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1.
Medicine (Baltimore) ; 99(8): e19067, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32080080

RESUMEN

Unplanned resection of soft-tissue sarcomas (STS) predispose the patients to recurrences and metastases, secondary wide resection is usually warranted.To investigate the outcomes of re-excision of STS after unplanned initial resection.The records of 39 patients undergoing re-excision of STS after unplanned initial resection from January 2006 through December 2015 were retrospectively investigated.There were 17 males and 22 females, the mean age was 45.7 years. Most initial unplanned resections were performed in rural hospitals by surgeons from general surgery department, dermatology department, plastic surgery department, and orthopedic department. Thirty-five patients underwent secondary wide resections in our department. Histopathological findings indicated positive margins after primary surgeries in 18 patients. Until the conclusion of 37.2-month follow-up, 7 patients developed metastasis, 3 had local recurrence, and 7 were dead. Positive margins were associated with increased metastases and lower survival rates (P < .05). There was no significant difference in recurrences between the 2 groups.Unplanned initial resection of STS often lead to unfavorable prognosis. Primary wide resections are warranted for this disease entity.


Asunto(s)
Reoperación/estadística & datos numéricos , Sarcoma/mortalidad , Sarcoma/cirugía , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Hospitales Rurales/estadística & datos numéricos , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Metástasis de la Neoplasia/patología , Recurrencia Local de Neoplasia/patología , Tomografía Computarizada por Tomografía de Emisión de Positrones/métodos , Pronóstico , Reoperación/mortalidad , Estudios Retrospectivos , Sarcoma/diagnóstico por imagen , Sarcoma/patología , Tasa de Supervivencia , Adulto Joven
2.
J Surg Res ; 246: 395-402, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31629495

RESUMEN

BACKGROUND: Laparoscopic appendectomy is a preferred approach in children with appendicitis. Patient characteristics associated with open appendectomy are poorly characterized, although such information can help optimize the care. MATERIAL AND METHODS: To characterize the factors associated with open appendectomy, we performed a retrospective analysis using the 2014 Nationwide Readmissions Database, capturing 49.3% of US hospitalizations. We identified surgically managed appendicitis using International Classification of Diseases, Ninth Revision, Clinical Modification among patients aged 18 or younger. Factors associated with open appendectomy, 30-d readmission rate, and hospitalization length were assessed using logistic regression, Cox proportional hazards regression, and Poisson regression, respectively. RESULTS: Of 46,147 children with surgically managed appendicitis, 85.2% had laparoscopic appendectomy. Low-volume hospitals (odds ratio, OR: 3.01 [95% confidence interval, CI: 1.81-5.01]), rural hospitals (OR: 2.36 [95%CI: 1.63-3.40]), public insurance (OR: 1.19 [95%CI: 1.03-1.36]), lower-income neighborhood residence (OR: 1.40 [95%CI: 1.06-1.86]), younger age (OR: 5.00 [95%CI: 3.64-6.86] in <5 year-old), and abscess complicating appendicitis (OR: 1.91 [95%CI: 1.58-2.31]) were associated with open appendectomy. Laparoscopic appendectomy was associated with shorter hospitalization (incidence rate ratio: 0.77 [95%CI: 0.69-0.87]) and less readmission with wound infection, but not with 30-d readmission, or readmission with intraabdominal abscess. CONCLUSIONS: Along with clinical factors, non-clinical factors including appendicitis volume and rural/teaching status of the treating hospitals play a role in the choice of surgical approach. Awareness of the patient- and hospital-level factors associated with open appendectomy may allow for future resource distribution or improvement in access to care, resulting in population-level impact.


Asunto(s)
Absceso Abdominal/epidemiología , Apendicectomía/efectos adversos , Apendicitis/cirugía , Readmisión del Paciente/estadística & datos numéricos , Infección de la Herida Quirúrgica/epidemiología , Absceso Abdominal/etiología , Absceso Abdominal/cirugía , Adolescente , Factores de Edad , Apendicectomía/métodos , Apendicitis/complicaciones , Niño , Preescolar , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Factores Socioeconómicos , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/cirugía
3.
J Surg Res ; 245: 629-635, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31522036

RESUMEN

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Asunto(s)
Tratamiento de Urgencia/efectos adversos , Disparidades en Atención de Salud/economía , Renta/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adolescente , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Pacientes Internos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Población Rural/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos , Adulto Joven
4.
Int J Dermatol ; 58(11): 1341-1349, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31498882

RESUMEN

Skin diseases are considered to be common in Nyala, Sudan. This study was carried out to verify the prevalence of skin diseases in Nyala. This prospective observational study included skin examination of a total of 1802 people: 620 patients who were evaluated in the outpatient clinics (OC) and 1182 people from orphanages and refugee camps (ORC) in Nyala, Sudan. χ2 test was used. The total prevalence of skin disorders in the sample was 92.6% (1670/1802). One thousand and fifty of 1182 (88.8%) people from ORC had a skin disorder. The most common skin diseases in this community were: fungal infections (32.6%), dermatitis/eczema (10.5%), bacterial skin infections (10.3%), disorders of skin appendages (8.7%), parasitic infestations (7.7%), atrophic skin disorders (7.4%), disorders of pigmentation (7.4%), hypertrophic skin disorders (6.4%), viral infections (5.8), benign neoplasm (1.9%), dermatoses due to animal injury (0.4%), bullous dermatoses (0.1%), and malignant neoplasm (0.1%). Hypertrophic and atrophic disorders of the skin were mainly lesions of scarification (mostly atrophic) (5.7%) and keloids (5.6%). Fungal infection, bacterial infection, and parasitic infestation were more common in the ORC group, while dermatitis and eczema, disorders of skin appendages, hypertrophic and atrophic disorders of the skin, disorders of pigmentation, and benign neoplasm were more common in the OC group. The prevalence of skin diseases in the rural Nyala was more than our expectation and was dominated by infectious skin diseases. In addition, infectious skin diseases were more common in ORC rather than OC.


Asunto(s)
Hospitales Rurales/estadística & datos numéricos , Orfanatos/estadística & datos numéricos , Campos de Refugiados/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Enfermedades de la Piel/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Sudán/epidemiología , Adulto Joven
5.
Am J Health Syst Pharm ; 76(1): 17-25, 2019 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-31381097

RESUMEN

PURPOSE: To evaluate the impact of a pharmacy-directed pain management service (PPMS) designed to optimize analgesic pharmacotherapy, minimize adverse events, and improve patients' experience of pain management. METHODS: A retrospective analysis was conducted to evaluate the PPMS consisting of 3 dedicated pain management clinical pharmacists who perform both consult-based and stewardship functions. Multiple measures of opioid use and associated patient satisfaction outcomes during 3-year periods before and after implementation of the PPMS were compared. RESULTS: Significant decreases in use of institutionally defined high-risk opioid medications (e.g., parenteral hydromorphone, fentanyl, transdermal fentanyl patches), a decrease in total institutional opioid use, increased coanalgesic and adjunctive medication use, and a decrease in rapid response team (RRT) and code blue events associated with opioid-induced oversedation were seen after service implementation. Despite decreased opioid use, available patient satisfaction data suggested ongoing improvement in associated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey domains. CONCLUSION: Our data highlights the impact of a pharmacy directed pain management service on institutional opioid use with available data suggesting improved patient satisfaction scores and indirect cost savings. Despite decreased opioid use, available patient satisfaction data suggested ongoing improvement in associated HCAHPS survey pain management domains.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Administración del Tratamiento Farmacológico/organización & administración , Manejo del Dolor/métodos , Dolor/tratamiento farmacológico , Farmacéuticos , Adulto , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Implementación de Plan de Salud , Hospitales Rurales/organización & administración , Hospitales Rurales/estadística & datos numéricos , Humanos , Masculino , Administración del Tratamiento Farmacológico/estadística & datos numéricos , Trastornos Relacionados con Opioides/etiología , Trastornos Relacionados con Opioides/prevención & control , Dolor/diagnóstico , Dimensión del Dolor , Seguridad del Paciente , Satisfacción del Paciente , Rol Profesional , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos
6.
Artículo en Inglés | MEDLINE | ID: mdl-31450663

RESUMEN

Disability-disaggregated data are increasingly considered important to monitor progress in Universal Eye Health Care. Hospital-based data are still elusive because of the cultural ambiguities of the term disability, especially in under-resourced Health Information Systems in low-and middle-income countries. The aim of this study was to estimate the hospital-based rate of disability in patients presenting at an eye department of a rural hospital in Paraguay and to discuss implications for the management of access barriers. Therefore, we introduced two standardized sets of the Washington Group (WG) Questions as a pilot project. In total, 999 patients answered the self-report WG short set (WG-SS) questionnaire with six functional domains, and 501 of these patients answered an extended set, which included additional domains for "anxiety" and "depression" (WG-ES3). Overall, 27.7% (95% Confidence Interval (CI) 24.9-30.3) were categorized as having a disability. A total of 9.6% (95% CI 7.9-11.6) were categorized as having a disability because of communication difficulties, which was second only to visual difficulties. The odds ratio for disability for patients aged 70 years and older was 8.5 (95% CI 5.0-14.4) and for male patients, it was 0.83 (95% CI 0.62-1.1). Of those patients who answered the WG-ES3, 3.4% were categorized as having a disability because of being worried, nervous or anxious and 1.4% because of feeling depressed. An analysis of the questions of the "depression" domain was impeded by a high rate of measurement errors. The results of the different domains can now be used to inform the identification and mitigation of potential access barriers to eye health services for different types of impairments.


Asunto(s)
Personas con Discapacidad/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Adolescente , Adulto , Anciano , Ansiedad , Niño , Preescolar , Depresión , Oftalmopatías , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Paraguay , Proyectos Piloto , Encuestas y Cuestionarios , Adulto Joven
8.
Health Serv Res ; 54(5): 994-1006, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31215029

RESUMEN

OBJECTIVE: To evaluate the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. DATA SOURCES/STUDY SETTING: Fall-risk-reduction process and outcome measures from 16 small rural hospitals participating in a research demonstration and dissemination study from August 2012 to July 2014. Previously, these hospitals lacked a fall-event reporting system to drive improvement. STUDY DESIGN: A one-group pretest-posttest embedded in a participatory research framework. We required hospitals to implement MTSs, which we supported by conducting education, developing an online toolkit, and establishing a fall-event reporting system. DATA COLLECTION: Hospitals used gap analyses to assess the presence of fall-risk-reduction processes at study beginning and their frequency and effectiveness at study end; they reported fall-event data throughout the study. PRINCIPAL FINDINGS: The extent to which hospitals implemented 21 processes to coordinate the fall-risk-reduction program and trained staff specifically about the program predicted unassisted and injurious fall rates during the end-of-study period (January 2014-July 2014). Bedside fall-risk-reduction processes were not significant predictors of these outcomes. CONCLUSIONS: Multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.


Asunto(s)
Accidentes por Caídas/prevención & control , Accidentes por Caídas/estadística & datos numéricos , Enfermería Basada en la Evidencia/organización & administración , Hospitales Rurales/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Grupo de Atención al Paciente/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Conducta Cooperativa , Enfermería Basada en la Evidencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medio Oeste de Estados Unidos , Factores de Riesgo
9.
Afr Health Sci ; 19(1): 1536-1543, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31148981

RESUMEN

Background: In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths. Objective: The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system. Methods: Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed. Results: Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral. Conclusion: The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.


Asunto(s)
Parto Obstétrico , Personal de Salud , Hospitales Rurales/estadística & datos numéricos , Servicios de Salud Materna/organización & administración , Complicaciones del Trabajo de Parto/prevención & control , Derivación y Consulta/estadística & datos numéricos , Servicios de Salud Rural/normas , Adulto , Estudios Transversales , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Hemorragia Posparto/prevención & control , Embarazo , Complicaciones del Embarazo , Investigación Cualitativa , Zambia
10.
Health Serv Res ; 54(3): 526-536, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-31066468

RESUMEN

OBJECTIVE: To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation. DATA SOURCES/STUDY SETTING: Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File. STUDY DESIGN: We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. DATA COLLECTION: Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census. PRINCIPAL FINDINGS: We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. CONCLUSIONS: We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Reembolso de Seguro de Salud/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Humanos , Maryland , Alta del Paciente/estadística & datos numéricos , Estados Unidos
11.
Aust J Rural Health ; 27(2): 139-145, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30942515

RESUMEN

OBJECTIVE: We examined the factors that influence medical school graduates' choices for the place of internship, so that they can guide policy-makers to attract interns to rural hospitals. DESIGN: A national survey. SETTING: Rural and metropoles of Israel. PARTICIPANTS: Three-hundred-and-thirty-nine interns who did their internships during the years 2016-2018. MAIN OUTCOME MEASURE: The participants completed a web survey. We used the results of this survey to deduce which factors were influential in helping the interns choose a hospital for their year of internship. RESULTS: We received 339 questionnaires from medical school graduates of years 2015-2017. We found that the most influential factors in attracting interns to rural hospital internships are the availability of desired residency and exposure to a rural curriculum in medical school. This far outweighed any economic or life quality incentives. In addition, we found that the exposure to rural hospitals during the medical school years increases the likelihood of choosing an internship in a rural hospital. CONCLUSIONS: The most important factor for choosing a hospital for internship is the availability of lucrative residencies. Thus, we believe the best way to attract good interns would be to make the desired residency positions available for them. Furthermore, it might be more successful to target either students who have studied in a university affiliated with rural hospital rotations or graduates of universities outside of the country.


Asunto(s)
Selección de Profesión , Hospitales Rurales/estadística & datos numéricos , Internado y Residencia/organización & administración , Ubicación de la Práctica Profesional , Servicios de Salud Rural/organización & administración , Estudiantes de Medicina/psicología , Estudiantes de Medicina/estadística & datos numéricos , Adulto , Femenino , Humanos , Israel , Masculino , Encuestas y Cuestionarios , Adulto Joven
12.
Med Care ; 57(6): 407-409, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30994524

RESUMEN

BACKGROUND: A high volume of emergency department (ED) visits in the rural United States may be the result of barriers to accessing primary care. The Affordable Care Act (ACA) increased the number of insured, which may improve patient access to primary care and therefore reduce ED utilization. The objective of this study is to estimate the trends and cost of ED utilization pre-ACA and post-ACA implementation in a rural United States. DATA AND METHODS: We use 2009-2013 ED utilization data from a rural Georgia hospital to estimate trends and costs by demographic characteristics, referring source, and payor information. T tests and log-linear regression models are used to assess the sociodemographic factors impacting ED inflation-adjusted costs before (2009-2010) and after ACA (2011-2013) implementation. RESULTS: During 2009-2013, 39,970 ED encounters were recorded with an average cost (AC) of $2002 per visit. Results indicate that during pre-ACA, on average, 8702 encounters were recorded per year with an AC of $1759. During post-ACA, there were 7521 annual visits, with an annual AC of $2241. Regression model results indicate that AC were significantly higher for men, older adults, nonblack patients, those with private insurance, and during the post-ACA period. CONCLUSIONS: Results suggest that post-ACA, declining ED visits may be due to more patients with insurance accessing primary care instead of ED. We further hypothesize that increased AC during this period may be due to ED visits being of an emergent nature, which require more resources to treat. Further comprehensive investigation is warranted to study the impact of ACA on ED utilization for nonemergency purposes among rural and nonrural hospitals.


Asunto(s)
Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitales Rurales/economía , Hospitales Rurales/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Georgia , Humanos , Patient Protection and Affordable Care Act , Estados Unidos , Revisión de Utilización de Recursos
13.
J Surg Res ; 241: 247-253, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31035139

RESUMEN

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.


Asunto(s)
Hernia Inguinal/cirugía , Herniorrafia/estadística & datos numéricos , Selección de Paciente , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Afroamericanos/estadística & datos numéricos , Anciano , Femenino , Herniorrafia/economía , Herniorrafia/tendencias , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/economía , Procedimientos Quirúrgicos Robotizados/tendencias , Factores Sexuales , Cirujanos/estadística & datos numéricos , Estados Unidos , Carga de Trabajo/estadística & datos numéricos
14.
Public Health Nurs ; 36(4): 469-477, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-30957926

RESUMEN

OBJECTIVE: The purpose was to compare nurse education, patient-to-nurse staffing, nursing skill mix, and nurse work environments across hospitals depending on extent of rurality. DESIGN: Cross-sectional, comparative, and descriptive. SAMPLE: The final sample included 566 urban, 49 large, 18 small, and 9 isolated hospitals from California, Florida, and Pennsylvania. MEASUREMENT: Data collected from large random samples from the 2005-2008 Multi-State Nursing Care and Patient Safety Study funded by the National Institute of Nursing Research and National Institutes of Health were linked to 2005-2006 American Hospital Association data. Rural-Urban Commuting Area codes developed by the University of Washington and the United States Department of Agriculture Economic Research Service were used to determine the extent of hospital rurality across the sample. RESULTS: Hospital percentages of baccalaureate prepared nurses differed significantly among urban (38%), large (28%), small (31%), and isolated rural hospitals (21%). Patient-to-registered nurse ratios in urban (4.8), large (5.6), small (5.6), and isolated rural hospitals (7.3) differed. Rural hospital nursing skill mix differed, and was lowest in isolated rural hospitals (65%). Nursing foundations for quality care were poorer in large, small, and isolated rural hospitals. CONCLUSION: Results support bolstering rural nursing resources in more remote locations, potentially through rural health policies.


Asunto(s)
Educación en Enfermería/estadística & datos numéricos , Asignación de Recursos para la Atención de Salud , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Personal de Enfermería en Hospital/estadística & datos numéricos , Carga de Trabajo/estadística & datos numéricos , California , Estudios Transversales , Florida , Política de Salud , Recursos en Salud , Humanos , Masculino , Pennsylvania , Calidad de la Atención de Salud , Salud Rural , Estados Unidos , Lugar de Trabajo
15.
Rural Remote Health ; 19(1): 4342, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30889960

RESUMEN

INTRODUCTION: Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and a common presentation in general practice. Scoring systems to guide antithrombotic treatment have been available since 1996, with the CHA2DS2-VASC in current use; however, little is known about adherence to guidelines in rural general practice. The purpose of this study was to determine whether patients in a rural population and with documented history of AF are prescribed antithrombotic treatment according to recognised guidelines. METHODS: A retrospective cohort study of inpatients was performed at a rural country hospital in South Australia. All patients with an ICD-10 CM code at the time of discharge were selected from June 2008 to July 2013. This included both newly diagnosed AF as well cases with existing history of AF. RESULTS: Among the 59 patients studied, 77% of patients received appropriate anticoagulation according to CHADS2 score and 83% according to CHA2DS2-VASC score. CONCLUSIONS: This study confirms that the guidelines are routinely followed in clinical practice in this rural population.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Adhesión a Directriz/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Guías de Práctica Clínica como Asunto/normas , Anciano , Auditoría Clínica , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Australia del Sur , Accidente Cerebrovascular/prevención & control
16.
West J Emerg Med ; 20(2): 232-236, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30881541

RESUMEN

Introduction: Procedural sedation and analgesia (PSA) provides safe and effective relief for pain, anxiety and discomfort during procedures performed in the emergency department (ED). Our objective was to identify hospital-level factors associated with routine PSA capnography use in the ED. Methods: This study was a cross-sectional telephone survey of ED nurse managers and designees in a Midwestern state. Respondents identified information about hospital infrastructure, physician staffing, family practice (FP) physicians only, board-certified emergency physicians (EPs) only (or both), and critical intervention capabilities. Additional characteristics including ED volume and hospital designation (i.e., rural-urban classification) were obtained from the Centers for Medicare and Medicaid Services and the state hospital association database, respectively. The primary outcome was reported use of PSA capnography. We conducted univariate analyses (relative risks, 95% confidence interval [CI]) to identify associations between hospital-level characteristics and PSA capnography use. Results: We had an overall response rate of 98% (n=118 participating hospitals). The majority of EDs were in rural settings (78%), with a median of 5,057 visits per year (interquartile range 2,823-14,322). Nearly half of the EDs were staffed by FP physicians only, while 16% had board-certified EPs only. Nearly all hospitals (n=114, 97%), reported using continuous capnography for ventilated patients, and 74% reported use of capnography during PSA. Urban hospitals were more likely to use PSA capnography than critical access hospitals (relative risk 1.45; 95% CI, 1.22-1.73), and PSA capnography use increased with each ED volume quartile. Facilities with only EPs were 1.46 (95% CI, 1.15-1.87) times more likely to use PSA capnography than facilities with FP physicians only. Conclusion: Continuous capnography was available in nearly all EDs, independent of size, location or patient volume. The implementation of capnography during PSA was less penetrant. Smaller, rural departments were less likely than their larger, urban counterparts to implement these national guidelines. Rurality and hospital size may be potential institutional barriers to capnography implementation.


Asunto(s)
Dióxido de Carbono/análisis , Hospitales Comunitarios/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Analgesia/estadística & datos numéricos , Capnografía/estadística & datos numéricos , Certificación , Estudios Transversales , Servicio de Urgencia en Hospital/estadística & datos numéricos , Encuestas Epidemiológicas , Hospitales Urbanos/estadística & datos numéricos , Humanos , Medicare/estadística & datos numéricos , Manejo del Dolor , Salud Rural , Encuestas y Cuestionarios , Estados Unidos , Salud Urbana/estadística & datos numéricos
17.
Int J Antimicrob Agents ; 53(2): 171-176, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30722961

RESUMEN

Many regional and remote hospitals (RRHs) do not have the specialist services that usually support antimicrobial stewardship (AMS) programmes in major city hospitals. It is not known if this is associated with higher rates of inappropriate antimicrobial prescribing. The aim of this study was to identify similarities and differences in antimicrobial prescribing patterns between major city hospitals and RRHs in Australia. The Australian Hospital National Antimicrobial Prescribing Survey (H-NAPS) datasets from 2014, 2015 and 2016 (totalling 47,876 antimicrobial prescriptions) were analysed. The antimicrobial prescribed, indications for use, documentation of indication, recording of a review date and assessment of the appropriateness of prescribing were evaluated. Overall, inappropriate prescribing of antimicrobials was higher in RRHs than in major city hospitals (24.0% vs. 22.1%; P<0.001). Compared with major city hospitals, inappropriate prescribing of ceftriaxone was higher in RRHs (33.9% vs. 27.6%; P<0.001), as was inappropriate prescribing for cellulitis (25.7% vs. 19.0%; P≤0.001). A higher rate of inappropriate prescribing was noted for some high-risk infections in RRHs compared with major city hospitals, including Gram-positive bacteraemia with sepsis (12.6% vs. 6.5%; P=0.004), empiric therapy for sepsis (26.0% vs. 12.0%; P<0.001) and endocarditis (8.2% vs. 2.7%; P=0.02). To the authors' knowledge, this is the largest study to date comparing antimicrobial prescribing of RRHs with major city hospitals. A key finding was that antimicrobial prescribing was more frequently inappropriate for some high-risk infections treated in RRHs. Targeted strategies that support appropriate antimicrobial prescribing in RRHs are required.


Asunto(s)
Antibacterianos/uso terapéutico , Programas de Optimización del Uso de los Antimicrobianos , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Prescripción Inadecuada/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Australia , Bacteriemia/tratamiento farmacológico , Ceftriaxona/uso terapéutico , Celulitis (Flemón)/tratamiento farmacológico , Endocarditis/tratamiento farmacológico , Humanos , Sepsis/tratamiento farmacológico
18.
J Invasive Cardiol ; 31(2): E23-E29, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30700627

RESUMEN

AIMS: Impella 2.5 and Impella CP (Abiomed) are percutaneous left ventricular assist devices that can be easily deployed in the cardiac catheterization laboratory without need for surgery and provide effective hemodynamic support. The utility of Impella devices for management of acute myocardial infarction complicated by cardiogenic shock (AMI-CS) at a rural community hospital without on-site surgical back-up has not been reported. METHODS: We retrospectively reviewed all consecutive patients who underwent percutaneous coronary intervention (PCI) with Impella support between 2012 and 2017 for AMI-CS at our institution. Survival, in-hospital complications, and recovery of native heart function at follow-up were assessed. RESULTS: A total of 90 consecutive patients (age, 63.8 ± 11.56 years; 28.8% female) with AMI-CS were supported with Impella and underwent PCI. At admission, 82.2% had cardiogenic shock and 32.2% sustained out-of-hospital cardiac arrest (OHCA). Survival rates at discharge, 30 days, 180 days, and 365 days were 61.1%, 60.0%, 57.7%, and 57.3%, respectively. Survivors were younger (P=.02) and had lower rates of OHCA (P<.01). Survival rate at 180 days was 72.4% when door-to-Impella support time was ≤48 minutes, 53.9% when Impella was initiated between 49 to 86 minutes, and 39.3% when Impella support was initiated after 86 minutes (P=.04). Recovery of native heart function was observed in 88.7% of 62 patients weaned off Impella support. CONCLUSIONS: Early hemodynamic support with the Impella percutaneous left ventricular assist device in severely ill patients with AMI-CS at a rural community hospital without on-site surgical back-up yielded very favorable survival outcomes, with recovery of native heart function.


Asunto(s)
Corazón Auxiliar , Hemodinámica/fisiología , Hospitales Comunitarios/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Infarto del Miocardio/complicaciones , Sistema de Registros , Choque Cardiogénico/terapia , Anciano , Electrocardiografía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Estudios Retrospectivos , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiología
19.
Tohoku J Exp Med ; 247(1): 27-34, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30651405

RESUMEN

Japan is an aging society, and the incidence of diseases related to aging, such as pneumonia, heart failure, vertebral compression fracture (VCF), is increasing. Prolonged hospital stays are becoming a serious social problem, leading to elevated medical expenses. Thus, shortening the period of hospitalization is important. This study aimed to reveal determinants associated with prolonged hospital stays for patients with VCF. Our institution is the primary hospital in a rural area in the Kanto region of Japan. Altogether, 110 patients with a VCF, aged 65 years or older, including 79 women, were divided into two groups according to the average hospital stay period of 28 days: the long-stay group (mean stay 40.0 ± 11.6 days, n = 39) and the short-stay group (mean stay 20.6 ± 4.4 days, n = 71). Notably, the short-stay group included 55 women. Multivariate logistic regression analyses in male showed no variates significantly associated with prolonged hospitalization. By contrast, multivariate logistic regression analyses in female showed requiring emergency transportation to hospital was significantly associated with prolonged hospitalization [odds ratio 7.69, 95% confidence interval 1.13-52.29, P = 0.04]. In conclusion, this study implies that patients with better levels of activities of daily living are able to walk alone sooner and are easily discharged. Furthermore, the patient requiring emergency transportation might be in a poor social living environment, such as living alone. These results may give us a good opportunity to re-consider fundamental problems surrounding the elderly.


Asunto(s)
Fracturas por Compresión/complicaciones , Fracturas por Compresión/epidemiología , Hospitales Rurales/estadística & datos numéricos , Tiempo de Internación , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/epidemiología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Japón/epidemiología , Modelos Logísticos , Masculino , Análisis Multivariante , Resultado del Tratamiento
20.
BMC Health Serv Res ; 19(1): 33, 2019 Jan 14.
Artículo en Inglés | MEDLINE | ID: mdl-30642309

RESUMEN

BACKGROUND: Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals. METHODS: Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another. RESULTS: Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals' diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another. CONCLUSIONS: Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.


Asunto(s)
Diabetes Mellitus/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Agentes Comunitarios de Salud/estadística & datos numéricos , Terapias Complementarias/estadística & datos numéricos , Estudios Transversales , Utilización de Instalaciones y Servicios , Composición Familiar , Femenino , Instituciones de Salud/estadística & datos numéricos , Personal de Salud/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/psicología , Prioridad del Paciente/psicología , Prioridad del Paciente/estadística & datos numéricos , Sector Privado/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Salud Rural/estadística & datos numéricos , Uganda
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