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1.
PLoS One ; 15(7): e0236554, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32716922

RESUMO

The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.


Assuntos
Infecções por Coronavirus/terapia , Registros Eletrônicos de Saúde , Pneumonia Viral/terapia , Medição de Risco/métodos , Rotas de Resultados Adversos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Tomada de Decisões , Feminino , Hospitais de Veteranos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
2.
Medicine (Baltimore) ; 99(24): e20385, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541458

RESUMO

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.


Assuntos
Benchmarking/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Idoso , Algoritmos , Benchmarking/normas , Estudos de Coortes , Grupos Diagnósticos Relacionados/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hispano-Americanos/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/organização & administração
4.
Med Care ; 58(3): 273-279, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32049948

RESUMO

BACKGROUND: The prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) have increased substantially among children and adolescents over the past decade; however, little is known regarding trends in adult populations. OBJECTIVE: The objective of this study was to explore trends in the prevalence, incidence, and correlates of adult ADHD in a national sample of veterans receiving care at Veteran Affairs (VA) hospitals and clinics. RESEARCH DESIGN: A retrospective design was used to examine ADHD diagnosed in all VA primary care (PC) and mental health clinics (MHCs) from fiscal years (FYs) 2009 to 2016. Age-adjusted prevalence and incidence were calculated using direct standardization, and Poisson regressions modeled differences in trends between demographic groups. SUBJECTS: All veterans with VA PC or MHC visits during the observation period. MEASURES: ADHD incidence and prevalence, psychiatric comorbidity, neuropsychological evaluation. RESULTS: An annual average of 5.09 million (range: 4.63-5.42 million) VA patients attended a PC or MHC appointment between FY09 and FY16. During this period, age-adjusted annual prevalence increased 258% from 0.23% to 0.84% and incidence increased 240% from 0.14% to 0.48%. Black veterans and older veterans had the lowest prevalence and incidence across all years. Increases in prevalence and incidence occurred across all demographic subgroups. The proportion of patients who had a neuropsychological evaluation within 6 months before or after a new ADHD diagnosis decreased from 12.6% to 10.8% [χ(1)=16.59, P<0.001]. CONCLUSION: Overall increases and demographic differences in adult veterans diagnosed with ADHD suggest a growing need to establish the reliability of diagnostic practices to ensure appropriate and equitable care.


Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Comorbidade , Hospitais de Veteranos , Veteranos/estatística & dados numéricos , Adulto , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Prevalência , Atenção Primária à Saúde , Estudos Retrospectivos , Estados Unidos/epidemiologia
6.
Med Care ; 58(4): 301-306, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31895308

RESUMO

BACKGROUND: The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES: Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN: Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS: Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS: While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.


Assuntos
Hospitais de Veteranos , Alta do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Cuidado Transicional/tendências , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicaid , Medicare , Mortalidade/tendências , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
7.
Int J Radiat Oncol Biol Phys ; 106(3): 639-647, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31983560

RESUMO

PURPOSE: We sought to develop a quality surveillance program for approximately 15,000 US veterans treated at the 40 radiation oncology facilities at the Veterans Affairs (VA) hospitals each year. METHODS AND MATERIALS: State-of-the-art technologies were used with the goal to improve clinical outcomes while providing the best possible care to veterans. To measure quality of care and service rendered to veterans, the Veterans Health Administration established the VA Radiation Oncology Quality Surveillance program. The program carries forward the American College of Radiology Quality Research in Radiation Oncology project methodology of assessing the wide variation in practice pattern and quality of care in radiation therapy by developing clinical quality measures (QM) used as quality indices. These QM data provide feedback to physicians by identifying areas for improvement in the process of care and identifying the adoption of evidence-based recommendations for radiation therapy. RESULTS: Disease-site expert panels organized by the American Society for Radiation Oncology (ASTRO) defined quality measures and established scoring criteria for prostate cancer (intermediate and high risk), non-small cell lung cancer (IIIA/B stage), and small cell lung cancer (limited stage) case presentations. Data elements for 1567 patients from the 40 VA radiation oncology practices were abstracted from the electronic medical records and treatment management and planning systems. Overall, the 1567 assessed cases passed 82.4% of all QM. Pass rates for QM for the 773 lung and 794 prostate cases were 78.0% and 87.2%, respectively. Marked variations, however, were noted in the pass rates for QM when tumor site, clinical pathway, or performing centers were separately examined. CONCLUSIONS: The peer-review protected VA-Radiation Oncology Surveillance program based on clinical quality measures allows providers to compare their clinical practice to peers and to make meaningful adjustments in their personal patterns of care unobtrusively.


Assuntos
Institutos de Câncer/normas , Hospitais de Veteranos/normas , Desenvolvimento de Programas , Garantia da Qualidade dos Cuidados de Saúde/normas , Radioterapia (Especialidade)/normas , Carcinoma Pulmonar de Células não Pequenas/radioterapia , Medicina Baseada em Evidências/normas , Humanos , Neoplasias Pulmonares/radioterapia , Masculino , Revisão por Pares , Avaliação de Programas e Projetos de Saúde/normas , Neoplasias da Próstata/radioterapia , Garantia da Qualidade dos Cuidados de Saúde/métodos , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Carcinoma de Pequenas Células do Pulmão/radioterapia , Sociedades Médicas/normas , Estados Unidos , Veteranos
8.
Anesth Analg ; 130(2): 402-408, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31335405

RESUMO

BACKGROUND: Ketamine is routinely used within the context of combat casualty care. Despite early concerns that ketamine administration may be associated with elevated risk of posttraumatic stress disorder (PTSD), more recent evidence suggests no relationship. Because PTSD occurs with regular frequency in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Service Members (SMs) and combat-related injuries are associated with higher likelihood of PTSD, it is important to investigate the relationship between ketamine exposure during inpatient medical and surgical care and PTSD symptoms in OIF/OEF SMs. METHODS: Medical record data from OIF/OEF SMs medically evacuated from combat (N = 1158) included demographic characteristics, injury severity, body areas injured, and PTSD Checklist (PCL) scores. The primary analysis assessed the association between ketamine versus nonketamine exposure on positive PTSD screen (logistic regression) and PCL scores (linear regression) after using 1:1 propensity score matching to adjust for available potential confounding variables. Because there were 2 primary outcomes, the binary positive PTSD screen (yes/no) and continuous PCL score, the significance level was set at P ≤ .025. In sensitivity analyses, propensity scores were used to match ketamine to nonketamine records in a 1:4 ratio, as well as to conduct inverse probability treatment weighting (IPTW). Regressions examining the relationship between ketamine exposure and outcomes were repeated for unconditional, 1:4 matching, and IPTW models. RESULTS: In the sample, 107 received ketamine and 1051 did not. In the logistic regression, the probability of a positive PTSD screen was not significantly different between ketamine versus nonketamine patients (odds ratio [OR] = 1.28; 95% confidence interval [CI], 0.48-3.47; P = .62). In the linear regression, PCL scores were not significantly different between ketamine versus nonketamine patients (mean difference = 1.98 [95% CI, -0.99 to 4.96]; P = .19). The results were consistent in the unconditional, 1:4 matching, and IPTW models. CONCLUSIONS: No differences in PTSD screening risk or symptom levels between ketamine exposed and nonexposed were found. Given the small sample size, wide CIs of the effects, and additional confounds inherent to retrospective studies, future studies are needed to examine the complex relationships between ketamine and psychological symptoms.


Assuntos
Anestésicos Dissociativos/administração & dosagem , Distúrbios de Guerra/psicologia , Hospitalização/tendências , Ketamina/administração & dosagem , Militares/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Adulto , Anestésicos Dissociativos/efeitos adversos , Estudos de Coortes , Distúrbios de Guerra/diagnóstico , Feminino , Hospitais de Veteranos/tendências , Humanos , Ketamina/efeitos adversos , Masculino , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/induzido quimicamente , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Resultado do Tratamento , Adulto Jovem
9.
J Clin Ethics ; 30(4): 338-346, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851625

RESUMO

Although tissue plasminogen activator (tPA) is the only medication approved by the United States Food and Drug Administration (FDA) for acute ischemic stroke, there is no consensus about the need for informed consent for its use. As a result, hospitals throughout the U.S. have varying requirements regarding obtaining informed consent from patients for the use of tPA, ranging from no requirement for informed consent to a requirement for verbal or written informed consent. We conducted a study to (1) determine current beliefs about obtaining patients' informed consent for tPA among a large group of stroke clinicians and (2) identify the ethical, clinical, and organizational factors that influence tPA consent practices. Semi-structured interviews were conducted by trained and experienced investigators and research staff to identify key barriers to implementing acute stroke services. Part of the interview explored current beliefs and practices around informed consent for tPA. This was a multicenter study that included 38 Veterans Health Administration (VHA) hospital locations. Participants were 68 stroke team clinicians, serving primarily on the neurology (35 percent) or emergency medicine (41 percent) service. We conducted thematic analysis based on principles of grounded theory to identify codes about consent for tPA. We used interpretive convergence to ensure consistency among the individual investigators' codes and to ensure that all of the investigators agreed on coding and themes. We found that 38 percent of the stroke clinicians did not believe any form of consent was necessary for tPA, 47 percent thought that some form of consent was necessary, and 15 percent were unsure. Clinicians who believed tPA required informed consent were divided on whether consent should be written (40 percent) or verbal (60 percent). We identified three factors describing clinicians' attitudes about consent: (1) legal and policy factors, (2) ethical factors, and (3) medical factors. The lack of consensus regarding consent for tPA creates the potential for delays in treatment, uneasiness among clinicians, and legal liability. The identified factors provide a potential framework to guide discussions about developing a standard of care for acquiring the informed consent of patients for the administration of tPA.


Assuntos
Isquemia Encefálica/terapia , Consentimento Livre e Esclarecido , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Atitude do Pessoal de Saúde , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Hospitais de Veteranos , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Estados Unidos , Serviços de Saúde para Veteranos Militares
10.
Perm J ; 232019.
Artigo em Inglês | MEDLINE | ID: mdl-31634112

RESUMO

The time it takes for clinical innovation and evidence-based practices to reach patients remains a major challenge for the health care sector. In 2015, the Veterans Health Administration (VHA) launched the Diffusion of Excellence Initiative aimed at aligning organizational resources with early-stage to midstage promising practices and innovations to replicate, scale, and eventually spread those with greatest potential for impact and positive outcomes. Using a 5-step systematic approach refined over time, frontline VHA staff have submitted more than 1676 practices since the initiative's inception, 47 of which have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated more than 412 times in Veterans Affairs hospitals across the country, improving care for more than 100,000 veterans and approximately $22.6 million in cost avoidance for the VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) and rapid availability of intranasal naloxone have saved veterans' lives. Several practices are now being implemented across the country, and the Diffusion of Excellence Initiative is playing a pivotal role as the VHA works to modernize its health care system. This initiative serves as a promising model for other health care systems seeking to accelerate the spread and adoption of clinical innovation and evidence-based practices.


Assuntos
Inovação Organizacional , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde/organização & administração , United States Department of Veterans Affairs/organização & administração , Hospitais de Veteranos/organização & administração , Hospitais de Veteranos/normas , Humanos , Modelos Organizacionais , Estados Unidos
11.
Med Care ; 57(11): 913-920, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31609847

RESUMO

OBJECTIVE: There is limited knowledge about how general hospitals and Veterans Health Administration (VHA) hospitals fare relative to each other on a broad range of inpatient psychiatry-specific patient safety outcomes.This research compares data from 2 large-scale epidemiological studies of adverse events (AEs) and medical errors (MEs) in inpatient psychiatric units, one in VHA hospitals and the other in community-based general hospitals. METHOD: Retrospective medical record reviews assessed the prevalence of AEs and MEs in a sample of 4371 discharges from 14 community-based general hospitals (derived from 69,081 discharges at 85 hospitals) and a sample of 8005 discharges from 40 VHA hospitals (derived from 92,103 discharges at 105 medical centers). Rates of AEs and MEs across hospital systems were calculated, controlling for relevant patient and hospital characteristics. RESULTS: The overall rate of AEs and MEs in inpatient psychiatric units of VHA hospitals was 7.11 and 1.49 per 100 patient discharges; at community-based acute care hospitals, these rates were 13.48 and 3.01 per 100 patient discharges. The adjusted odds ratio of a patient experiencing an AE and a ME at community-based hospitals as compared with VHA hospitals was 2.11 and 2.08, respectively. CONCLUSION: Although chart reviews may not document the complete nature and outcomes of care, even after controlling for differences in patient and hospital characteristics, psychiatric inpatients at community-based hospitals were twice as likely to experience AEs or MEs as inpatients at VHA hospitals. While community-based hospitals may lag behind VHA hospitals, both hospital systems should continue to pursue evidence-based improvements in patient safety. Future research aimed at changing hospital practices should draw on established strategies for bridging the gap from research to practice in order to improve the quality of care for this vulnerable patient population.


Assuntos
Hospitais Comunitários/estatística & dados numéricos , Hospitais Gerais/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Pacientes Internados/psicologia , Erros Médicos/estatística & dados numéricos , Unidade Hospitalar de Psiquiatria/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Erros Médicos/psicologia , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
12.
Perm J ; 232019.
Artigo em Inglês | MEDLINE | ID: mdl-31496502

RESUMO

Bringing about change in a large organization can be a herculean task, similar to tales of old with the hero overcoming the slow and powerful giant. In this article, we discuss some of the lessons learned from our own journey: 1) Don't present your ideas in a whisper because you are afraid of feedback; share your project with a megaphone, because feedback can only result in a better product; 2) Be enthusiastic; every discussion about your practice is an opportunity to engage others; 3) Focus on those who are willing to participate in your vision; don't spend too much time and energy on naysayers; 4) Use the language of your audience. You do not need to become an expert in every subject matter, but you must be able to verbalize your project in a way that matches their terminology and priorities; 5) Streamline your facts and present enough information to remove the frightening unknown, but not so much that the details distract from the purpose; 6) Share your results, successes, and struggles; your authentic efforts will affect your audience far more than promises or predictions; and 7) Couple the fires of passion with the cold determination of commitment; the combination will help you persevere and achieve success.


Assuntos
Hospitais de Veteranos/organização & administração , Inovação Organizacional , Retroalimentação , Humanos , Ohio , Administração de Recursos Humanos , Suicídio/prevenção & controle , Veteranos
13.
Am J Health Syst Pharm ; 76(16): 1248-1253, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369117

RESUMO

PURPOSE: Results of a study to determine the proportion of anticoagulation clinic workload that could be performed by clinical pharmacy technicians (CPTs) and the potential impact on operational efficiency of pharmacist-managed anticoagulation clinics (ACCs) are reported. METHODS: In a quality improvement project involving 11 Veterans Affairs (VA) medical centers, investigators conducted a 3-day time study in pharmacist-managed ACCs followed by scoring of task appropriateness for CPTs via the RAND/UCLA appropriateness method by the VA Anticoagulation Subject Matter Expert (SME) Workgroup. The primary outcome was the percentage of tasks deemed appropriate for a CPT to perform. RESULTS: The Anticoagulation SME Workgroup determined that a wide variety of mainly administrative ACC tasks could be completed by a CPT. At the 11 VA ACCs, an average of 53.4% (range, 39.9-76.1%) of tasks being performed by pharmacists were deemed appropriate for CPTs. The average percentage of total clinic time associated with performing tasks appropriate for a CPT equated to an estimated 1,111 hours per year. Shifting that portion of the annual work hours to a CPT could potentially result in cost avoidance of $55,302. CONCLUSION: At the ACCs evaluated, a significant proportion of tasks (53.4% on average) may be appropriate to assign to CPTs to improve the operational efficiency of these clinics. This finding supports development of business plans for the addition of CPTs in ACCs along with elements to inform crafting of an effective template for ACC structure, including clearly defined CPT roles.


Assuntos
Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/prevenção & controle , Hemorragia/prevenção & controle , Ambulatório Hospitalar/organização & administração , Técnicos em Farmácia/organização & administração , Transtornos da Coagulação Sanguínea/sangue , Monitoramento de Medicamentos/métodos , Monitoramento de Medicamentos/estatística & dados numéricos , Eficiência Organizacional , Hemorragia/sangue , Hemorragia/induzido quimicamente , Hospitais de Veteranos/organização & administração , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Coeficiente Internacional Normatizado , Ambulatório Hospitalar/estatística & dados numéricos , Serviço de Farmácia Hospitalar/organização & administração , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Técnicos em Farmácia/estatística & dados numéricos , Papel Profissional , Avaliação de Programas e Projetos de Saúde , Varfarina/uso terapêutico , Carga de Trabalho/estatística & dados numéricos
14.
Mayo Clin Proc ; 94(8): 1444-1456, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31378227

RESUMO

OBJECTIVE: To compare incident dementia risk among patients who initiated treatment with metformin or sulfonylurea in Veterans Health Affairs (VHA) patients with replication in Kaiser Permanente Washington (KPW) patients to determine whether first-choice antidiabetic medications are associated with reduced risk of dementia. PATIENTS AND METHODS: Cohorts contained 75,187 VHA patients and 10,866 KPW patients, 50 years and older, who initiated monotherapy with metformin or sulfonylurea. Patients were free of dementia diagnoses and any diabetes treatment for 2 years before cohort entry. Variables were extracted from electronic health data from VHA (1999-2015) and KPW (1996-2015), which included diagnosis codes, pharmacy data, laboratory values, and demographic characteristics. Propensity scores and inverse probability of treatment weighting controlled for confounding. RESULTS: Veterans Health Affairs patients were 60.8±6.8 years of age on average, and KPW patients were 63.1±9.5 years of age. In the VHA sample, 72,769 (96.8%) were male; and in the KPW sample, 5480 (50.4%). After adjusting for confounding, metformin initiation was associated with a significantly (P=.02) lower risk of dementia in VHA (hazard ratio, 0.9; 95% CI, 0.9-1.0), with a similar point estimate in KPW (hazard ratio, 0.9; 95% CI, 0.7-1.1). Metformin was not associated with dementia risk in patients 75 years and older. CONCLUSION: Existing epidemiological studies of metformin and incident dementia have been inconsistent. Using a similar study design in 2 patient populations that differed in clinical and demographic characteristics, our results provide robust evidence that metformin use is associated with a modestly lower risk of incident dementia.


Assuntos
Demência/induzido quimicamente , Demência/epidemiologia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Metformina/efeitos adversos , Compostos de Sulfonilureia/efeitos adversos , Fatores Etários , Idoso , Bases de Dados Factuais , Demência/fisiopatologia , Diabetes Mellitus Tipo 2/diagnóstico , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Hospitais de Veteranos , Humanos , Incidência , Masculino , Metformina/uso terapêutico , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Compostos de Sulfonilureia/uso terapêutico , Estados Unidos
15.
Am J Health Syst Pharm ; 76(1): 26-33, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31381096

RESUMO

PURPOSE: The results of a study to assess the effectiveness and safety of hyperglycemia management provided by clinical pharmacy specialists (CPSs) versus usual care in outpatients with diabetes from 53 Veterans Affairs (VA) medical centers are reported. METHODS: An historical cohort study of outpatients with baseline glycosylated hemoglobin (HbA1c) values of >9% who were referred to a CPS for management of hyperglycemia and primary care patients who were not referred to a CPS was conducted. The primary outcomes were change in HbA1c over time and time to reach an HbA1c value of <8%. Secondary outcomes included the number of visits to achieve an HbA1c value of <8%, proportion of patients with an HbA1c value of <6% who were receiving secretagogues, and proportion of patients with serious hypoglycemia. RESULTS: After propensity score matching by baseline characteristics, there were 12,327 patients in each group. The mean ± S.D. number of visits to reach an HbA1c value of <8% was 2.46 ± 1.58 in the pharmacist-managed group and 1.82 ± 1.27 with usual care (p < 0.001). The proportion of patients with an HbA1c value of <6% who were receiving secretagogues was 39.9% with pharmacist-managed care and 38.6% with usual care (p = 0.73). Serious hypoglycemia was noted in 4.3% of pharmacist-managed patients and 3.1% of usual care patients (p < 0.001). CONCLUSION: Data from 53 VA medical centers revealed that CPSs managed the care of ambulatory care patients with hyperglycemia as well as primary care providers.


Assuntos
Diabetes Mellitus/tratamento farmacológico , Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Conduta do Tratamento Medicamentoso/organização & administração , Farmacêuticos , Idoso , Assistência Ambulatorial , Estudos de Coortes , Diabetes Mellitus/sangue , Feminino , Hemoglobina A Glicada/análise , Hospitais de Veteranos/organização & administração , Humanos , Hiperglicemia/sangue , Masculino , Pessoa de Meia-Idade , Serviço de Farmácia Hospitalar/organização & administração , Papel Profissional , Avaliação de Programas e Projetos de Saúde , Secretagogos/uso terapêutico
17.
Infect Control Hosp Epidemiol ; 40(9): 963-967, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31339085

RESUMO

OBJECTIVE: In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs). DESIGN: Prospective surveys during January-June 2018. SETTING: All acute and long-term care units of 4 Veterans' Affairs facilities. METHODS: The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ). RESULTS: A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings. CONCLUSIONS: Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.


Assuntos
Gestão de Antimicrobianos/métodos , Atitude do Pessoal de Saúde , Bacteriúria/tratamento farmacológico , Prescrição Inadequada/prevenção & controle , Padrões de Prática em Enfermagem , Padrões de Prática Médica , Infecções Assintomáticas , Hospitais de Veteranos , Humanos , Equipe de Assistência ao Paciente , Estudos Prospectivos , Gestão da Segurança , Inquéritos e Questionários , Estados Unidos , Procedimentos Desnecessários
18.
Am J Cardiol ; 124(6): 907-911, 2019 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-31311659

RESUMO

Methamphetamine is one of the most commonly abused illicit substances worldwide. Chronic methamphetamine abuse (MA) is associated with the development of a dilated cardiomyopathy. MA in patients with heart failure (MethHF) is increasingly reported yet poorly characterized. This was a retrospective cohort study of veterans treated at the VA Medical Center in San Diego between 2005 and 2015 with a diagnosis of HF and a history of MA. The incidence of MA each year was calculated, and clinical characteristics and outcomes of veterans with HF with and without MA were compared. Among 9,491 veterans with HF, 429 were identified as having a history of MA. Between 2006 and 2015, the incidence of MA in veterans with HF doubled from 3.44% to 6.70%. Of the 429 identified, 106 veterans had a hospitalization for HF and they were compared with veterans with HF without evidence of MA (HF). Compared with veterans with HF, veterans with MethHF were significantly younger (60.7 ± 7.3 vs 71.6 ± 11.6 years, p <0.001), with more frequent co-morbid post-traumatic stress disorder (16.8% vs 4.4%, p = 0.006), depression (28.7% vs 11.0%, p = 0.002), homelessness (27.9% vs 8.9%, p = 0.001), and unemployment (55.8% vs 30.0%, p <0.001). Despite their younger age, veterans with MethHF had high rates of HF readmission or emergency room visit (49% vs 38% in MethHF vs HF, p = 0.34) and mortality at 6 months (27% vs 38% in MethHF vs HF, p = 0.10) compared with HF. In conclusion, MA in veterans with HF is on the rise. Certain demographic and clinical characteristics of veterans with MethHF may contribute to their poor outcomes.


Assuntos
Insuficiência Cardíaca/induzido quimicamente , Hospitais de Veteranos/estatística & dados numéricos , Metanfetamina/efeitos adversos , Transtornos Relacionados ao Uso de Substâncias/complicações , Veteranos/estatística & dados numéricos , Idoso , California/epidemiologia , Estimulantes do Sistema Nervoso Central/efeitos adversos , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/tendências , Prognóstico , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Taxa de Sobrevida/tendências
19.
Womens Health Issues ; 29 Suppl 1: S15-S23, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31253237

RESUMO

INTRODUCTION: Female veterans smoke cigarettes at high rates compared with both male veterans and nonveteran women. Proactive outreach to smokers may reduce gender disparities in cessation care. The objectives of this study were to compare baseline experiences with VA smoking cessation care for men and women and to assess for gender differences in response to a proactive outreach intervention. METHODS: We conducted a post hoc subgroup analysis of a pragmatic, multisite randomized, controlled trial comparing proactive outreach with usual care (UC). Baseline experiences included physician advice to quit, satisfaction with care, and past-year treatment use. At the 1-year follow-up, treatment use, quit attempts, and 6-month prolonged abstinence for women and men randomized to proactive outreach versus UC were compared using logistic regression. RESULTS: Baseline and follow-up surveys were returned by 138 women and 2,516 men. At baseline, women were less likely than men to report being very or somewhat satisfied with the process of obtaining smoking cessation medications in the VA (47% of women vs. 62% of men), but no less likely to report having used cessation medications from the VA in the past year (39% of women vs. 34% of men). After the intervention, phone counseling and combined therapy increased among both women and men in proactive outreach as compared with UC. At the 1-year follow-up, men in proactive outreach were significantly more likely to report prolonged abstinence than those in UC (odds ratio, 1.65; 95% CI, 1.28-2.14); results for women were in the same direction but not statistically significant (odds ratio, 1.39; 95% CI, 0.48-3.99). CONCLUSIONS: Satisfaction with cessation care in VA remains low. Proactive outreach to smokers was associated with an increased use of cessation therapies, and increased odds of achieving prolonged abstinence. A subgroup analysis by gender did not reveal significant differences in the treatment effect.


Assuntos
Aconselhamento/métodos , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/psicologia , Fumar/psicologia , Fumar/terapia , Veteranos/estatística & dados numéricos , Adulto , Feminino , Hospitais de Veteranos , Humanos , Masculino , Estudos Multicêntricos como Assunto/métodos , Médicos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Abandono do Hábito de Fumar/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologia
20.
Womens Health Issues ; 29 Suppl 1: S32-S38, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31253240

RESUMO

BACKGROUND: Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care. METHODS: Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics. RESULTS: The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women. CONCLUSIONS: It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.


Assuntos
Assistência à Saúde , Obesidade/psicologia , Satisfação do Paciente , Qualidade da Assistência à Saúde , Estereotipagem , Veteranos/psicologia , Adulto , Idoso , Comunicação , Feminino , Hospitais de Veteranos/organização & administração , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Obesidade/terapia , Atenção Primária à Saúde , Autogestão , Estados Unidos , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos , Saúde dos Veteranos
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