Multimorbidity as a predictor of health service utilization in primary care: a registry-based study of the Catalan population

Background

Multimorbidity is highly relevant for both service commissioning and clinical decision-making. Optimization of variables assessing multimorbidity in order to enhance chronic care management is an unmet need. To this end, we have explored the contribution of multimorbidity to predict use of healthcare resources at community level by comparing the predictive power of four different multimorbidity measures.

Methods

A population health study including all citizens ≥18 years (n = 6,102,595) living in Catalonia (ES) on 31 December 2014 was done using registry data. Primary care service utilization during 2015 was evaluated through four outcome variables: A) Frequent attendants, B) Home care users, C) Social worker users, and, D) Polypharmacy. Prediction of the four outcome variables (A to D) was carried out with and without multimorbidity assessment. We compared the contributions to model fitting of the following multimorbidity measures: i) Charlson index; ii) Number of chronic diseases; iii) Clinical Risk Groups (CRG); and iv) Adjusted Morbidity Groups (GMA).

Results

The discrimination of the models (AUC) increased by including multimorbidity as covariate into the models, namely: A) Frequent attendants (0.771 vs 0.853), B) Home care users (0.862 vs 0.890), C) Social worker users (0.809 vs 0.872), and, D) Polypharmacy (0.835 vs 0.912). GMA showed the highest predictive power for all outcomes except for polypharmacy where it was slightly below than CRG.

Conclusions

We confirmed that multimorbidity assessment enhanced prediction of use of healthcare resources at community level. The Catalan population-based risk assessment tool based on GMA presented the best combination of predictive power and applicability.

[Vertical integration and contracting-out in generic hospital services in Spain]

OBJECTIVES

This study examines the factors that influence make or buy decisions corresponding to four generic services (housekeeping, laundry, food services, and maintenance and security) in Spanish hospitals (3,160 transactions in 790 hospitals).

METHODS

The empirical estimation of a logistic model based on hospital utility maximization is presented. Factors included in the model are not only those related to transaction costs, but also those related to public intervention and the political dimension.

RESULTS

A total of 55.7% of hospitals contracted-out at least one of the generic services. The services most frequently contracted-out were housekeeping and maintenance and security(45.1 and 32.5%, respectively). In contrast, the services (94.3% and 80.1%, respectively). Hospital size (economies of scale), measured by the number of beds, was one of the most important factors influencing make or buy decisions.

CONCLUSIONS

We find evidence that economies of scale are related to a higher level of vertical integration, while specialization and for-profit objectives favor the decision to contract-out. The choice of organizational model for laundry services presents a different pattern from that of the other three services. Empirical results show that some asset specificity could be present in laundry services.

Disruption of neuronal migration and radial glia in the developing cerebral cortex following ablation of Cajal-Retzius cells

Cortical neurons are generated within the proliferative layer and follow a strict 'inside-out' gradient of migration and positioning, which determines the characteristic layering and pattern of neural connections in the adult cerebral cortex. Thus, directional migration of postmitotic neuroblasts towards layer I and regulation of the radial glia phenotype subserving cortical migration are central issues in corticogenesis. Recent studies showing that the gene disrupted in the reeler mutation--reelin--is expressed in Cajal-Retzius cells have indicated a role for these pioneer neurons in cortical migration. We show here that ablation of Cajal-Retzius cells in layer I by local application of domoic acid in newborn mice arrests migration of the late-generated neurons, destined to cortical layers II-III, that have been labeled by 5-bromodeoxyuridine injections administered at E16. In addition, degeneration of Cajal-Retzius cells in newborn mice dramatically decreases the number of radial glial apical processes identified by nestin-immunostaining, but increases the number of maturing glial fibrillary acidic protein-positive astrocytes. These findings support an essential role for Cajal-Retzius cells in neuronal migration and corticogenesis, by regulating the identity and function of radial glia and the radial glia-to-astrocyte transformation.

The early development of thalamocortical and corticothalamic projections in the mouse

The initial ingrowth of corticothalamic and thalamocortical projections was examined in mice at embryonic and perinatal stages. Fibers, in fixed brains, were labeled with the carbocyanine dye 1, 1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocianine perchlorate (DiI). By E13, the corticofugal fibers had entered the lowest intermediate zone through which they ran, turned over the corpus striatum, and left the cortex. The fibers were arranged in scattered bundles throughout the corpus striatum. At E14 corticofugal axons reached the internal capsule and at E14.5-E15 they established contact within the thalamus. Meanwhile, the thalamocortical afferents reached the neocortex at E13. At this time fibers ran tangentially within the intermediate zone, immediately underneath the cortical plate. By E14, the fibers had started to invade the subplate and, by E15, thalamocortical fibers had begun their radial growth into the cortex. Such radial growth proceeded steadily, invading each cortical layer as it differentiated cytoarchitectonically from the dense cortical plate. The first retrogradely labeled cells were detected at the cortical plate at E15. By the day of birth (E20), thalamocortical fibers had formed a dense branching system within layers VI and V. Our observations indicate that, in mice, the thalamic axons reach the cortex before corticothalamic projections enter the thalamic nuclei. Moreover, the results suggest that the pathway followed by each fiber system is different. By DiI injections into the internal capsule we have also determined that subplate cells are the first to send axons to the thalamus.