RESUMO
PURPOSE: Doctors must understand patients' priorities to create an effective treatment partnership. Little is known about whether subspecialist pediatricians understand chronically ill adolescents' preferences. METHODS: A survey was conducted of 155 adolescents with chronic illnesses and 52 subspecialty physicians recruited from the same clinics of a children's hospital. Adolescents and physicians rated the importance that adolescents place on items relating to quality of care and physician-patient communication styles using a previously validated measure. RESULTS: For quality of care items, rank order correlation between physicians and patient responses was high (r = .63, p < .001) and both rated pain management items as most important. Physicians underestimated the importance adolescents placed on communicating with the physician as a friend and medical-technical aspects of care. For communication items, physicians' responses were significantly different than adolescents for 13 of 17 items. Except for three items pertaining to autonomy, physician and patient responses were in the same direction, but adolescent responses were less extreme. CONCLUSIONS: Physicians understood the importance of pain management to adolescents with chronic illnesses, but overestimated their desired level of autonomy. Asking adolescents for their preferences may be the first step in improving adolescents' experience of care.
Assuntos
Serviços de Saúde do Adolescente/estatística & dados numéricos , Manejo da Dor , Relações Médico-Paciente , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adolescente , Comportamento do Adolescente/psicologia , Serviços de Saúde do Adolescente/organização & administração , Adulto , Anemia Falciforme/complicações , Artrite Juvenil/complicações , Criança , Doença Crônica , Fibrose Cística/complicações , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Doenças Inflamatórias Intestinais/complicações , Masculino , Dor/etiologia , Dor/psicologia , Satisfação do Paciente , Vigilância da População , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Scant information exists on the effects of legislation mandating coverage of minimum postnatal hospital stays on infant health outcomes. There are also gaps in knowledge regarding the effectiveness of early follow-up visits for newborns. The objective of this study was to determine the impact of 1) legislation mandating coverage of minimum postnatal hospital stays and 2) early follow-up visits by the age of 4 days on infant outcomes during the first month of life. METHODS: A retrospective analysis was conducted of Ohio Medicaid claims data linked with birth certificate data for the period 1991-1998. The impact of the legislation was evaluated using interrupted time-series analysis of health-related utilization. The effects of early follow-up visits for vaginally delivered newborns with short stays were analyzed using the day of the week on which the birth occurred (eg, Monday, Tuesday) as an instrumental variable to account for potential confounding. A total of 155,352 full-term newborns who were born to mothers who receive Medicaid were studied. The main outcomes measured were rehospitalizations, emergency department (ED) visits, and diagnoses of dehydration and infection within 10 and 21 days of birth. RESULTS: Few outcomes exhibited significant changes after legislation mandating coverage of minimum postnatal hospital stays. Rates of rehospitalization for jaundice within 10 days of birth fell from 0.78% to 0.47% in the year after legislation was introduced but leveled off after the legislation took effect. Rates of ED visits within 21 days increased from 6.0% to 10.4% during periods of increasing short stay but fell to 8.0% during the year after introduction of the legislation and leveled off when the legislation took effect. Rates of all-cause rehospitalization, dehydration, and infection diagnoses showed no consistent relationship to Ohio's legislation. Using instrumental variable analysis, newborns who received early follow-up visits were significantly less likely to have rehospitalizations within the first 10 days of life than those who did not. CONCLUSIONS: In this state Medicaid population, legislation mandating coverage of minimum postnatal hospital stays was associated with reductions in the rates of rehospitalization for jaundice and ED visits. For newborns with short stays, early follow-up visits may reduce rehospitalizations in the early postpartum period.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Icterícia Neonatal/epidemiologia , Tempo de Internação/legislação & jurisprudência , Readmissão do Paciente/estatística & dados numéricos , Desidratação/epidemiologia , Humanos , Recém-Nascido , Infecções/epidemiologia , Modelos Lineares , Medicaid , Ohio , Alta do Paciente/legislação & jurisprudência , Estudos RetrospectivosAssuntos
Seguro de Hospitalização/estatística & dados numéricos , Tempo de Internação/legislação & jurisprudência , Tempo de Internação/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Cuidado Pós-Natal/legislação & jurisprudência , Cuidado Pós-Natal/estatística & dados numéricos , Regulamentação Governamental , Humanos , Recém-Nascido , Cobertura do Seguro/classificação , Seguro de Hospitalização/legislação & jurisprudência , Tempo de Internação/tendências , Medicaid/legislação & jurisprudência , Ohio , Cuidado Pós-Natal/economia , Governo EstadualRESUMO
OBJECTIVES: To examine the impact of state legislation mandating minimum maternal and newborn length of stay (LOS). STUDY DESIGN: By using Medicaid claims data linked to vital statistics files, LOS, and "short stay" (=1 day after vaginal delivery, =2 days after cesarean delivery) were determined for 151,464 term newborns born to mothers receiving Medicaid in Ohio from July 1, 1991 to June 30, 1998. Changes in LOS and "short stay" were examined for 4 periods that reflected events occurring in Ohio at the time. RESULTS: The proportion of newborns discharged after a "short stay" increased dramatically before legislation (7/1/91-8/31/95) but decreased after the introduction of legislation (9/1/95-6/30/96). In the 4 months after passage of the law, but before its effective date (Period III), the odds of a "short stay" decreased. This decrease continued in the 20 months after the law went into effect (Period IV). White, young, married mothers without a high school degree or with poor prenatal care and lower birth weight infants were more likely to be discharged early. CONCLUSIONS: LOS and "short stay" returned to near-1991 levels for Medicaid newborns in Ohio after legislative activity.
Assuntos
Tempo de Internação/legislação & jurisprudência , Medicaid/legislação & jurisprudência , Assistência Perinatal/legislação & jurisprudência , Parto Obstétrico/métodos , Humanos , Recém-Nascido , Tempo de Internação/economia , Modelos Logísticos , Berçários Hospitalares , Razão de Chances , Ohio , Assistência Perinatal/economia , Estudos Retrospectivos , Governo Estadual , Estados UnidosRESUMO
OBJECTIVE: To examine the relationship between the use and type of primary care and visits to the emergency department (ED) in early infancy by healthy infants who are Medicaid recipients. DESIGN: A population-based cohort study using a database linking birth certificate data to Medicaid claims. PARTICIPANTS: A total of 151 464 full-term infants born in Ohio to mothers receiving Medicaid from July 1, 1991, through June 30, 1998. MAIN OUTCOME MEASURES: The primary outcome of interest was the occurrence of an ED visit within 91 days of the neonate's birth. Bivariate and multivariate analyses were performed to determine the effect of early linkage with primary care (within 21 days of birth) on ED use in early infancy. RESULTS: Only 53% of the infants had a documented primary care visit within 21 days of birth. Twenty-eight percent of infants had at least 1 ED visit within 91 days of birth and 9% had more than 1 visit. The mean age of the neonate at the first ED visit was 39.7 days. Fifteen percent of primary care visits within 21 days of birth occurred at a hospital-based primary care clinic. After adjusting for maternal, infant, and residency characteristics and temporal differences, early primary care linkage was associated with a 16% increase in the likelihood of ED use. When the primary care visit occurred in a hospital-based primary care clinic, it was associated with a 27% increase in the likelihood of ED use. CONCLUSION: Contrary to our expectations, early primary care linkage did not result in a decreased risk of ED use.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cuidado Pós-Natal/estatística & dados numéricos , Cuidado Pré-Natal/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Humanos , Lactente , Cuidado do Lactente/estatística & dados numéricos , Recém-Nascido , Medicaid/estatística & dados numéricos , Análise Multivariada , Ohio/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS: Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS: Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION: Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.