics, rend difficile une transformation d’ampleur qui réponde à ces multiples contraintes.Dans ce contexte, la loi de modernisation de notre système de Santé de 2016 impose désormais à tous les hôpitaux publics de France d’adhérer à un Groupement Hospitalier de Territoire (GHT). Le GHT s’inscrit à la suite de nombreux instruments d’action publique visant à réorganiser le paysage hospitalier, mais dont les effets ont été souvent modestes. De multiples interrogations entourent cette nouvelle réforme, aussi bien à propos de ses finalités que de ses conditions de mise en œuvre. En effet, elle tranche avec le mouvement de reprise en main par l’Etat qui prévalait jusqu’à présent, en laissant une large autonomie aux acteurs de terrain dans son application.La thèse repose sur l’analyse de cette mesure, à travers l’étude de trois cas de construction de GHT. La principale ambition de notre travail est de s’interroger sur l’inscription de la réforme des GHT dans un nouveau paradigme de l’action publique.Nous montrons que malgré ses objectifs en apparence relativement vagues, cette réforme marque une véritable rupture dans l’action de l’Etat, visant à amorcer des dynamiques locales d’exploration de nouvelles modalités d’orga-nisation territoriale de l’offre de soins. Cette approche correspond à un nouveau régime de gouvernementalité, qui offre aux acteurs des objets de gouvernement, comme les parcours des patients, capables d’enclencher des apprentis-sages collectifs à travers la mise en place de partenariats d’exploration. Toutefois, en raison de plusieurs incohérences persistant dans l’action de l’Etat, les trajectoires de ces GHT s’annoncent hétérogène. Nous formulons donc quelques préconisations pour le management de ces dynamiques exploratoires, ainsi que pour une ingénierie de l’action publique plus cohérente, afin de mener à bien ces nouvelles orientations. / As in most of developed countries, French public hospitals are facing several challenges: shortage of medical resources, development of new care practices, 
as well as recurrent reforms introducing new financing or governance rules. The fragmented organization of the hospital network, which is made up of nearly a thousand public institutions, makes it difficult to implement a large-scale transformation that would meet these multiple constraints.In such a context, the latest healthcare law (2016) now requires all public hospitals in France to join a Territorial Hospital Group (THG). THGs come after a series of instruments that aimed at reorganizing the territorial hospital organisation, with mixed results up to now. This new reform has aroused many questions regarding its objectives and implementation conditions. Indeed, it contrasts with the strong state-control trend that had prevailed so far, by giving local actors a large amount of autonomy.The thesis is based on the analysis of this reform through a multiple case study. The main ambition of this work is to question the inclusion of the THG law in a new public action paradigm.Despite its apparently relatively vague objectives, I show that this reform is a real break in public action, as it aims at initiating local exploration dynamics around new territorial organizations. This approach corresponds to a new governmentality regime, providing actors with specific objects of government, such as care pathways, capable of triggering collective learning through the creation of exploration partnerships. However, due to remaining inconsistencies in the government’s action, the trajectories of these THGs appear to be very heterogeneous. Therefore, I suggest several recommendations for the management of these exploration dynamics, as well as for consistent public action engineering, in order to carry out such new orientations.

Le stade terminal de l’insuffisance cardiaque peut nécessiter l’inscription en liste d’attente pour une greffe cardiaque. L’offre en greffon étant faible, l’accès à cette thérapeutique est priorisé pour les malades les plus graves dans le système d’allocation actuel, faisant de l’équité un enjeu éthique et sociétal important. L’objectif de cette thèse, grâce à des méthodes originales et de nouvelles sources de données, était d’analyser les déterminants d’accès à la greffe cardiaque liés aux candidats et aux équipes de greffe en France sur une période récente et d’apporter des éléments nouveaux sur le parcours de soin de ces malades. L’analyse du devenir des candidats à une greffe cardiaque inscrits entre 2010 et 2013 en intégrant la méthode de risques compétitifs a permis de dissocier le risque médical du risque induit par le système d’allocation actuel. Nous avons ainsi trouvé 7 facteurs relatifs au candidat associés à un risque de mortalité élevé dont 4 reliés à la sévérité de l’insuffisance cardiaque et 3 non spécifiques de l’insuffisance cardiaque mais associés à un faible accès à la greffe. La prise en compte de l’effet centre sur les inscrits entre 2010 et 2014 grâce à un modèle mixte de survie a permis de déterminer les facteurs équipe associés à l’accès à la greffe. Parmi les 23 équipes de greffe en France, l’ajustement sur les facteurs candidat et équipe, permettait d’observer que 5 équipes avaient des résultats différents des autres dont 3 avec un accès défavorisé. La mise en évidence de disparités médicales, géographiques et structurelles, révélatrices de failles dans le système actuel d’allocation des greffons cardiaques, nous a permis d’étayer la discussion sur la mise en place d’un nouveau système d’attribution en France. L’attribution au patient plutôt qu’à l’équipe de greffe devrait être plus pertinente. Les méthodologies utilisées permettront d’évaluer précisément ces répercussions. Enfin, l’étude du parcours hospitalier un an avant greffe (2010-2015) à l’aide des données du PMSI a permis de constater un nombre élevé d’hospitalisations pré-inscription majoritairement liées à leur défaillance cardiaque et de longue durée, confirmant le caractère réfractaire de ces insuffisants cardiaques. Ce travail sera poursuivi par une étude approfondie de la consommation de soins de ces malades grâce aux données du SNDS, indispensable étape pour évaluer la prise en charge et estimer les besoins en greffe cardiaque. / Heart transplantation (HTx) is the preferred option for medically refractory advanced heart failure. Due to the small number of available grafts, current allocation policy in France, as in many other countries, is based on the severity of the candidate’s heart disease. This Ph. D thesis was designed to determine candidate and center factors associated with access to heart transplantation in France and in-hospital care pathways one year before heart transplantation using appropriate methodologies and the national hospital database. We first analyzed 1-year mortality in patients listed for HTx in France from 2010 to 2013 using competing risk models in order to distinguish patient-related predictors and the influence of allocation policy. We then distinguished the proportions explained by candidate characteristics and center factors with the persistent between-center variability on 1-year access to transplantation (2010-2014). These disparities are mediated by the severity of the candidate’s heart disease, the allocation system and listing practices rather than by transplant activity. These findings provide a new contribution to improve the heart transplant allocation scoring system in France. The study based on the nationwide administrative database overcomes a major limitation of the national transplantation registry by shedding light on the healthcare pathway of heart transplanted recipients (2010-2015) during the year prior to transplantation. These findings will be useful to assess the medical benefits and criteria for registration on the heart transplant waiting list. This study will be continued by a detailed analysis of the healthcare consumption of these patients based on French national health insurance (SNDS) data.

La sclérose en plaques (SEP) est une maladie neurologique chronique du jeune adulte affectant environ 100 000 personnes en France. Au cours des deux dernières décennies, les stratégies thérapeutiques ont fortement évolué avec l’apparition de nouvelles molécules dont les premières formes orales. Le parcours de soins dans la SEP implique plusieurs professionnels de santé médicaux (généralistes, neurologues) et paramédicaux (kinésithérapeutes, infirmiers). Actuellement, aucune recommandation sur ces parcours n’a été définie, et peu de données existent sur le recours aux soins des individus ayant une SEP et l’utilisation des traitements spécifiques à la SEP en France. L’utilisation des données du Système National des Données de Santé (SNDS), c’est-à-dire les bases de l'Assurance Maladie, couplée avec les méthodes d’analyse de séquences donne l’opportunité d’étudier ces parcours de soins. L’objectif principal de cette thèse était d’étudier les parcours de soins des personnes ayant une SEP en France, à partir du SNDS, afin de décrire les consommations de soins et de mettre en évidence une typologie de parcours. Les objectifs secondaires étaient d’étudier l’utilisation des traitements de fond de la SEP en France (fréquence et place dans la séquence thérapeutique), et d’étudier la faisabilité de mesurer le niveau de handicap moteur dans ces bases. Au total sur la période de suivi de 2010 à 2015, 112 745 patients ont été identifiés, dont 47,4% avaient reçu au moins une délivrance d’un traitement de fond spécifique à la SEP. Une typologie a été obtenue identifiant cinq groupes cliniquement distincts. En parallèle, un indicateur de quantification du niveau de handicap moteur, pouvant être répliqué dans d’autres études, a été proposé afin d’enrichir les données du SNDS. Au travers des différentes analyses réalisées et des questions méthodologiques soulevées, des éléments clés permettant l’utilisation des méthodes d’analyse de séquences en santé, notamment la multichannel sequence analysis, ont pu être mis en évidence. / Multiple sclerosis (MS) is a chronic neurological disease starting in young adulthood and affecting about 100,000 persons in France. During the last two decades, therapeutic practices have evolved with the release of new substances, especially oral disease-modifying therapies (DMTs). Care pathways in MS involve both medical (general practitioners, neurologists) and paramedical (physiotherapists and nurses) health care professionals. However, no recommendation on care pathways in MS exists so far in France. Moreover, few data are available on care-seeking of persons with MS (PwMS) and the utilization of DMTs in France. The use of state sequence analysis (SSA) on data issued from the French National Health Data System (SNDS, i.e. databases from the French Health Insurance System) offers the opportunity to study care pathways. The main objective of this PhD thesis was to study the care pathways of PwMS in France using data from SNDS, in order to describe care-seeking and to create a typology of pathways. The secondary objectives were to study MS DMTs utilization in France (frequency and therapeutic sequences), and the feasibility to measure the level of motor disability in SNDS. Over the 2010-2015 study period, 112,745 PwMS were identified. Amongst them, 47.4% had at least one delivery of a MS-specific DMT. A typology was obtained allowing the identification of five clinically distinct groups of patients. In parallel, a parameter quantifying the level of motor disability in SNDS, which could be replicated in other studies, was defined. Thanks to the different analyses and raised methodological questions, key-elements allowing the use of SSA in health field, especially multichannel sequence analysis, were highlighted.