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The built and social neighborhood environment where a child lives has been increasingly studied as an exposure that may affect child weight long term. We conducted a systematic review of primary research articles published in 2011 through 2019 that reported results from longitudinal analyses of associations between neighborhood environment characteristics and child obesity or weight. Neighborhood environment measures included proximity to food stores, parks, and recreational facilities, walkability, crime, perceived safety, and social cohesion. Information on study population, exposure and outcome measures, and main results were extracted from 39 studies and results were presented for full cohorts and stratified by sex. Most studies were prospective cohorts (90%) with a median follow-up time of six years. Studies analyzing changes in the neighborhood versus changes in weight were less common than approaches analyzing baseline measures of the neighborhood environment in relation to obesity incidence or weight trajectories. Associations varied by sex, race/ethnicity, and age group. Within the food environment domain, the strongest evidence of adverse impact was for fast food restaurants but the effect was only apparent among girls. Results suggested green space, parks, and recreational facilities may have a beneficial effect on weight. Increased crime and low perceived safety may be risk factors for increased weight although not all studies were consistent. Standardization of measures across studies, investigation of multiple social and physical environment measures simultaneously, effect modification by demographic characteristics, and change in the environment vs change in weight analyses are needed to strengthen conclusions.
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Obesidade Infantil , Criança , Planejamento Ambiental , Feminino , Humanos , Estudos Longitudinais , Obesidade Infantil/epidemiologia , Obesidade Infantil/etiologia , Estudos Prospectivos , Características de Residência , Meio SocialRESUMO
BACKGROUND: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown. METHODS: A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts. RESULTS: To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico's previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India's previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030. CONCLUSION: With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.
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Saúde Global , Mão de Obra em Saúde/tendências , Cirurgiões/provisão & distribuição , Países em Desenvolvimento , Humanos , Modelos Estatísticos , Cirurgiões/tendênciasRESUMO
OBJECTIVE: Study the prevalence of otologic disease in a pediatric post-palatoplasty population with no prior ear tube placement in resource-deprived countries and assess patient characteristics associated with these abnormal results. DESIGN: Retrospective data review. PARTICIPANTS: Ecuadorian and Chinese children identified during humanitarian cleft lip and palate repair trips with cleft palates undergoing palatoplasty from 2007 to 2010. INTERVENTIONS: Tympanometry and otoacoustic emission (OAE) testing performed following palatoplasty. Patients' parents administered surveys regarding perceived hearing deficits. MAIN OUTCOME MEASURES: Age, gender, Veau classification, follow-up time, laterality, and country of origin were evaluated for possible association with type B tympanogram, "Refer" Otoacoustic results, and presence of hearing difficulty as identified by a parent. Significant predictors were further evaluated with multivariate analysis. RESULTS: The cohorts included 237 patients (129 Ecuadorian, 108 Chinese); mean age: 3.9 years; mean follow-up: 4.2 years. Thirty-nine percent scored type B, 38% failed OAE testing, and 8% of parents noted hearing deficits. The country of origin and a younger age were identified as predictive variables regarding type B tympanogram. Follow-up time, country of origin, and bilateral OAE "Refer" results all significantly predicted parental questionnaire results. Subsequent multivariable analysis further demonstrated effect modification between the 2 variables of age at palatoplasty and country of origin when predicting type B vs type A tympanometry. CONCLUSION: Without otologic intervention, cleft palate children in resource-deprived settings suffer type B tympanometry and failed OAE results with similar to increased incidences to other studied cleft palate populations with otologic interventions available.
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Fissura Palatina/cirurgia , Otopatias/etiologia , Complicações Pós-Operatórias/etiologia , Testes de Impedância Acústica , Pré-Escolar , China/epidemiologia , Otopatias/diagnóstico , Otopatias/epidemiologia , Equador/epidemiologia , Feminino , Humanos , Masculino , Missões Médicas , Emissões Otoacústicas Espontâneas , Complicações Pós-Operatórias/epidemiologia , Prevalência , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States. METHODS: This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation. RESULTS: The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation. CONCLUSIONS: Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.
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Fissura Palatina/cirurgia , Fístula Bucal/etiologia , Organizações sem Fins Lucrativos , Procedimentos de Cirurgia Plástica/métodos , Padrões de Prática Médica/estatística & dados numéricos , Centros de Atenção Terciária , Canadá , Criança , Pré-Escolar , China , Competência Clínica , Feminino , Humanos , Lactente , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Estados UnidosRESUMO
PURPOSE: Most patients with juvenile idiopathic arthritis (JIA) have temporomandibular joint (TMJ) involvement, but little is known about the natural history of TMJ disease as these children enter adulthood. The purpose of this study was to evaluate adults with a history of JIA to document the frequency and severity of TMJ abnormalities and morbidity. The authors hypothesized that most would have persistent TMJ disease as adults. MATERIALS AND METHODS: This cross-sectional study included adults (>19 years of age) with JIA who were managed at Boston Children's Hospital (BCH) as children and at Brigham and Women's Hospital (BWH) as adults. History of a TMJ problem was not considered for enrollment. Patients completed a questionnaire and underwent physical examination and maxillofacial cone-beam computed tomography (CBCT). Additional data were obtained from medical records. Associations between TMJ abnormalities at CBCT and arthritis history, TMJ pain and function, facial asymmetry, malocclusion, and cephalometric analysis were examined. RESULTS: Of 129 eligible patients contacted, 21 (42 TMJs) were enrolled. Mean age was 26.0 ± 6.1 years and mean duration of care for JIA at the BCH and BWH was 13.7 ± 6.5 years. TMJ pain was present in 62% of patients (n = 13); 43% (n = 9) had a TMJ functional limitation and 76% (n = 16) had lower facial asymmetry. Abnormalities were found in the TMJs on 55% of CBCT scans, with 79% showing bilateral deformities. There was at least 1 cephalometric measurement of mandibular size or position that was more than 1 standard deviation beyond normal in 81% of patients (n = 17). Only 4 patients (19%) had previously been evaluated for a TMJ problem. CONCLUSION: TMJ abnormalities and related morbidity are common in adult patients with a history of JIA. Therefore, an early screening protocol for TMJ involvement in children with a new diagnosis of JIA would be beneficial and long-term follow-up into adulthood should be routine.
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Artrite Juvenil/complicações , Transtornos da Articulação Temporomandibular/etiologia , Adulto , Cefalometria , Tomografia Computadorizada de Feixe Cônico , Estudos Transversais , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Inquéritos e Questionários , Transtornos da Articulação Temporomandibular/diagnóstico por imagemRESUMO
OBJECTIVE: Patient-specific three-dimensional (3D) models are increasingly used to virtually plan rare surgical procedures, providing opportunity for preoperative preparation, better understanding of individual anatomy, and implant prefabrication. The purpose of this study was to assess the benefit of 3D models related to patient safety, operative time, and cost. DESIGN: Retrospective review. SETTING: Academic, tertiary care hospital. PATIENTS, PARTICIPANTS: Midfacial distraction was studied as a representative craniofacial operation. A consecutive series of 29 patients who underwent a single type of midfacial distraction was included. INTERVENTION: For a subset of patients, computed tomography-derived 3D models were used to study patient-specific anatomy and precontour hardware. MAIN OUTCOME MEASURES: Complications, operative time, blood loss, and estimated cost. RESULTS: Twenty patients underwent midfacial distraction without and nine with preoperative use of a 3D model. Seven complications occurred in six patients without model use, including premature consolidation (3), cerebrospinal fluid leak (2), and hardware malfunction (2). No complications were reported in the model group. Controlling for surgeon variation, model use resulted in a 31.3-minute (7.8%) reduction in operative time. Time-based cost savings were estimated to be $1036. CONCLUSIONS: Three-dimensional models are valuable for preoperative planning and hardware precontouring in craniofacial surgery, with potential positive effects on complications and operative time. Savings related to operative time and complications may offset much of the cost of the model.
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Disostose Craniofacial/cirurgia , Modelos Anatômicos , Osteogênese por Distração/economia , Osteogênese por Distração/métodos , Perda Sanguínea Cirúrgica , Criança , Análise Custo-Benefício , Feminino , Humanos , Masculino , Duração da Cirurgia , Osteotomia de Le Fort/métodos , Projetos Piloto , Complicações Pós-Operatórias , Impressão Tridimensional , Estudos Retrospectivos , Resultado do TratamentoRESUMO
EXECUTIVE SUMMARY: Hospitals in the United States have started collecting information related to the patient experience with the objective of improving overall patient satisfaction. Between 2012 and 2015, the authors collected data from 2,875 patient satisfaction surveys. The purpose of this study was to analyze the effects of several variables-wait time, physician courtesy, administrative staff courtesy, patients' opportunity to ask questions, and patients' understanding of the answers-on a patient satisfaction score. A linear regression model was used to analyze the effects of these variables on patient satisfaction. All variables but one were significantly associated with patient satisfaction in the multivariable model. Healthcare provider courtesy was the strongest predictor of patient satisfaction; a score of "excellent" was associated with a 2.63-point (95% confidence interval [2.36, 2.90]) increase on a 5-point scale for patient satisfaction compared with a courtesy score of "poor." These findings suggest that patients had a positive experience when physicians and staff members were courteous.
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Satisfação do Paciente , Cirurgia Bucal , Cirurgia Plástica , Criança , Serviço Hospitalar de Emergência , Humanos , Médicos , Estados UnidosRESUMO
BACKGROUND: Surgical delivery varies 150-fold across countries. However, no direct correlation exists between surgical delivery and health outcomes, making it difficult to pinpoint a goal for surgical scale-up. We attempted to determine the amount of surgery that would be delivered worldwide, if the world aligned itself with countries providing the best health outcomes. METHODS: The number of cases performed annually has previously been published for 55 countries, which we stratified by World Bank income group. Life expectancy, maternal mortality, under-5 mortality, adult mortality, and a composite outcome of the four were plotted against reported surgical delivery. Univariate and multivariate polynomial regression curves were fit, and the optimum point on each regression curve was determined by solving for first-order conditions. The country closest to the optimum for each health outcome was taken as representative of the best-performing health system. Monetary inputs to, and surgical procedures provided by, these health systems were scaled to the global population. FINDINGS: For the five health outcomes, four countries (Sweden, Germany, Singapore, and Canada) performed at the optimum. Currently, 318 million procedures are provided annually around the world. If global surgical delivery mirrored delivery in the four best-performing countries, however, between 630 million (maternal survival) and 870 million cases (composite outcome) would be provided annually. With population growth, this will increase to between 750 million and 1 billion annual cases, respectively, by 2030. The best-performing health systems spend roughly 10% of their gross domestic product on health-care, providing 9000-12 000 cases per 100 000 individuals in the population. INTERPRETATION: To the best of our knowledge this is the first study to provide empirical evidence for the surgical output that an ideal health system would provide. The findings in this study provide a potential goal for surgical scale-up around the world. FUNDING: National Institutes of Health/National Cancer Institute.
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BACKGROUND: Countries with fewer than 20 specialist surgeons, anaesthetists, and obstetricians (SAO) per 100â000 population have worse health outcomes. To achieve surgical workforce densities of 20 per 100 000 by 2030, a scale up of the surgical workforce is required. No previous study has shown what this will cost, how many providers will be required, or how long it will take to increase the global surgical workforce. We aim to identify these answers for health-care systems that employ SAO alone and for those that use a hybrid model of SAO and task shifting to inform strategic planning. METHODS: Data for the density of SAO per country were obtained from the WHO Global Surgical Workforce Database. To find the total number of SAO that need to enter the workforce by 2030 to achieve surgical workforce thresholds of 20 per 100â000, the population growth formula (P=0e(rt)) was used and we assumed exponential surgical workforce growth and two potential retirement rates of either 1% or 10%. We did not account for migration. The same calculations were used for associate clinicians needed to enter the workforce in either a 2:1 or 4:1 associate clinicians-to-SAO ratio. The costs to train SAO and associate clinicians were estimated with data for training costs imputed into a regression analysis with health-care expenditure per capita for each country. We assumed training costs will remain constant, and we did not account for inflation. The time needed to train new surgical and anaesthetic providers was estimated with average length of training for SAO and associate clinicians and was measured in person years. Two models (one for a system of SAO only and one for a hybrid of SAO and associate clinicians) were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030. The model did not involve the scale-up of the surgical workforce needed to address unmet needs of essential surgical services. FINDINGS: By 2030, the world will need 1â272â586 new surgical workforce providers to meet a surgical workforce density of 20 per 100â000 assuming a 1% retirement rate. This will cost US$71-146 billion depending on the model used. Low-income and lower-middle-income countries show the largest required scale-up. An additional 806â352 (median 3412 [IQR 691-6851]) providers are needed in those countries. In the SAO only model, this will cost a median of US$19·66 per 2013 capita (IQR 15·79-25·07) and will take a median of 34â121 person years (IQR 6911-68â509). In the 4:1 associate clinician-to-SAO ratio, it will cost a median of US$7·57 per capita and take 20â472 person years. When accounting for the delay of entry to the workforce due to training in these countries, the median rate of entry to meet the goal density will have to increase 10·9 times after a 10 year delay in an SAO only model as opposed to 4·98 times with a 5 year delay in the hybrid 4:1 associate clinician-to-SAO model. INTERPRETATION: Although low-income countries, lower-middle-income countries, and upper-middle-income countries will require a surgical workforce scale-up, lower-middle-income countries will require the largest scale-up. In these countries, implementing a system of task shifting can decrease costs and training times by 40%. Meeting densities of 20 per 100â000 will not guarantee quality care or improved access in rural areas, and equal attention must be paid to the provision of safe, affordable, accessible surgical care to all who need it. FUNDING: None.
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BACKGROUND: Humanitarian surgical organisations provide cleft palate repair for patients without access to surgical care. Despite decades of experience, very little research has assessed the outcomes of these trips. This study investigates the fistula rate in patients from two cohorts in rural China and one in the USA. METHODS: This retrospective study compared the odds of fistula presentation among three cohorts whose palates were repaired between April, 2005, and November, 2009. The primary cohort included 97 Chinese patients operated on in China by surgeons from ReSurge International. A second Chinese cohort of 250 patients was operated on at Huaxi University Hospital by Chinese surgeons. The third cohort of 120 patients from the University of California San Francisco (UCSF) was included for comparison over the same time period; data was taken from medical records. Age, fistula presentation, and Veau Class were compared between the three cohorts with χ(2) tests. Logistic regression was used to analyse predictors of fistula presentation among the three cohorts. This study received institutional review board approval from the UCSF, the Harvard School of Public Health, and physicians at Huaxi University Hospital, and written consent was obtained from study participants in China. FINDINGS: The fistula risk was 35·4% in ReSurge patients, 12·8% for patients at Huaxi University Hospital, and 2·5% for patients at UCSF (p<0·001). At the time of surgery 15·5% of the ReSurge patients were younger than 2 years old, whereas 90·8% of the UCSF children and 41·6% of the Huaxi children were (p<0·001). In the ReSurge cohort, 20·6% of patients had a Veau class of I or II, wheras 40·8% and 58·9% of UCSF and Huaxi patients, respectively, were in class I or II (p<0·001). Age and Veau Class were associated with fistula formation in a univariate analysis. (Veau Class III or IV vs I or II, odds ratio [OR] 6·399 [95% CI 3·182-12·871]; age, OR 1·071 [95% CI 1·024-1·122]). A multivariate model controlling for the surgical group, age at palatoplasty, and sex showed an association between Veau Class and the odds of fistula presentation (Class III or IV vs I or II, OR 5·630 [95% CI 2·677-11·837). In this model, UCSF patients and Huaxi patients had 0·064 and 0·451 times the odds of developing a fistula, respectively, compared with ReSurge patients (p<0·001 both). INTERPRETATION: Chinese children undergoing palatoplasty on surgical missions have higher post-operative odds of palatal fistula than do children treated by local physicians. Children in low-resource settings have higher complication rates than do children in high-resource settings. Older age at palatoplasty and a Veau class III and IV are associated with post-palatoplasty fistula. Furthermore demographic, socioeconomic, and cultural differences could play a part in palatoplasty fistula outcomes between these three populations. More research is needed to determine the effects of post-operative care, the skill of the providers, and the technique used in the surgery that play a role on fistula outcomes after primary palatoplasty, particularly in low-resource environments. FUNDING: None.
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During August 4-September 1, 2015, eight cases of Verona integron-encoded metallo-beta-lactamase (VIM)-producing Carbapenem-resistant Enterobacteriaceae (CRE) colonization were identified in six patients, using weekly active surveillance perirectal cultures in a Kentucky tertiary care hospital. No cases of clinical infection or complications attributable to colonization were reported. Four of the eight isolates were identified as Enterobacter cloacae; other organisms included Raoultella species (one), Escherichia coli (one), and Klebsiella pneumoniae (two). Six isolates were reported in a neonatal intensive care unit (ICU), and two isolates in an adult trauma and surgical ICU. Patient ages at isolate culture date ranged from 21 days to 68 years. Fifty percent of the patients were male. Previously, only one VIM-producing CRE-colonized patient (an adult, in 2013) had been reported by the same hospital. The six cases are the largest occurrence of VIM-producing CRE colonization reported in the United States and the only recognized cluster of VIM-producing CRE colonization in the United States reported to include a neonatal population. Despite environmental sampling over the same period, surveying patients for exposure to health care outside the United States, surveying health care providers for risk factors, and surveillance culturing of health care provider nares and axillae, a source of VIM-producing CRE has not been identified for this cluster. Prevention measures throughout the ICUs have been enhanced in response to this cluster, as detailed in CDC's 2015 CRE toolkit update.
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Carbapenêmicos/farmacologia , Farmacorresistência Bacteriana , Enterobacteriaceae/efeitos dos fármacos , Enterobacteriaceae/enzimologia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , beta-Lactamases/biossíntese , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Integrons , Kentucky , Masculino , Pessoa de Meia-Idade , Adulto Jovem , beta-Lactamases/genéticaRESUMO
BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.
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Países em Desenvolvimento , Cirurgia Geral/normas , Acessibilidade aos Serviços de Saúde/normas , Hospitais/normas , Cesárea , Emergências , Feminino , Fraturas Expostas/cirurgia , Recursos em Saúde/provisão & distribuição , Humanos , Laparotomia , GravidezRESUMO
PURPOSE: To determine the effects on time, cost, and complication rates of integrating physician assistants (PAs) into the procedural components of an outpatient oral and maxillofacial surgery practice. MATERIALS AND METHODS: This is a prospective cohort study of patients from the Department of Plastic and Oral Surgery at Boston Children's Hospital who underwent removal of 4 impacted third molars with intravenous sedation in our outpatient facility. Patients were separated into the "no PA group" and PA group. Process maps were created to capture all activities from room preparation to patient discharge, and all activities were timed for each case. A time-driven activity-based costing method was used to calculate the average times and costs from the provider's perspective for each group. Complication rates were calculated during the periods for both groups. Descriptive statistics were calculated, and significance was set at P < .05. RESULTS: The total process time did not differ significantly between groups, but the average total procedure cost decreased by $75.08 after the introduction of PAs (P < .001). The time that the oral and maxillofacial surgeon was directly involved in the procedure decreased by an average of 19.2 minutes after the introduction of PAs (P < .001). No significant differences in postoperative complications were found. CONCLUSIONS: The addition of PAs into the procedural components of an outpatient oral and maxillofacial surgery practice resulted in decreased costs whereas complication rates remained constant. The increased availability of the oral and maxillofacial surgeon after the incorporation of PAs allows for more patients to be seen during a clinic session, which has the potential to further increase efficiency and revenue.
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Dente Serotino/cirurgia , Procedimentos Cirúrgicos Bucais/economia , Assistentes Médicos/economia , Papel Profissional , Melhoria de Qualidade , Dente Impactado/cirurgia , Boston/epidemiologia , Controle de Custos , Eficiência , Feminino , Humanos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Salários e Benefícios/economiaRESUMO
EXECUTIVE SUMMARY: The purpose of this study was to understand the true cost of administering prophylactic antibiotics postoperatively to patients undergoing cleft lip and lip adhesion procedures for which the rate of infection is historically low. Using time-driven activity-based costing (TDABC) methodologies, the plastic surgery department of one hospital created a process map with related time intervals and personnel cost rates for administering the antibiotic. The cost for each provider, based on standard salary information, was multiplied by the time required to complete his or her stage of the process, and this outcome was added to the supply costs. Overall cost was determined by summing the cost of all the steps. The cost of administering four doses of ampicillin/sulbactam to a patient during an inpatient stay ranged from $61.91 to $81.83. The total cost included all steps, from the initial antibiotic prescription through the final administration by a nurse. We attributed variations in cost to the staff member's level of familiarity with the antibiotic and dosing protocols for that patient. Over the course of a year, the cost of administering prophylactic antibiotics for this patient population was between $3,281.23 and $4,336.99. The results of this study effectively demonstrate the use of TDABC to determine the cost of administering prophylactic postoperative antibiotics. If we assume that antibiotics are of limited value for all clean-contaminated plastic surgery procedures, the plastic surgery department can expect to save $18,000 to $22,000 each year by forgoing their use. Furthermore, when clinically supported, reducing the use of prophylactic antibiotics not only diminishes the cost of care but also reduces the complexity of postoperative care.
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Antibioticoprofilaxia/economia , Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Padrões de Prática Médica/economia , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/prevenção & controle , Aderências Teciduais/cirurgia , HumanosRESUMO
Purpose: This study estimated the magnitude and duration of risk of cardiovascular events and mortality following acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and whether risks varied by number and severity of exacerbation in a commercially insured population in the United States. Methods: This was a retrospective cohort study of newly diagnosed COPD patients ≥40 years old in the Healthcare Integrated Research Database from 2012 to 2019. Patients experiencing exacerbations comprised the "exacerbation cohort". Moderate exacerbations were outpatient visits with contemporaneous antibiotic or glucocorticoid administration; severe exacerbations were emergency department visits or hospitalizations for AECOPD. Follow-up started on the exacerbation date. Distribution of time between diagnosis and first exacerbation was used to assign index dates to the "unexposed" cohort. Cox proportional hazards models estimated risks of a cardiovascular event or death following an exacerbation adjusted for medical and prescription history and stratified by follow-up time, type of cardiovascular event, exacerbation severity, and rank of exacerbation (first, second, or third). Results: Among 435,925 patients, 170,236 experienced ≥1 exacerbation. Risk of death was increased for 2 years following an exacerbation and was highest during the first 30 days (any exacerbation hazard ratio (HR)=1.79, 95% CI=1.58-2.04; moderate HR=1.22, 95% CI=1.04-1.43; severe HR=5.09, 95% CI=4.30-6.03). Risks of cardiovascular events were increased for 1 year following an AECOPD and highest in the first 30-days (any exacerbation HR=1.34, 95% CI=1.23-1.46; moderate HR=1.23 (95% CI 1.12-1.35); severe HR=1.93 (95% CI=1.67-2.22)). Each subsequent AECOPD was associated with incrementally higher rates of both death and cardiovascular events. Conclusion: Risk of death and cardiovascular events was greatest in the first 30 days and rose with subsequent exacerbations. Risks were elevated for 1-2 years following moderate and severe exacerbations, highlighting a sustained increased cardiopulmonary risk associated with exacerbations.
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Doenças Cardiovasculares , Doença Pulmonar Obstrutiva Crônica , Humanos , Adulto , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Estudos Retrospectivos , Antibacterianos , Análise por Conglomerados , Doenças Cardiovasculares/diagnósticoRESUMO
OBJECTIVE: To assess whether recombinant zoster vaccine (RZV) is associated with an increased risk of new-onset gout among US adults aged ≥50 years. METHODS: We conducted a real-world, retrospective safety study with a self-controlled risk interval (SCRI) design using administrative claims data. We included health plan members aged ≥50 years with RZV exposure, followed by incident gout within 60 days. Days 1-30 following RZV exposure were considered the risk window (RW), and days 31-60 were considered the control window (CW). We estimated the risk ratio (RR) of gout in the RW versus CW, using a conditional Poisson model. The primary analysis estimated the risk of incident gout following any RZV dose. Sensitivity analyses evaluated dose 1- and dose 2-specific risks, risk among patients compliant with recommended dose spacing of 60-183 days, adjustment for seasonality, and restriction to the pre-COVID-19 era (before December 1, 2019). RESULTS: A total of 461,323 individuals received ≥1 RZV dose; we included 302 individuals (mean age 72.5 years; 66 % male) with evidence of new-onset gout within 60 days in SCRI analyses. A total of 153 (50.7 %) individuals had gout events in the RW and 149 (49.3 %) in the CW (RR 1.03; 95 % confidence interval 0.81, 1.29). All sensitivity analyses had consistent results, with no association of RZV with incident gout. CONCLUSION: In a population of US adults aged ≥50 years, there was no statistically significant increase in the risk of gout during the 30 days immediately after RZV exposure, compared with a subsequent 30-day CW.
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Objective-This report presents national estimates of selected fertility measures for men and women aged 15-49 in the United States in 2015-2019, based on data from the National Survey of Family Growth (NSFG). Overall estimates for 2015-2019 are compared with those for 2011-2015.
Assuntos
Fertilidade , Feminino , Humanos , Masculino , Estados Unidos , Adolescente , Adulto , Pessoa de Meia-IdadeRESUMO
Objective-This report describes methods of contraception ever used by U.S. women ages 15-49 who had ever had sexual intercourse with a male partner. Estimates are shown overall and by Hispanic origin and race, education, religious affiliation and importance, and urban-rural residence. Discontinuation of selected contraceptive methods is also described. Methods-This report focuses on information collected from the 11,695 women ages 15-49 interviewed in the 2015-2019 National Survey of Family Growth, a nationally representative survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Most estimates shown are based on data on contraceptive methods ever used by the 10,122 interviewed women who had ever had sexual intercourse with a male partner. Results-Based on 2015-2019 data, virtually all women of reproductive age who had ever had sexual intercourse with a male partner used at least one contraceptive method at some point in their life up to the time of interview (99.2%, or 63.2 million women ages 15-49), including 87.8% who had ever used a "most or moderately effective reversible method": the pill, an injectable, contraceptive patch, contraceptive ring, contraceptive implant, or intrauterine device. Most women had used the male condom with a partner (94.5%), the pill (79.8%), or withdrawal (65.7%). About one in four women reported ever using long-acting reversible contraception (intrauterine device or contraceptive implant) (24.9%) or emergency contraception (23.5%). The type of methods ever used varied by Hispanic origin and race, nativity among Hispanic women, education, religious affiliation and importance, and urban-rural residence. Among women who had ever discontinued use of the pill or intrauterine devices due to dissatisfaction (and not for seeking a pregnancy), side effects were the most common reason.
Assuntos
Dispositivos Intrauterinos , Contracepção Reversível de Longo Prazo , Gravidez , Masculino , Feminino , Humanos , Estados Unidos , Anticoncepção , Anticoncepcionais , Preservativos , Comportamento ContraceptivoRESUMO
OBJECTIVE: To assess the risk of select safety outcomes including endometrial cancer, endometrial hyperplasia, and breast cancer among women using conjugated estrogens/bazedoxifene (CE/BZA) as compared with estrogen/progestin combination hormone therapy (EP). METHODS: We conducted a new-user cohort study in five US healthcare claims databases representing more than 92 million women. We included CE/BZA or EP new users from May 1, 2014, to August 30, 2019. EP users were propensity score (PS) matched to users of CE/BZA. Incidence of endometrial cancer, endometrial hyperplasia, breast cancer, and eight additional cancer and cardiovascular outcomes were ascertained using claims-based algorithms. Rate ratios (RR) and differences pooled across databases were estimated using random-effects models. RESULTS: The study population included 10,596 CE/BZA and 33,818 PS-matched EP new users. Rates of endometrial cancer and endometrial hyperplasia were slightly higher among CE/BZA users (1.6 and 0.4 additional cases per 10,000 person-years), although precision was limited because of small numbers of cases (endometrial cancer: RR, 1.50 [95% confidence interval {CI}, 0.79-2.88]; endometrial hyperplasia: RR, 1.69 [95% CI, 0.51-5.61]). Breast cancer incidence was lower in CE/BZA users (9.1 fewer cases per 10,000 person-years; RR, 0.79; 95% CI, 0.58-1.05). Rates of other outcomes were slightly higher among CE/BZA users, but with confidence intervals compatible with a wider range of possible associations. CONCLUSIONS: CE/BZA users might experience slightly higher rates of endometrial cancer and endometrial hyperplasia, and a lower rate of breast cancer, than EP users in the first years of use.