RESUMO
Radiation-induced brachial plexus neuropathy (RIBPN) is an uncommon problem. It is a delayed nontraumatic brachial plexus neuropathy following radiation treatment for carcinomas in the region of neck, axilla, and chest wall. The incidence is more commonly reported following radiation treatment for carcinoma of breast. The neurological features are characterized by severe neurogenic pain with progressive sensory-motor deficits in the affected upper limb. The incidence has increased following improved survival rate of patients with carcinomas of neck, axilla, and chest wall. The diagnosis of RIBPN is often confused with recurrence of the tumor in the neck and axilla. The management options are limited, and external neurolysis of the involved brachial plexus with excision of the perineural scar tissue is recommended in patients with severe clinical manifestations. We review our experience in the management of RIBPN from 2004 to 2017 and highlight the features of the 11 patients with this disorder whom we encountered during this period. The relevant clinical findings, natural history, pathophysiology, radiological characteristics, and various management options are briefly discussed.
Assuntos
Neuropatias do Plexo Braquial/diagnóstico , Neuropatias do Plexo Braquial/cirurgia , Neoplasias da Mama/radioterapia , Lesões por Radiação/diagnóstico , Lesões por Radiação/cirurgia , Neoplasias da Mama/complicações , Humanos , Resultado do TratamentoAssuntos
Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Equipamento de Proteção Individual/provisão & distribuição , Pneumonia Viral/prevenção & controle , Ventiladores Mecânicos/provisão & distribuição , COVID-19 , Infecções por Coronavirus/epidemiologia , Pessoal de Saúde , Humanos , Pneumonia Viral/epidemiologia , Estados Unidos/epidemiologiaAssuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição/legislação & jurisprudência , California , Combinação de Medicamentos , Epidemias/prevenção & controle , Infecções por HIV/epidemiologia , Gastos em Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Governo Estadual , Estados Unidos/epidemiologiaRESUMO
Lawrence Gostin and colleagues offer a set of priorities for global health preparedness and response for future infectious disease threats.
Assuntos
Saúde Global , Doença pelo Vírus Ebola/prevenção & controle , Cooperação Internacional , Programas Nacionais de Saúde , Saúde Pública , PesquisaAssuntos
Administração Hospitalar/normas , Administração dos Cuidados ao Paciente/normas , Melhoria de Qualidade , Centers for Medicare and Medicaid Services, U.S. , Política de Saúde , Humanos , Relações Interinstitucionais , Avaliação de Processos e Resultados em Cuidados de Saúde , Administração dos Cuidados ao Paciente/organização & administração , Estados UnidosRESUMO
BACKGROUND: A reduction in hospital readmissions may improve quality and reduce costs. The Centers for Medicare and Medicaid Services has initiated a national effort to measure and publicly report on the conduct of discharge planning. We know little about how U.S. hospitals perform on the current discharge metrics, the factors that underlie better performance, and whether better performance is related to lower readmission rates. METHODS: We examined hospital performance on the basis of two measures of discharge planning: the adequacy of documentation in the chart that discharge instructions were provided to patients with congestive heart failure, and patient-reported experiences with discharge planning. We examined the association between performance on these measures and rates of readmission for congestive heart failure and pneumonia. RESULTS: We found a weak correlation in performance between the two discharge measures (r=0.05, P<0.001). Although larger hospitals performed better on the chart-based measure, smaller hospitals and those with higher nurse-staffing levels performed better on the patient-reported measure. We found no association between performance on the chart-based measure and readmission rates among patients with congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 23.7% vs. 23.5%; P=0.54) and only a very modest association between performance on the patient-reported measure and readmission rates for congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 22.4% vs. 24.7%; P<0.001) and pneumonia (17.5% vs. 19.5%, P<0.001). CONCLUSIONS: Our findings suggest that current efforts to collect and publicly report data on discharge planning are unlikely to yield large reductions in unnecessary readmissions.
Assuntos
Administração Hospitalar/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Benchmarking , Administração Hospitalar/métodos , Administração Hospitalar/normas , Humanos , Alta do Paciente/normas , Estados UnidosAssuntos
Benchmarking , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Qualidade da Assistência à Saúde/legislação & jurisprudência , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde/legislação & jurisprudência , Readmissão do Paciente/tendências , Indicadores de Qualidade em Assistência à Saúde , Estados UnidosRESUMO
OBJECTIVE: This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture. DATA SOURCES: We used individual-level patient data from five care settings. STUDY DESIGN: We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized.. DATA COLLECTION/EXTRACTION METHODS: The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting. CONCLUSION: Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care.
Assuntos
Custos de Medicamentos/estatística & dados numéricos , Idoso Fragilizado/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Fraturas do Quadril , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Austrália , Comparação Transcultural , Países Desenvolvidos , Europa (Continente) , Feminino , Fraturas do Quadril/economia , Fraturas do Quadril/cirurgia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , América do Norte , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Centros de Reabilitação/economia , Centros de Reabilitação/estatística & dados numéricosRESUMO
Social distancing remains an important strategy to combat the COVID-19 pandemic in the United States. However, the impacts of specific state-level policies on mobility and subsequent COVID-19 case trajectories have not been completely quantified. Using anonymized and aggregated mobility data from opted-in Google users, we found that state-level emergency declarations resulted in a 9.9% reduction in time spent away from places of residence. Implementation of one or more social distancing policies resulted in an additional 24.5% reduction in mobility the following week, and subsequent shelter-in-place mandates yielded an additional 29.0% reduction. Decreases in mobility were associated with substantial reductions in case growth two to four weeks later. For example, a 10% reduction in mobility was associated with a 17.5% reduction in case growth two weeks later. Given the continued reliance on social distancing policies to limit the spread of COVID-19, these results may be helpful to public health officials trying to balance infection control with the economic and social consequences of these policies.
Assuntos
COVID-19/epidemiologia , COVID-19/prevenção & controle , Locomoção , Distanciamento Físico , Política de Saúde , Humanos , Saúde Pública , SARS-CoV-2 , Estados Unidos/epidemiologiaAssuntos
Reembolso de Seguro de Saúde , Medicare , Readmissão do Paciente/normas , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Métodos de Controle de Pagamentos/métodos , Centers for Medicare and Medicaid Services, U.S. , Economia Hospitalar , Política de Saúde , Humanos , Reembolso de Seguro de Saúde/normas , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Métodos de Controle de Pagamentos/legislação & jurisprudência , Fatores de Tempo , Estados UnidosRESUMO
Health is influenced by many factors outside the health system. This is often expressed by decomposing contributors to health into factors that sum to 100 percent. In this commentary, we assess the (few) strengths and (many) limitations of such decompositions. We conclude that they fail to be useful for policy guidance. We conclude by proposing an alternative approach to assessing how various factors affect health: evaluations of interventions.
Assuntos
Política de Saúde , Disparidades nos Níveis de Saúde , Determinantes Sociais da Saúde/etnologia , Prática Clínica Baseada em Evidências , Comportamentos Relacionados com a Saúde/etnologia , HumanosRESUMO
Climate change increasingly threatens the ability of the US health care system to deliver safe, effective, and efficient care to the American people. The existing health care system has key vulnerabilities that will grow more problematic as the effects of climate change on Americans' lives become stronger. Thus, health care policy makers must integrate a climate lens as they develop health system interventions. Applying a climate lens means assessing climate change-driven health risks and integrating them into policies and other actions to improve the nation's health. This lens can be applied to rethinking how to take a more population-based approach to health care delivery, prioritize health care system decarbonization and resilience, adapt data infrastructure, develop a climate-ready workforce, and pay for care. Our recommendations outline how to include climate-informed assessments into health care decision making and health policy, ultimately leading to a more resilient and equitable health care system that is better able to meet the needs of patients today and in the future.
Assuntos
Mudança Climática , Política de Saúde , Programas Governamentais , Humanos , Estados Unidos , Recursos HumanosRESUMO
BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure developed in conjunction with the Medicare Payment Advisory Commission. METHODS: We identified beneficiary age, sex, race, and Medicaid eligibility, death date, chronic conditions and healthcare utilization among a 20% sample of Medicare beneficiaries in 2016. For each beneficiary we calculated HDAH for the year by subtracting the following measure components from 365 days: mortality days, the total number of days spent in inpatient, observation, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation and long-term hospital settings as well as the number of outpatient emergency department and home health visits. We examined how HDAH and its components varied by beneficiary demographic characteristics and chronic condition burden as well as by healthcare market (Hospital Referral Region). We specified a patient-level linear regression adjustment model with HDAH as the outcome and incorporated market fixed effects as well as beneficiary age, sex, and Chronic Conditions Warehouse categories as covariates. We examined the impact of including home health visits in the measure, as well as the association between market demographics and health system characteristics and mean market HDAH. We examined how HDAH changed from 2013 to 2016. RESULTS: The 6,637,568 beneficiaries age 65 and older in our sample had a mean of 347.2 HDAH, those 80 and older had a mean of 325.3 while those with three or more chronic conditions had a mean of 333.7. The components that led to the largest reduction in HDAH were mortality (7.4 days), home health (2.7 visits), SNF utilization (2.4 days) and inpatient care (1.5 days). The worst performing market had 5.8 fewer adjusted HDAH on average compared to the national mean, while beneficiaries in the best-performing market had 5.0 more HDAH on average compared to the national mean, among all beneficiaries age 65 and older. CONCLUSIONS: HDAH is a population-based quality measure with substantial market-level variation. IMPLICATIONS: HDAH recognizes the multidimensional nature of healthcare and may afford providers greater flexibility to tailor quality-improvement initiatives to the unique needs of their patients. LEVEL OF EVIDENCE: Level II.