Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Parental care as a game

A new game model of parental care is presented where fitnesses of males and females depend on frequencies of care and no-care strategies in the population, as well as strategies of individuals and those of their mates. Evolutionarily stable states (ESS) of biparental-care ( BC ), female-care ( FC ), male-care ( MC ), and no-care ( NC ) are represented as regions in a 3-dimensional parameter space, comprising the ratio of the number of offspring raised by FC or MC to that by BC , the ratio of that by NC to that by FC or MC , and the sex ratio. ESSs are not necessarily uniquely determined: ESS regions of FC and MC overlap in parts, as well as those of BC and NC . In a region where none of the four states is ever an ESS, a polymorphism (a mixed state of care and no-care strategies in one or both sexes) is stable. Although an asymmetry between prezygotic investment times of males and females results in the difference in sizes of the ESS regions of FC and MC , it is not responsible for determining whether FC or MC evolves from other modes of parental care as a result of slowly changing parameters. The key factor is the sex ratio of adults in the population. By a slightly modified model, it is also shown that paternity uncertainty at fertilization of eggs is highly important for evolution of FC .     

Brood care in a Silurian ostracod

An exceptionally preserved new ostracod crustacean from the Silurian of Herefordshire, England, preserves eggs and possible juveniles within its carapace, providing an unequivocal and unique view of parental brood care in the invertebrate fossil record. The female fossil is assigned to a new family and superfamily of myodocopids based on its soft-part anatomy. It demonstrates a remarkably conserved egg-brooding reproductive strategy within these ostracods over 425 Myr. The soft-tissue anatomy urges extreme caution in classifying 'straight-hinged' Palaeozoic ostracods based on the carapace alone and fundamentally questions the nature of the shell-based Palaeozoic ostracod record.     

Lesbian health care. What a primary care physician needs to know.

Many primary care physicians take care of lesbians and women sexually active with women without being aware of their patients'' sexual orientation. These women have unique medical and psychosocial needs that each physician must consider. Lesbian identity or being sexually active exclusively with women influences care in areas such as sexually transmitted diseases, risk of human immunodeficiency virus infection, counseling, cancer risk, screening, parenting, depression, alcohol use, and violence. We review an approach to taking a history with all women that facilitates open, comfortable communication with lesbians. We also review specific medical and psychosocial areas of primary care in which caring for lesbians is different from caring for other women. Further research is needed on lesbian health issues to provide appropriate guidelines to clinicians.     

Innovative parental care in a myrmecophageous mammal

Male bat-eared foxes, Otocyon megalotis, are known to contribute extensively to parental care. Yet, the exact roles that males and females play in raising offspring remain relatively unexplored. Here, we describe interactions between adult foxes and their presumed offspring based on a pilot study on three family groups of a wild population in South Africa. We report the first recorded instance of dung provisioning observed in canids. A male bat-eared fox provided dung to his offspring during a foraging trip, presumably to give them access to the ensconced insects. Further, this male provisioned the young foxes with large, live insects. Similar to other researchers, we never observed provisioning by females, but the females in this population did interact socially with their young in addition to suckling. We emphasize the importance of anecdotal reports of novel behavioural responses in wild canids, as an accumulation of such evidence may reveal patterns of innovative behaviour presently unrecognized in this family.     

Parental care: a freshwater phenomenon?

Synopsis Attempts have been made to explain the over-representation of parental care in teleost fish families in freshwater habitats by selection due to environmental conditions typical of freshwater. I argue that alternative hypotheses, such as selection for pelagic spawning in marine habitats, can account for the pattern. The fact that parental care is less common among primary freshwater fishes contradicts the view that there is strong selection for parental care in fresh waters, and suggests that phylogenetic relationships must be taken into account.     

Respite care on a children's ward.

In March 1984 a short term respite care facility for handicapped children was opened in a children''s ward catering primarily for acute medical and surgical problems. The facility was based on a four bedded room designed so that if beds became short in the main ward it could revert immediately to the care of acutely sick children. Three nurses were appointed specifically to staff the facility, the nursing budget for the rest of the ward being reduced proportionately. Conversions were funded by charities and some of the conversion work done by volunteers. The main users were totally dependent children aged under 5 with severe mental and physical handicaps. Parents found the service invaluable, and in addition to planned admissions it was usually possible to accept a child at short notice--for example, when some domestic crisis occurred. Only very rarely was admission impossible because of the needs of acutely ill children. A short term respite care facility not only helps parents cope and may provide beneficial experience for a handicapped child but is also a useful training ground for medical students and junior staff.