RESUMEN
BACKGROUND: The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS: We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS: A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS: One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION: Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.
Asunto(s)
Atención a la Salud/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hepatopatías/terapia , Servicios de Salud Mental/organización & administración , Cuidados Paliativos/organización & administración , United States Department of Veterans Affairs/organización & administración , Alcoholismo/tratamiento farmacológico , Atención Ambulatoria/organización & administración , Servicios de Diagnóstico/organización & administración , Endoscopía del Sistema Digestivo/estadística & datos numéricos , Humanos , Trasplante de Hígado , Oncología Médica/organización & administración , Manejo del Dolor , Cuidados Paliativos/estadística & datos numéricos , Grupo de Atención al Paciente , Radiología Intervencionista/organización & administración , Derivación y Consulta/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Integrating interventional radiology (IR) into clinical practice faces challenges in emerging countries in Asia and Africa. Overcoming them requires innovative solutions customized to local needs. After an in-depth gap analysis of these challenges, we began an organized skill development initiative in late 2015 offering radiologists and their supporting staff fully paid scholarships for IR training. Its concept, structure, and progress are reported here. This initiative covered 8 countries, IR specialists (n = 51), senior residents (n = 24), and 15 educational events (training institute [n = 3]; participating countries [n = 12]). This initiative is intended to develop a global network of trained personnel who can support IR programs in challenging locations of emerging countries.
Asunto(s)
Prestación Integrada de Atención de Salud , Países en Desarrollo , Educación de Postgrado en Medicina , Radiografía Intervencional , Radiólogos/educación , Radiología Intervencionista/educación , Competencia Clínica , Curriculum , Prestación Integrada de Atención de Salud/organización & administración , Educación de Postgrado en Medicina/organización & administración , Humanos , Curva de Aprendizaje , Radiólogos/organización & administración , Radiología Intervencionista/organización & administraciónRESUMEN
BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.
Asunto(s)
Aorta/cirugía , Enfermedades de la Aorta/cirugía , Procedimientos Quirúrgicos Cardíacos , Servicios Centralizados de Hospital/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Radiólogos/organización & administración , Radiología Intervencionista/organización & administración , Cirujanos/organización & administración , Centros Traumatológicos/organización & administración , Procedimientos Quirúrgicos Vasculares/organización & administración , Procedimientos Quirúrgicos Cardíacos/clasificación , Servicio de Cardiología en Hospital/organización & administración , Servicios Centralizados de Hospital/clasificación , Conducta Cooperativa , Bases de Datos Factuales , Prestación Integrada de Atención de Salud/clasificación , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Florida , Humanos , Comunicación Interdisciplinaria , Grupo de Atención al Paciente/clasificación , Grupo de Atención al Paciente/organización & administración , Transferencia de Pacientes/organización & administración , Evaluación de Programas y Proyectos de Salud , Radiólogos/clasificación , Servicio de Radiología en Hospital/organización & administración , Radiología Intervencionista/clasificación , Derivación y Consulta/organización & administración , Estudios Retrospectivos , Cirujanos/clasificación , Terminología como Asunto , Factores de Tiempo , Tiempo de Tratamiento/organización & administración , Centros Traumatológicos/clasificación , Procedimientos Quirúrgicos Vasculares/clasificación , Flujo de Trabajo , Carga de TrabajoRESUMEN
PURPOSE: To quantify preprocedural patient flow in interventional radiology (IR) and to identify potential contributors to preprocedural delays. MATERIALS AND METHODS: An administrative dataset was used to compute time intervals required for various preprocedural patient-flow processes. These time intervals were compared across on-time/delayed cases and inpatient/outpatient cases by Mann-Whitney U test. Spearman ρ was used to assess any correlation of the rank of a procedure on a given day and the procedure duration to the preprocedure time. A linear-regression model of preprocedure time was used to further explore potential contributing factors. Any identified reason(s) for delay were collated. P < .05 was considered statistically significant. RESULTS: Of the total 1,091 cases, 65.8% (n = 718) were delayed. Significantly more outpatient cases started late compared with inpatient cases (81.4% vs 45.0%; P < .001, χ(2) test). The multivariate linear regression model showed outpatient status, length of delay in arrival, and longer procedure times to be significantly associated with longer preprocedure times. Late arrival of patients (65.9%), unavailability of physicians (18.4%), and unavailability of procedure room (13.0%) were the three most frequently identified reasons for delay. The delay was multifactorial in 29.6% of cases (n = 213). CONCLUSIONS: Objective measurement of preprocedural IR patient flow demonstrated considerable waste and highlighted high-yield areas of possible improvement. A data-driven approach may aid efficient delivery of IR care.
Asunto(s)
Citas y Horarios , Prestación Integrada de Atención de Salud/organización & administración , Modelos Organizacionales , Radiografía Intervencional , Servicio de Radiología en Hospital/organización & administración , Radiología Intervencionista/organización & administración , Atención Ambulatoria/organización & administración , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Eficiencia Organizacional , Hospitales Universitarios/organización & administración , Humanos , Pacientes Internos , Modelos Lineales , Análisis Multivariante , Quirófanos/organización & administración , Pacientes Ambulatorios , Admisión y Programación de Personal/organización & administración , Mejoramiento de la Calidad/organización & administración , Indicadores de Calidad de la Atención de Salud/organización & administración , Estudios Retrospectivos , Factores de Riesgo , Texas , Factores de Tiempo , Estudios de Tiempo y MovimientoRESUMEN
PURPOSE: We tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center. METHODS: Two time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution's comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution's electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013. RESULTS: Clinic visits increased from 9 to 204 (P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 (P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05). CONCLUSIONS: The establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.
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Instituciones Oncológicas/organización & administración , Embolización Terapéutica/estadística & datos numéricos , Neoplasias/terapia , Oncología por Radiación/organización & administración , Radiografía Intervencional/estadística & datos numéricos , Radiología Intervencionista/organización & administración , Atención Integral de Salud/estadística & datos numéricos , Eficiencia Organizacional , Humanos , Modelos Organizacionales , National Cancer Institute (U.S.)/organización & administración , Neoplasias/diagnóstico , Neoplasias/epidemiología , Prevalencia , Tennessee/epidemiología , Estados Unidos , Carga de TrabajoAsunto(s)
Prestación Integrada de Atención de Salud/organización & administración , Costos de la Atención en Salud , Modelos Organizacionales , Mejoramiento de la Calidad/organización & administración , Indicadores de Calidad de la Atención de Salud/organización & administración , Radiología Intervencionista/organización & administración , Ahorro de Costo , Análisis Costo-Beneficio , Prestación Integrada de Atención de Salud/economía , Humanos , Objetivos Organizacionales , Mejoramiento de la Calidad/economía , Indicadores de Calidad de la Atención de Salud/economía , Radiografía Intervencional/economía , Radiología Intervencionista/economíaAsunto(s)
Manejo de Caso/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Modelos Organizacionales , Guías de Práctica Clínica como Asunto , Gestión de la Práctica Profesional/organización & administración , Radiología Intervencionista/organización & administración , Estados UnidosRESUMEN
The foundation of endovascular procedures by nephrologists was laid in the private practice arena. Because of political issues such as training, credentialing, space and equipment expenses, and co-management concerns surrounding the performance of dialysis-access procedures, the majority of these programs provided care in an outpatient vascular access center. On the basis of the improvement of patient care demonstrated by these centers, several nephrology programs at academic medical centers have also embraced this approach. In addition to providing interventional care on an outpatient basis, academic medical centers have taken a step further to expand collaboration with other specialties with similar expertise (such as with interventional radiologists and cardiologists) to enhance patient care and research. The enthusiastic initiative, cooperative, and mutually collaborative efforts used by academic medical centers have resulted in the successful establishment of interventional nephrology programs. This article describes various models of interventional nephrology programs at academic medical centers across the United States.
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Centros Médicos Académicos , Atención Ambulatoria/organización & administración , Procedimientos Endovasculares , Nefrología , Radiología Intervencionista , Centros Médicos Académicos/organización & administración , Cateterismo Cardíaco , Competencia Clínica , Curriculum , Prestación Integrada de Atención de Salud , Educación de Postgrado en Medicina , Procedimientos Endovasculares/educación , Becas , Humanos , Comunicación Interdisciplinaria , Nefrología/educación , Nefrología/organización & administración , Objetivos Organizacionales , Grupo de Atención al Paciente , Desarrollo de Programa , Radiología Intervencionista/educación , Radiología Intervencionista/organización & administración , Estados UnidosRESUMEN
Rapid clinical dissemination of CT colonography (CTC) is occurring in parallel with continued research into technique optimisation and diagnostic performance. A need exists therefore for current guidance as to basic prerequisites for effective clinical implementation. A questionnaire detailing CTC technique, analysis, training and clinical implementation was developed by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) CTC committee and circulated to all faculty members of previous ESGAR "hands-on" CTC training courses. Responses were collated and a consensus statement produced. Of 27 invited to participate, 24 responded. Reasonable consensus was reached on bowel preparation, colonic distension, patient positioning, use of IV contrast and optimal scan parameters. Both primary 2D and primary 3D analysis were advocated equally, with some evidence that more experienced readers prefer primary 2D. Training was universally recommended, although there was no consensus regarding minimum requirements. CTC was thought superior to barium enema, although recommended for screening only in the presence of validated local experience. There was consensus that polyps 4 mm or less could be ignored assuming agreement from local gastroenterological colleagues. There is increasing consensus amongst European experts as to the current best practice in CTC.