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1.
Pilot Feasibility Stud ; 5: 123, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31720002

RESUMEN

Background: Recruitment of a diverse participant pool to cancer clinical trials is an essential component of clinical research as it improves the generalizability of findings. Investigating and piloting novel recruitment strategies that take advantage of ubiquitous digital technologies has become an important component of facilitating broad recruitment and addressing inequities in clinical trial participation. Equitable and inclusive recruitment improves generalizability of clinical trial outcomes, benefiting patients, clinicians, and the research community. The increasing prevalence of online connectivity in the USA and use of the Internet as a resource for medical information provides an opportunity for digital recruitment strategies in cancer clinical trials. This study aims to measure the acceptability, preliminary estimates of efficacy, and feasibility of the Trial Library intervention, an Internet-based cancer clinical trial matching tool. This study will also examine the extent to which the Trial Library website, designed to address the linguistic and literacy needs of broader patient populations, influences patient-initiated conversations with physicians about clinical trial participation. Methods: This is a study protocol for a non-randomized, single-arm pilot study. This is a mixed methods study design that utilizes the statistical analysis of quantitative survey data and the qualitative analysis of interview data to assess the participant experience with the Trial Library intervention. This study will examine (1) acceptability as a measure of participant satisfaction with this intervention, (2) preliminary measure of efficacy as a measure of proportion of participants with documented clinical trial discussion in the electronic medical record, and (3) feasibility of the intervention as a measure of duration of clinical visit. Discussion: The principles that informed the design of the Trial Library intervention aim to be generalizable to clinical trials across many disease contexts. From the ground up, this intervention is built to be inclusive of the linguistic, literacy, and technological needs of underrepresented patient populations. This study will collect essential preliminary data prior to a multi-site randomized clinical trial of the Trial Library intervention. Trial registration: This study has received institutional approval from the Committee of Human Subjects Research at the University of California, San Francisco.

2.
Pediatr Qual Saf ; 4(3): e172, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31579871

RESUMEN

Introduction: Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles. Methods: A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff. Results: The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management. Conclusions: The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

3.
Pediatr Crit Care Med ; 20(10): e473-e479, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31232856

RESUMEN

OBJECTIVES: To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices. DESIGN: Prospective observational study. SETTING: In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard. SUBJECTS: Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest. INTERVENTIONS: High-fidelity simulation of resuscitation with continuous audiovisual feedback. MEASUREMENTS AND MAIN RESULTS: Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 ± 10 compressions per minute; chest compression depth 2.05 ± 0.6 in; chest compression fraction 74% ± 10%; chest compression in target 22% ± 21%; preshock pause 8.6 ± 7.2 seconds; and postshock pause 6.4 ± 8.9 seconds. When all healthcare providers were analyzed, the association coefficient (κ) for chest compression rate (κ = 0.078), chest compression depth (κ = 0.092), chest compression fraction (κ = 0.004), preshock pause (κ = 0.321), and postshock pause (κ = 0.40) was low, with no variable achieving moderate agreement (κ > 0.4). CONCLUSIONS: Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback.

4.
Membranes (Basel) ; 8(3)2018 Aug 25.
Artículo en Inglés | MEDLINE | ID: mdl-30149634

RESUMEN

Electrospun nanofiber-supported thin film composite membranes are among the most promising membranes for seawater desalination via forward osmosis. In this study, a high-performance electrospun polyvinylidenefluoride (PVDF) nanofiber-supported thin film composite (TFC) membrane was successfully fabricated after molecular layer-by-layer polyelectrolyte deposition. Negatively-charged electrospun polyacrylic acid (PAA) nanofibers were deposited on electrospun PVDF nanofibers to form a support layer consisted of PVDF and PAA nanofibers. This resulted to a more hydrophilic support compared to the plain PVDF nanofiber support. The PVDF-PAA nanofiber support then underwent a layer-by-layer deposition of polyethylenimine (PEI) and PAA to form a polyelectrolyte layer on the nanofiber surface prior to interfacial polymerization, which forms the selective polyamide layer of TFC membranes. The resultant PVDF-LbL TFC membrane exhibited enhanced hydrophilicity and porosity, without sacrificing mechanical strength. As a result, it showed high pure water permeability and low structural parameter values of 4.12 L m-2 h-1 bar-1 and 221 µm, respectively, significantly better compared to commercial FO membrane. Layer-by-layer deposition of polyelectrolyte is therefore a useful and practical modification method for fabrication of high performance nanofiber-supported TFC membrane.

5.
Neurosurgery ; 82(3): 378-387, 2018 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-28486687

RESUMEN

BACKGROUND: Several studies suggest significant variation in cost for spine surgery, but there has been little research in this area for spinal deformity. OBJECTIVE: To determine the utilization, cost, and factors contributing to cost for spinal deformity surgery. METHODS: The cohort comprised 55 599 adults who underwent spinal deformity fusion in the 2001 to 2013 National Inpatient Sample database. Patient variables included age, gender, insurance, median income of zip code, county population, severity of illness, mortality risk, number of comorbidities, length of stay, elective vs nonelective case. Hospital variables included bed size, wage index, hospital type (rural, urban nonteaching, urban teaching), and geographical region. The outcome was total hospital cost for deformity surgery. Statistics included univariate and multivariate regression analyses. RESULTS: The number of spinal deformity cases increased from 1803 in 2001 (rate: 4.16 per 100 000 adults) to 6728 in 2013 (rate: 13.9 per 100 000). Utilization of interbody fusion devices increased steadily during this time period, while bone morphogenic protein usage peaked in 2010 and declined thereafter. The mean inflation-adjusted case cost rose from $32 671 to $43 433 over the same time period. Multivariate analyses showed the following patient factors were associated with cost: age, race, insurance, severity of illness, length of stay, and elective admission (P < .01). Hospitals in the western United States and those with higher wage indices or smaller bed sizes were significantly more expensive (P < .05). CONCLUSION: The rate of adult spinal deformity surgery and the mean case cost increased from 2001 to 2013, exceeding the rate of inflation. Both patient and hospital factors are important contributors to cost variation for spinal deformity surgery.


Asunto(s)
Costos de Hospital/tendencias , Enfermedades de la Columna Vertebral/economía , Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/economía , Fusión Vertebral/tendencias , Adulto , Anciano , Estudios de Cohortes , Bases de Datos Factuales/tendencias , Femenino , Hospitalización/economía , Hospitalización/tendencias , Humanos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Análisis Multivariante , Procedimientos Neuroquirúrgicos/economía , Procedimientos Neuroquirúrgicos/tendencias , Enfermedades de la Columna Vertebral/epidemiología , Estados Unidos/epidemiología
6.
JAMA Netw Open ; 1(4): e181018, 2018 08 03.
Artículo en Inglés | MEDLINE | ID: mdl-30646095

RESUMEN

Importance: Current methods for identifying hospitalized patients at increased risk of delirium require nurse-administered questionnaires with moderate accuracy. Objective: To develop and validate a machine learning model that predicts incident delirium risk based on electronic health data available on admission. Design, Setting, and Participants: Retrospective cohort study evaluating 5 machine learning algorithms to predict delirium using 796 clinical variables identified by an expert panel as relevant to delirium prediction and consistently available in electronic health records within 24 hours of admission. The training set comprised 14 227 adult patients with non-intensive care unit hospital stays and no delirium on admission who were discharged between January 1, 2016, and August 31, 2017, from UCSF Health, a large academic health institution. The test set comprised 3996 patients with hospital stays who were discharged between August 1, 2017, and November 30, 2017. Exposures: Patient demographic characteristics, diagnoses, nursing records, laboratory results, and medications available in electronic health records during hospitalization. Main Outcomes and Measures: Delirium was defined as a positive Nursing Delirium Screening Scale or Confusion Assessment Method for the Intensive Care Unit score. Models were assessed using the area under the receiver operating characteristic curve (AUC) and compared against the 4-point scoring system AWOL (age >79 years, failure to spell world backward, disorientation to place, and higher nurse-rated illness severity), a validated delirium risk-assessment tool routinely administered in this cohort. Results: The training set included 14 227 patients (5113 [35.9%] aged >64 years; 7335 [51.6%] female; 687 [4.8%] with delirium), and the test set included 3996 patients (1491 [37.3%] aged >64 years; 1966 [49.2%] female; 191 [4.8%] with delirium). In total, the analysis included 18 223 hospital admissions (6604 [36.2%] aged >64 years; 9301 [51.0%] female; 878 [4.8%] with delirium). The AWOL system achieved a baseline AUC of 0.678. The gradient boosting machine model performed best, with an AUC of 0.855. Setting specificity at 90%, the model had a 59.7% (95% CI, 52.4%-66.7%) sensitivity, 23.1% (95% CI, 20.5%-25.9%) positive predictive value, 97.8% (95% CI, 97.4%-98.1%) negative predictive value, and a number needed to screen of 4.8. Penalized logistic regression and random forest models also performed well, with AUCs of 0.854 and 0.848, respectively. Conclusions and Relevance: Machine learning can be used to estimate hospital-acquired delirium risk using electronic health record data available within 24 hours of hospital admission. Such a model may allow more precise targeting of delirium prevention resources without increasing the burden on health care professionals.


Asunto(s)
Delirio/epidemiología , Registros Electrónicos de Salud , Hospitalización , Aprendizaje Automático , Modelos Educacionales , Adolescente , Adulto , Anciano , Disfunción Cognitiva , Estudios de Cohortes , Femenino , Predicción , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo/métodos , Adulto Joven
7.
J Hosp Med ; 12(9): 723-730, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28914276

RESUMEN

OBJECTIVE: To describe appropriate discharge reconciliation of cardiovascular medications and assess associations with postdischarge healthcare utilization in surgical patients. DESIGN: Retrospective cohort study from January 2007 to December 2011. SETTING: An academic medical center. PATIENTS: Seven hundred and fifty-two adults undergoing elective noncardiac surgery and taking antiplatelet agents, beta-blockers, renin-angiotensin system inhibitors, or statin lipid-lowering agents before surgery. MEASUREMENTS: Primary predictor: appropriate discharge reconciliation of preoperative cardiovascular medications (continuation without documented contraindications). Primary outcomes: acute hospital visits (emergency department visits or hospitalizations) and unplanned ambulatory visits (primary care or surgical) at 30 days after surgery. RESULTS: Preoperative medications were appropriately reconciled in 436 (58.0%) patients. For individual medications, appropriate discharge reconciliation occurred for 156 of the 327 patients on antiplatelet agents (47.7%), 507 of the 624 patients on beta-blockers (81.3%), 259 of the 361 patients on renin-angiotensin system inhibitors (71.8%), and 302 of the 406 patients on statins (74.4%). In multivariable analyses, appropriate reconciliation of all preoperative medications was not associated with acute hospital (adjusted odds ratio [AOR], 0.94; 95% confidence interval [CI], 0.63-1.41) or unplanned ambulatory visits (AOR, 1.48; 95% CI, 0.94-2.35). Appropriate reconciliation of statin therapy was associated with lower odds of acute hospital visits (AOR, 0.47; 95% CI, 0.26-0.85). There were no other statistically significant associations between appropriate reconciliation of individual medications and either outcome. CONCLUSIONS: Although large gaps in appropriate discharge reconciliation of chronic cardiovascular medications were common in patients undergoing elective surgery, these gaps were not consistently associated with postdischarge acute hospital or ambulatory visits.


Asunto(s)
Procedimientos Quirúrgicos Electivos , Conciliación de Medicamentos , Alta del Paciente/estadística & datos numéricos , Atención Primaria de Salud , Enfermedades Cardiovasculares/tratamiento farmacológico , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente/normas , Preparaciones Farmacéuticas/administración & dosificación , Estudios Retrospectivos , Factores de Riesgo
8.
J Hosp Med ; 12(8): 662-667, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28786434

RESUMEN

We describe a program called "Caring Wisely"®, developed by the University of California, San Francisco's (UCSF), Center for Healthcare Value, to increase the value of services provided at UCSF Health. The overarching goal of the Caring Wisely® program is to catalyze and advance delivery system redesign and innovations that reduce costs, enhance healthcare quality, and improve health outcomes. The program is designed to engage frontline clinicians and staff-aided by experienced implementation scientists-to develop and implement interventions specifically designed to address overuse, underuse, or misuse of services. Financial savings of the program are intended to cover the program costs. The theoretical underpinnings for the design of the Caring Wisely® program emphasize the importance of stakeholder engagement, behavior change theory, market (target audience) segmentation, and process measurement and feedback. The Caring Wisely® program provides an institutional model for using crowdsourcing to identify "hot spot" areas of low-value care, inefficiency and waste, and for implementing robust interventions to address these areas.


Asunto(s)
Ahorro de Costo , Prestación de Atención de Salud/métodos , Eficiencia Organizacional/economía , Grupo de Atención al Paciente/economía , Desarrollo de Programa , Prestación de Atención de Salud/economía , Humanos , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/organización & administración , San Francisco
9.
Spine (Phila Pa 1976) ; 42(15): E906-E913, 2017 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-28562473

RESUMEN

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation. SUMMARY OF BACKGROUND DATA: There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level. METHODS: We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region. RESULTS: The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast. CONCLUSION: The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery. LEVEL OF EVIDENCE: 3.


Asunto(s)
Vértebras Cervicales/cirugía , Bases de Datos Factuales/tendencias , Costos de la Atención en Salud/tendencias , Hospitalización/tendencias , Aceptación de la Atención de Salud , Fusión Vertebral/tendencias , Adulto , Anciano , Femenino , Costos de Hospital/tendencias , Hospitalización/economía , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/economía , Procedimientos Neuroquirúrgicos/tendencias , Fusión Vertebral/economía , Estados Unidos/epidemiología
10.
Anesth Analg ; 125(2): 507-513, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28514322

RESUMEN

BACKGROUND: Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. METHODS: We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). RESULTS: Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24). CONCLUSIONS: The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.


Asunto(s)
Mortalidad Hospitalaria , Sepsis/mortalidad , Sepsis/terapia , Choque Séptico/mortalidad , Choque Séptico/terapia , Adulto , Anciano , Estudios de Cohortes , Servicio de Urgencia en Hospital , Femenino , Fluidoterapia , Hospitalización , Humanos , Incidencia , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Admisión del Paciente , Resucitación , Estudios Retrospectivos
11.
Neurosurgery ; 81(6): 972-979, 2017 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-28402457

RESUMEN

BACKGROUND: There is a significant increase and large variation in craniotomy costs. However, the causes of cost differences in craniotomies remain poorly understood. OBJECTIVE: To examine the patient and hospital factors that underlie the cost variation in tumor craniotomies using 2 national databases: the National Inpatient Sample (NIS) and Vizient, Inc. (Irving, Texas). METHODS: For 41 483 patients who underwent primary surgery for supratentorial brain tumors from 2001 to 2013 in the NIS, we created univariate and multivariate models to evaluate the effect of several patient factors and hospital factors on total hospital cost. Similarly, we performed multivariate analysis with 15 087 cases in the Vizient 2012 to 2015 database. RESULTS: In the NIS, the mean inflation-adjusted cost per tumor craniotomy increased 30%, from $23 021 in 2001 to $29 971 in 2013. In 2001, the highest cost region was the Northeast ($24 486 ± $1184), and by 2013 the western United States was the highest cost region ($36 058 ± $1684). Multivariate analyses with NIS data showed that male gender, white race, private insurance, higher mortality risk, higher severity of illness, longer length of stay, elective admissions, higher wage index, urban teaching hospitals, and hospitals in the western United States were associated with higher tumor craniotomy costs (all P < .05). Multivariate analyses with Vizient data confirmed that longer length of stay and the western United States were significantly associated with higher costs (P < .001). CONCLUSION: After controlling for patient/clinical factors, hospital type, bed size, and wage index, hospitals in the western United States had higher costs than those in other parts of the country, based on analyses from 2 separate national databases.


Asunto(s)
Neoplasias Encefálicas/economía , Neoplasias Encefálicas/cirugía , Craneotomía/economía , Adulto , Anciano , Bases de Datos Factuales , Femenino , Costos de Hospital , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos
13.
Neurosurgery ; 81(2): 331-340, 2017 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-28327960

RESUMEN

BACKGROUND: Spinal surgery costs vary significantly across hospitals and regions, but there is insufficient understanding of what drives this variation. OBJECTIVE: To examine the factors underlying the cost variation for lumbar laminectomy/discectomy and lumbar fusions. METHODS: We obtained patient information (age, gender, race, severity of illness, risk of mortality, population of county of residence, median zipcode income, insurance status, elective vs nonelective admission, length of stay) and hospital data (region, hospital type, bed size, wage index) for all patients who underwent lumbar laminectomy/discectomy (n = 181 267) or lumbar fusions (n = 433 364) for degenerative conditions in the 2001 to 2013 National Inpatient Sample database. We performed unadjusted and adjusted analyses to determine which factors affect cost. RESULTS: Mean costs for lumbar laminectomy/discectomy and lumbar fusion increased from $8316 and $21 473 in 2001 (in inflation-adjusted 2013 dollars), to $11 405 and $29 438, respectively, in 2013. There was significant regional variation in cost, with the West being the most expensive region across all years and showing the steepest increase in cost over time. After adjusting for patient and hospital factors, the West was 23% more expensive than the Northeast for lumbar laminectomy/discectomy, and 25% more expensive than the Northeast for lumbar fusion ( P < .01). Higher wage index, smaller hospital bed size, and rural/urban nonteaching hospital type were also associated with higher cost for lumbar laminectomy/discectomy and fusion ( P < .01). CONCLUSION: After adjusting for patient factors and wage index, the Western region, hospitals with smaller bed sizes, and rural/urban nonteaching hospitals were associated with higher costs for lumbar laminectomy/discectomy and lumbar fusion.


Asunto(s)
Hospitalización , Laminectomía , Vértebras Lumbares/cirugía , Fusión Vertebral , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Laminectomía/economía , Laminectomía/estadística & datos numéricos , Estudios Retrospectivos , Fusión Vertebral/economía , Fusión Vertebral/estadística & datos numéricos
14.
J Telemed Telecare ; 23(2): 217-224, 2017 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26940797

RESUMEN

Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into "diagnosis," "treatment," and/or "monitoring." We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists' recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.


Asunto(s)
Centros Médicos Académicos/métodos , Atención Primaria de Salud/métodos , Consulta Remota/métodos , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Medicina , Persona de Mediana Edad , Médicos de Atención Primaria , Estudios Retrospectivos , Adulto Joven
15.
J Neurosurg ; 126(2): 620-625, 2017 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-27153160

RESUMEN

OBJECTIVE Disposable supplies constitute a large portion of operating room (OR) costs and are often left over at the end of a surgical case. Despite financial and environmental implications of such waste, there has been little evaluation of OR supply utilization. The goal of this study was to quantify the utilization of disposable supplies and the costs associated with opened but unused items (i.e., "waste") in neurosurgical procedures. METHODS Every disposable supply that was unused at the end of surgery was quantified through direct observation of 58 neurosurgical cases at the University of California, San Francisco, in August 2015. Item costs (in US dollars) were determined from the authors' supply catalog, and statistical analyses were performed. RESULTS Across 58 procedures (36 cranial, 22 spinal), the average cost of unused supplies was $653 (range $89-$3640, median $448, interquartile range $230-$810), or 13.1% of total surgical supply cost. Univariate analyses revealed that case type (cranial versus spinal), case category (vascular, tumor, functional, instrumented, and noninstrumented spine), and surgeon were important predictors of the percentage of unused surgical supply cost. Case length and years of surgical training did not affect the percentage of unused supply cost. Accounting for the different case distribution in the 58 selected cases, the authors estimate approximately $968 of OR waste per case, $242,968 per month, and $2.9 million per year, for their neurosurgical department. CONCLUSIONS This study shows a large variation and significant magnitude of OR waste in neurosurgical procedures. At the authors' institution, they recommend price transparency, education about OR waste to surgeons and nurses, preference card reviews, and clarification of supplies that should be opened versus available as needed to reduce waste.


Asunto(s)
Equipos Desechables/economía , Costos de la Atención en Salud , Procedimientos Neuroquirúrgicos/economía , Procedimientos Neuroquirúrgicos/instrumentación , Quirófanos/economía , Adulto , Humanos , San Francisco
16.
CMAJ ; 189(2): E56-E63, 2017 Jan 16.
Artículo en Inglés | MEDLINE | ID: mdl-27647618

RESUMEN

BACKGROUND: C-reactive protein (CRP) is increasingly being included in the diagnostic work-up for community-acquired pneumonia in primary care. Its added diagnostic value beyond signs and symptoms, however, remains unclear. We conducted a meta-analysis of individual patient data to quantify the added value of CRP measurement. METHODS: We included studies of the diagnostic accuracy of CRP in adult outpatients with suspected lower respiratory tract infection. We contacted authors of eligible studies for inclusion of data and for additional data as needed. The value of adding CRP measurement to a basic signs-and-symptoms prediction model was assessed. Outcome measures were improvement in discrimination between patients with and without pneumonia in primary care and improvement in risk classification, both within the individual studies and across studies. RESULTS: Authors of 8 eligible studies (n = 5308) provided their data sets. In all of the data sets, discrimination between patients with and without pneumonia improved after CRP measurement was added to the prediction model (extended model), with a mean improvement in the area under the curve of 0.075 (range 0.02-0.18). In a hypothetical cohort of 1000 patients, the proportion of patients without pneumonia correctly classified at low risk increased from 28% to 36% in the extended model, and the proportion with pneumonia correctly classified at high risk increased from 63% to 70%. The number of patients with pneumonia classified at low risk did not change (n = 4). Overall, the proportion of patients assigned to the intermediate-risk category decreased from 56% to 51%. INTERPRETATION: Adding CRP measurement to the diagnostic work-up for suspected pneumonia in primary care improved the discrimination and risk classification of patients. However, it still left a substantial group of patients classified at intermediate risk, in which clinical decision-making remains challenging.

17.
JAMA Surg ; 152(3): 284-291, 2017 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-27926758

RESUMEN

Importance: Despite the significant contribution of surgical spending to health care costs, most surgeons are unaware of their operating room costs. Objective: To examine the association between providing surgeons with individualized cost feedback and surgical supply costs in the operating room. Design, Setting, and Participants: The OR Surgical Cost Reduction (OR SCORE) project was a single-health system, multihospital, multidepartmental prospective controlled study in an urban academic setting. Intervention participants were attending surgeons in orthopedic surgery, otolaryngology-head and neck surgery, and neurological surgery (n = 63). Control participants were attending surgeons in cardiothoracic surgery, general surgery, vascular surgery, pediatric surgery, obstetrics/gynecology, ophthalmology, and urology (n = 186). Interventions: From January 1 to December 31, 2015, each surgeon in the intervention group received standardized monthly scorecards showing the median surgical supply direct cost for each procedure type performed in the prior month compared with the surgeon's baseline (July 1, 2012, to November 30, 2014) and compared with all surgeons at the institution performing the same procedure at baseline. All surgical departments were eligible for a financial incentive if they met a 5% cost reduction goal. Main Outcomes and Measures: The primary outcome was each group's median surgical supply cost per case. Secondary outcome measures included total departmental surgical supply costs, case mix index-adjusted median surgical supply costs, patient outcomes (30-day readmission, 30-day mortality, and discharge status), and surgeon responses to a postintervention study-specific health care value survey. Results: The median surgical supply direct costs per case decreased 6.54% in the intervention group, from $1398 (interquartile range [IQR], $316-$5181) (10 637 cases) in 2014 to $1307 (IQR, $319-$5037) (11 820 cases) in 2015. In contrast, the median surgical supply direct cost increased 7.42% in the control group, from $712 (IQR, $202-$1602) (16 441 cases) in 2014 to $765 (IQR, $233-$1719) (17 227 cases) in 2015. This decrease represents a total savings of $836 147 in the intervention group during the 1-year study. After controlling for surgeon, department, patient demographics, and clinical indicators in a mixed-effects model, there was a 9.95% (95% CI, 3.55%-15.93%; P = .003) surgical supply cost decrease in the intervention group over 1 year. Patient outcomes were equivalent or improved after the intervention, and surgeons who received scorecards reported higher levels of cost awareness on the health care value survey compared with controls. Conclusions and Relevance: Cost feedback to surgeons, combined with a small departmental financial incentive, was associated with significantly reduced surgical supply costs, without negatively affecting patient outcomes.


Asunto(s)
Costos Directos de Servicios/estadística & datos numéricos , Equipos y Suministros de Hospitales/economía , Hospitales Urbanos/economía , Quirófanos/economía , Especialidades Quirúrgicas/economía , Cirujanos/psicología , Concienciación , Ahorro de Costo , Costos y Análisis de Costo , Retroalimentación , Femenino , Humanos , Masculino , Estudios Prospectivos , Especialidades Quirúrgicas/estadística & datos numéricos , Servicio de Cirugía en Hospital/economía , Resultado del Tratamiento
19.
World Neurosurg ; 96: 177-183, 2016 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-27613498

RESUMEN

BACKGROUND: There is high variability in neurosurgical costs, and surgical supplies constitute a significant portion of cost. Anecdotally, surgeons use different supplies for various reasons, but there is little understanding of how supply choices affect outcomes. Our goal is to evaluate the effect of patient, procedural, and provider factors on supply cost and to determine if supply cost is associated with patient outcomes. METHODS: We obtained patient information (age, gender, payor, case mix index [CMI], body mass index, admission source), procedural data (procedure type, length, date), provider information (name, case volume), and total surgical supply cost for all inpatient neurosurgical procedures from 2013 to 2014 at our institution (n = 4904). We created mixed-effect models to examine the effect of each factor on surgical supply cost, 30-day readmission, and 30-day mortality. RESULTS: There was significant variation in surgical supply cost between and within procedure types. Older age, female gender, higher CMI, routine/elective admission, longer procedure, and larger surgeon volume were associated with higher surgical supply costs (P < 0.05). Routine/elective admission and higher surgeon volume were associated with lower readmission rates (odds ratio, 0.707, 0.998; P < 0.01). Only patient factors of older age, male gender, private insurance, higher CMI, and emergency admission were associated with higher mortality (odds ratio, 1.029, 1.700, 1.692, 1.080, 2.809). There was no association between surgical supply cost and readmission or mortality (P = 0.307, 0.548). CONCLUSIONS: A combination of patient, procedural, and provider factors underlie the significant variation in neurosurgical supply costs at our institution. Surgical supply costs are not correlated with 30-day readmission or mortality.


Asunto(s)
Costos y Análisis de Costo , Equipos y Suministros de Hospitales/economía , Procedimientos Neuroquirúrgicos/economía , Resultado del Tratamiento , Ahorro de Costo , Femenino , Humanos , Pacientes Internos , Tiempo de Internación/economía , Masculino , Procedimientos Neuroquirúrgicos/métodos , Oportunidad Relativa , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Cirujanos/economía , Cirujanos/psicología
20.
Am J Manag Care ; 22(5): e185-91, 2016 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-27266584

RESUMEN

OBJECTIVES: To develop local orthopedic guidelines for use in referral decision support and electronic consultation programs at University of California, San Francisco Health. STUDY DESIGN: Modified Delphi method. METHODS: We performed a 2-phase modified Delphi study to identify consensus between primary care and orthopedic clinicians for common musculoskeletal problems. RESULTS: Clinicians agreed that confirming patient interest in an orthopedic procedure should be completed prior to referral in 81% of clinical scenarios, as well as conservative management in 80%, physical therapy in 60%, and x-ray prior to referral in 42% of scenarios. Clinicians agreed an MRI should not be performed prior to referral in most (58%) clinical scenarios. CONCLUSIONS: In the absence of national guidelines, a process for local guideline generation is needed in order to provide nuanced and detailed decision support at the point of referral. The Delphi method proved an effective process to achieve this end.


Asunto(s)
Anomalías Musculoesqueléticas/diagnóstico , Anomalías Musculoesqueléticas/terapia , Ortopedia/normas , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud/normas , Derivación y Consulta/normas , Técnica Delfos , Femenino , Humanos , Masculino , San Francisco , Universidades
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