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1.
Popul Health Manag ; 22(5): 385-393, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30513070

RESUMO

In integrated health care systems, techniques that identify successes and opportunities for targeted improvement are needed. The authors propose a new method for estimating population health that provides a more accurate and dynamic assessment of performance and priority setting. Member data from a large integrated health system (n = 96,246, 73.8% female, mean age = 44 ± 0.01 years) were used to develop a mechanistic mathematical simulation, representing the top causes of US mortality in 2014 and their associated risk factors. An age- and sex-matched US cohort served as comparator group. The simulation was recalibrated and retested for validity employing the outcome measure of 5-year mortality. The authors sought to estimate potential population health that could be gained by improving health risk factors in the study population. Potential gains were assessed using both average life years (LY) gained and average quality-adjusted life years (QALYs) gained. The simulation validated well compared to integrated health system data, producing an AUC (area under the curve) of 0.88 for 5-year mortality. Current population health was estimated as a life expectancy of 84.7 years or 69.2 QALYs. Comparing potential health gain in the US cohort to the Kaiser Permanente cohort, eliminating physical inactivity, unhealthy diet, smoking, and uncontrolled diabetes resulted in an increase of 1.5 vs. 1.3 LY, 1.1 vs. 0.8 LY, 0.5 vs. 0.2 LY, and 0.5 vs. 0.5 LY on average per person, respectively. Using mathematical simulations may inform efforts by integrated health systems to target resources most effectively, and may facilitate goal setting.


Assuntos
Prestação Integrada de Cuidados de Saúde , Expectativa de Vida , Saúde da População , Anos de Vida Ajustados por Qualidade de Vida , Alocação de Recursos , Adulto , Idoso , Simulação por Computador , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Saúde da População/classificação , Fatores de Risco , Adulto Jovem
2.
Patient Educ Couns ; 101(2): 241-247, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28886974

RESUMO

OBJECTIVE: To understand the informational needs during active surveillance (AS) for prostate cancer from the perspectives of patients and providers. METHODS: We conducted seven focus groups with 37 AS patients in two urban clinical settings, and 24 semi-structured interviews with a national sample of providers. Transcripts were analyzed using applied thematic analysis, and themes were organized using descriptive matrix analyses. RESULTS: We identified six themes related to informational needs during AS: 1) more information on prostate cancer (biopsy features, prognosis), 2) more information on active surveillance (difference from watchful waiting, testing protocol), 3) more information on alternative management options (complementary medicine, lifestyle modification), 4) greater variety of resources (multiple formats, targeting different audiences), 5) more social support and interaction, and 6) verified integrity of information (trusted, multidisciplinary and secure). CONCLUSIONS: Patients and providers described numerous drawbacks to existing prostate cancer resources and a variety of unmet needs including information on prognosis, AS testing protocols, and lifestyle modification. They also expressed a need for different types of resources, including interaction and unbiased information. PRACTICAL IMPLICATIONS: These results are useful to inform the design of future resources for men undergoing AS.


Assuntos
Necessidades e Demandas de Serviços de Saúde , Neoplasias da Próstata/patologia , Conduta Expectante , Idoso , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Apoio Social
3.
Health Serv Res ; 51(3): 1021-51, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26423687

RESUMO

OBJECTIVE: To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING: Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN: We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS: We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS: Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.


Assuntos
Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Motivação , Neoplasias da Próstata/diagnóstico por imagem , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos
4.
BMC Med Inform Decis Mak ; 10: 75, 2010 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-21172022

RESUMO

BACKGROUND: Advance directives (AD) may promote preference-concordant care yet are absent in many patients with Chronic Obstructive Pulmonary Disease (COPD). In order to begin to inform AD discussions between clinicians and COPD patients, we constructed a decision tree to estimate the impact of alternative AD decisions on both quality and quantity of life (quality adjusted life years, QALYs). METHODS: Two aspects of the AD were considered, Do Not Intubate (DNI; i.e., no invasive mechanical ventilation) and Full Code (i.e., may use invasive mechanical ventilation). Model parameters were based on published estimates. Our model follows hypothetical patients with COPD to evaluate the effect of underlying COPD severity and of hypothetical patient-specific preferences (about long-term institutionalization and complications from invasive mechanical ventilation) on the recommended AD. RESULTS: Our theoretical model recommends endorsing the Full Code advance directive for patients who do not have strong preferences against having a potential complication from intubation (ETT complications) or being discharged to a long-term ECF. However, our model recommends endorsing the DNI advance directive for patients who do have strong preferences against having potential complications of intubation and are were willing to tradeoff substantial amounts of time alive to avoid ETT complications or permanent institutionalization. Our theoretical model also recommends endorsing the DNI advance directive for patients who have a higher probability of having complications from invasive ventilation (ETT). CONCLUSIONS: Our model suggests that AD decisions are sensitive to patient preferences about long-term institutionalization and potential complications of therapy, particularly in patients with severe COPD. Future work will elicit actual patient preferences about complications of invasive mechanical ventilation, and incorporate our model into a clinical decision support to be used for actual COPD patients facing AD decisions.


Assuntos
Diretivas Antecipadas , Técnicas de Apoio para a Decisão , Árvores de Decisões , Doença Pulmonar Obstrutiva Crônica , Humanos , Intubação Intratraqueal , Expectativa de Vida , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença
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