Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty.

BACKGROUND: Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. AIM: To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. METHODS: Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. RESULTS: A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. CONCLUSION: A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Performance of an automatic external cardioverter-defibrillator algorithm in the discrimination of supraventricular from ventricular tachycardia.

An automatic external cardioverter-defibrillator (AECD) with a programmable supraventricular-ventricular tachycardia (VT) zone underwent evaluation of arrhythmia discrimination performance in the electrophysiologic laboratory during induced supraventricular tachycardia (SVT) and unipolar and bipolar atrial pacing. The AECD SVT zone was programmed so that the induced SVT rate would fall within this zone. Atrial pacing was also performed at a rate within this zone. The ability of the AECD to accurately discriminate between VT and SVT and to recommend shock delivery was assessed. A total of 98 patients underwent conventional diagnostic electrophysiologic studies (49 men, age 59 +/- 19 years) with a total of 55 inducible sustained SVTs. High right atrial pacing was performed in 56 patients in unipolar and in 82 patients in bipolar fashion. In response to induced sustained SVT, the AECD correctly classified 47 episodes as nonshockable, 4 incorrectly as shockable, and 4 episodes correctly as shockable with a resultant sensitivity of 100% and specificity of 92%. Bipolar high right atrial pacing was correctly identified as nonshockable in 75 episodes, incorrectly identified as shockable in 5 episodes, and correctly identified as shockable in 2 episodes with a resultant sensitivity of 100% and specificity of 94%. The Powerheart AECD accurately discriminates SVT from VT and is expected to correctly deliver automatic external shocks rapidly in the presence of spontaneous life-threatening tachycardia and appropriately withhold therapy during SVT.

From the Office of the National Coordinator: the strategy for advancing the exchange of health information.

Electronic health information exchange addresses a critical need in the US health care system to have information follow patients to support patient care. Today little information is shared electronically, leaving doctors without the information they need to provide the best care. With payment reforms providing a strong business driver, the demand for health information exchange is poised to grow. The Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, has led the process of establishing the essential building blocks that will support health information exchange. Over the coming year, this office will develop additional policies and standards that will make information exchange easier and cheaper and facilitate its use on a broader scale.

Conocimiento y aplicación del consentimiento informado en pacientes del Hospital Escuela Universitario/Hospital Materno Infantil / Knowledge and Application of the Informed Consent in the patients of the Univers ity Hospital/ Maternal-Child Hospital

Antecedentes: En Honduras el Consentimiento Informado (CI) no ha sido objeto de estudio ni de publicación. Objetivo: Establecer el grado de conocimiento sobre el diagnóstico, tratamiento y pronóstico de su enfermedad y la aplicación del consentimiento informado en los pacientes ingresados en los servicios de Medicina Interna, Pediatría, Cirugía, Ginecología del Hospital Escuela Universitario (HEU)/Hospital Materno Infantil (HMI) Tegucigalpa en el período de marzo-mayo 2015. M étodos: Estudio cuantitativo, descriptivo, trasversal. La muestra fue 252 pacientes ingresados en las salas de los 4 servicios básicos (63 pacientes por servicio). Utilizando un muestreo no probabilístico. Los datos se recolectaron a través de una entrevista que constó de cuatro secciones: datos generales, conocimiento sobre su enfermedad, personal que le informó y aplicación del consentimiento informado. Para la validación del instrumento se realizó una prueba piloto. Los datos se presentan como frecuencias y porcentajes de las variables estudiadas. Se aplicó el CI a los participantes mayores de 18 años y el asentimiento informado a los mayores de 7 años, se guardó la conidencialidad de la información. Resultados : El 48% (120/252) de los pacientes tenía un grado de conocimiento insuiciente sobre su enfermedad. El Consentimiento Informado se aplicó en el 34% (86/252) de los pacientes entrevistados. El servicio que más aplicó el Consentimiento Informado fue Ginecología, ya que lo aplicó en el 62% (39/63) de sus pacientes. Conclusión: La mayoría de los pacientes tienen un grado de conocimiento insuiciente sobre su enfermedad. El porcentaje de aplicación del Consentimiento Informado por el personal de salud es bajo...(AU)

Research glut and information famine: making research evidence more useful for policymakers.

The gap between the two worlds of researchers and policymakers renders the use of research in the policy-making process problematic. Policymakers have three primary needs in their use of research evidence: clear translation, accessible and easy-to-use information, and relevance to the policy context. These needs are sometimes at odds with the priorities of the research community. This paper describes the Robert Wood Johnson Foundation's Synthesis Project, which aims to strengthen links between research and policy making by synthesizing evidence on pressing health policy questions.

The built environment and physical activity.

Regular physical activity has many health benefits, but in spite of the benefits many Americans are not sufficiently active. There is increasing recognition of the importance of environmental factors-including the built environment-to help promote physical activity. The built environment describes physical or manmade features such as sidewalks, streetlights, traffic and parks that may promote or discourage activity. This synthesis examines the evidence on the built environment-proximity to destinations, sidewalks, aesthetics, access to parks and open spaces, and the walkability of the community-and the relationship to increased physical activity. Findings include: There is reasonably strong evidence of an association between many factors of the built environment and increased physical activity, but the evidence on whether or not the built environment promotes activity is weak. Most research shows that individual and societal factors are stronger drivers of activity than the built environment.

Paying for Quality: Understanding and Assessing Physician Pay-for-Performance Initiatives.

Pay-for-performance (P4P) initiatives have been discussed since the early 1990s, but support for the concept has grown recently, fueled by experience with quality of care measures, endorsements by key players and research that underlines the need for quality improvements and reform to the physician payment system. This synthesis examines the evidence on P4P. Key findings include: About one-third of U.S. physicians already face quality-based incentives under their managed care contracts. These measures most often relate to clinical targets, efficiency, patient satisfaction and use of information technology, but apply to a limited set of specific diseases and preventive care services. While 80 percent of plans pay for meeting benchmarks, 20 percent pay for improvements in performance. Overall, incentive payments are small, averaging at most 5 percent of total payments. While large-scale, ""real-life"" research consistently shows improvement in quality indicators when P4P is in place, it is hard to disentangle the impact of P4P from that of other simultaneous quality initiatives. Evidence of P4P impact from small controlled studies has not been positive. Doctors are generally supportive of P4P but concerned about how well it can be implemented.

Medical malpractice: impact of the crisis and effect of state tort reforms.

As a result of rapidly rising medical malpractice insurance premiums, reduced availability of coverage, and financially distressed liability insurers, many states have passed tort reforms. This synthesis examines the medical malpractice ""crisis"" and the effect of state tort reforms. Evidence shows that caps on non-economic damages reduce the average size of malpractice awards by 20 to 30 percent and have a modest impact on malpractice insurance premium growth There is also evidence that the most severely injured patients are disproportionately affected by caps, however. Other state reforms such as changes to joint-and-several liability, statutes of limitations, or attorney contingency fees have had little impact. Studies do not support the notion that overall physician supply has decreased, nor that there is a relationship between malpractice cost and physician supply. There is ""good evidence"" that doctors ""often"" engage in defensive medicine, ordering referrals, medications and tests to protect themselves from liability, but the impact of this practice is difficult to quantify.

How has hospital consolidation affected the price and quality of hospital care?

During the 1990s, the hospital industry was transformed by mergers and acquisitions. This synthesis looks at why this rapid consolidation occurred and what impact it had on the price and quality for patients, and the cost of care for hospitals. Key findings include: Managed care was not a main driver of consolidation, but fear of managed care may have played a part. Other factors, including technological advances that reduced inpatient demand, and an antitrust environment that was receptive to consolidation contributed to consolidation. Research suggests hospital prices increased by 5 percent or more as a result of consolidation. When two hospitals merge, not only does the surviving hospital raise prices but so do its competitors. Evidence of the impact of consolidation on quality of care is limited and mixed, but the strongest studies show a reduction in quality. Hospital consolidation does modestly reduce the cost to hospitals of providing care.

How will employers respond to coverage reforms.

Any change in the health insurance market could prompt a reaction by employers in what kind and at what cost they offer coverage. This policy brief examines the research on employer decision-making. Key findings include: Firms are most likely to offer plans that respond to the preferences of their most valuable, hard-to-retain workers. Firms are more likely to offer health insurance if they employ high-wage workers; if they are unionized; or if they are in the manufacturing or public sectors. While theory suggests that employers will shift the cost of premiums to employees in the form of lower wages, this is not the case in practice. There are serious gaps in research, including: an absence of detailed data about individuals; little information about earnings distribution; ages and other characteristics within firms of different sizes; and little study of employer behavior.

An overview of recent state HCBS budget cuts.

This policy brief, covering the period FY 2002- FY 2004, examines state budget cuts and other state policy changes affecting long term care (LTC) services for the elderly, focusing on home and community based services (HCBS). In the second year of budget deficits, states made deeper Medicaid cuts and focused on LTC services because of their contribution to Medicaid budgets (fifteen states say LTC is one of the top three Medicaid spending drivers). In all, states made or planned an estimated 64 cuts to LTC services in the last three fiscal years. Reflecting overall budget-cutting strategies, many states first targeted LTC provider payments and have only more recently considered reducing LTC benefits or eligibility.

From coverage to care.

An important determinant of access is whether people have a usual source of care. Health insurance coverage is one factor that makes people more likely to have a usual provider, but coverage alone does not guarantee access. This synthesis examines the relationship between health insurance and having a regular care provider. Results indicate people with health insurance are more likely to have a usual source of care; the newly insured, as well as people with unstable coverage are less likely to have a regular source of care; and about two-thirds of those without a usual source of care say the main reason they have no such source is because they rarely get sick. Among those who have a usual source of care, most see an office-based doctor as their primary provider. The uninsured and publicly-insured are more likely to use an institution and to face access barriers.

Geographic variation in medicare per capita spending.

Persistent, widespread variations in Medicare spending across the country are largely and well-documented. In 1996, Medicare per capita spending across the country ranged from $3,000 to $8,500. This synthesis examines the Medicare spending variation, underlying causes, possible solutions, and whether people in higher-spending areas receive better care. Key findings include: Only 10 percent of the Medicare regions had spending within 10 percent of the average. The variation is seen across all Medicare services. Most studies suggest that less than half of the spending variation is accounted for by differences in population characteristics and price. More than half of the spending variation is attributable to differences in use of services. Although research is limited, there is no evidence that areas spending more money have better outcomes or quality of care. Research suggests it is hard to determine why patterns of care and spending vary so much.

Public program crowd-out of private coverage.

Coverage expansions by Medicaid, SCHIP and other state programs significantly increased the number of people covered by public insurance. Crowd-out occurs when people drop private coverage for public coverage, when those enrolled in public insurance turn down private coverage when eligible, or when employers opt not to offer private insurance because of the existence of a public program. This synthesis examines the extent of crowd-out and whether it can be reduced. Key findings include: Estimates of crowd-out are imprecise and vary depending on the type of coverage expansion; the assumptions, methods and data used; and the time period covered. Crowd-out is more likely to occur in programs that enroll families, and among families with incomes greater than 200 percent FPL. Programs have used waiting periods and cost-sharing to limit crowd-out, but these techniques can be difficult and costly to implement, and may reduce program participation by the uninsured.

Tax subsidies for private health insurance.

The exclusion from income and payroll taxes for employer-paid health insurance premiums amounted to more than $240 billion in 2010. As policy-makers search for ways to pay for health care reform and contain health care costs, this exclusion is coming under scrutiny, despite the fact that employee-sponsored insurance (ESI) is an integral part of the health insurance system. This update of a 2003 synthesis looks at the tax subsidy for private health insurance. Key findings include: The current tax subsidy benefits higher-income workers the most. The tax exclusion is worth more to those in higher tax brackets, higher-income workers are three times more likely to work for firms who offer ESI than lower-income workers, and they are more likely to purchase ESI when offered because they can afford it. Families earning $10,000 to $20,000 annually spend more than 25 percent of their income on health insurance but the value of their tax subsidy is only $1,500. By contrast, earners over $200,000 spend less than 5 percent on health insurance but their benefit is worth $4,500. Workers who cannot afford ESI or are ineligible, including the self-employed and many part-time workers, do not receive this subsidy when they purchase private, non-group coverage.