Frontloading, providing 60% of planned visits in the first 2 weeks of the home healthcare episode, was tested in two groups of patients: insulin-dependent patients with diabetes and patients with a primary diagnosis of heart failure. Frontloading was effective for patients with heart failure, decreasing rehospitalization by more than half (39.4-16%), with fewer visits (15.5 vs. 9.5) and equal clinical outcomes and patient satisfaction. There were no significant differences in outcomes for patients with diabetes.
Home care agencies are under pressure to deliver high-quality care with outcomes that demonstrate reduced patient rehospitalization. One approach found to be successful in reducing rehospitalization of heart failure patients is front loading visits. Our recent study showed front loading was effective for patients with heart failure, dramatically decreasing rehospitalization by more than one half (30.4% to 16%). Other methods utilized to enhance front loading are supplementation of visits with telehealth and/or telemonitoring and the use of established care paths. This article discusses the many challenges home care agencies face in implementing redesign and these best practice measures.
Despite being of fundamental importance, the late results of major arterial reconstruction rarely have been documented throughout a large metropolitan area. In this study of 932 patients entered into the computer registry of the Cleveland Vascular Society, 19 surgeons representing 13 community hospitals and referral centers in Cleveland and Akron report the intermediate-term outcome during a mean interval of 35 months after infrainguinal lower extremity revascularization performed in northeastern Ohio from 1978 through 1982. Operative risk (5%), the early amputation rate (7%), and actuarial 5-year survival (48% to 55%) for patients with rest pain or tissue necrosis were significantly worse (p less than 0.05) than comparable figures (0.6%, 0%, and 77%, respectively) for others who underwent procedures for disabling claudication. Although both materials had similar success above the knee, the cumulative 3-year patency rate of autogenous vein bypass to the distal popliteal (69% to 88%; p less than 0.05) and tibioperoneal arteries (43%; 0.05 less than p less than 0.1) was superior to the results of polytetrafluoroethylene grafts (32% to 50% and 19%, respectively). Moreover, polytetrafluoroethylene grafts required reoperations at three times the rate of vein grafts to maintain limb salvage.
Despite being of fundamental importance, the late results of major arterial reconstruction rarely have been documented throughout a large metropolitan area. In this study of 932 patients entered into the computer registry of the Cleveland Vascular Society, 19 surgeons representing 13 community hospitals and referral centers in Cleveland and Akron report the intermediate-term outcome during a mean interval of 35 months after infrainguinal lower extremity revascularization performed in northeastern Ohio from 1978 through 1982. Operative risk (5%), the early amputation rate (7%), and actuarial 5-year survival (48% to 55%) for patients with rest pain or tissue necrosis were significantly worse (p < 0.05) than comparable figures (0.6%, 0%, and 77%, respectively) for others who underwent procedures for disabling claudieation. Although both materials had similar success above the knee, the cumulative 3-year patency rate of autogenous vein bypass to the distal popliteal (69% to 88%; p< 0.05) and tibioperoneal arteries (43%; 0.05 < p < 0.1) was superior to the results ofpolytetrafluoroethylene grafts (32% to 50% and 19%, respectively). Moreover, polytetrafluoroethylene grafts required reoperations at three times the rate of vein grafts to maintain limb salvage.
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