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2.
Brasília, D.F.; OPAS; 2020-03-31. (OPAS/EOC/Covid-19/20-0004).
en Portugués | PAHO-IRIS | ID: phr2-52013

RESUMEN

[Introdução]: O objetivo deste documento é fornecer recomendações que facilitem o atendimento em situação de pico de demanda por cuidados médicos e a alocação de equipes médicas de emergência, para responder a grandes números de pacientes, que poderiam sobrecarregar a rede integrada de serviços de saúde em comunidades ou áreas de circulação da COVID-19. Com base nos dados de uma grande coorte de pacientes com COVID-19, 40% dos pacientes irão apresentar quadro leve e receber apenas tratamento sintomático, sem necessidade de internação; cerca de 40% irão apresentar quadro moderado e podem ou não precisar de internação; 15% terão quadro grave, com necessidade de oxigenoterapia, entre outras intervenções hospitalares; e cerca de 5% evoluem para um quadro crítico, com necessidade de ventilação mecânica. O monitoramento da trajetória do surto em alguns países também mostra que os casos estão dobrando a cada três dias, com uma proporção maior de casos graves e críticos, o que cria a necessidade urgente de expandir a capacidade dos sistemas de saúde para prevenir a exaustão e o esgotamento dos profissionais da saúde, bem como o esvaziamento dos estoques de materiais biomédicos indispensáveis para a resposta.


Asunto(s)
Infecciones por Coronavirus , Capacidad de Reacción , Sistemas de Salud , Hospitales de Alto Volumen , Servicios Médicos de Urgencia
4.
Am J Cardiol ; 125(5): 694-711, 2020 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-31924317

RESUMEN

Little is known about whether there is an inverse relation between provider volume and long-term adverse outcomes for percutaneous coronary interventions (PCIs). For patients who underwent PCI procedures from December 2013 through November 2014 in New York, we examined a continuous relation and different annual PCI volume cut points at hospital and operator levels to investigate the relation between volume and 1-year adverse outcomes (mortality and mortality/acute myocardial infarction). There were 34,498 patients who underwent PCI procedures from 60 hospitals and 408 operators. We detected a significant continuous inverse association between 1-year mortality and annual hospital PCI volume. However, we did not find that there was a hospital volume and 1-year mortality relation for the 2013 ACCF/AHA/SCAI's hospital annual PCI volume cutoff value of 200 or a significant inverse operator volume-outcome relation using the operator annual PCI volume cutoff value of 50, or for any other practical volume cutoffs. Similar findings were obtained when we used the 1-year mortality/acute myocardial infarction outcome. We did find that providers in the highest volume quartile were associated with lower adverse outcome rates than providers in the lowest volume quartile. In conclusion, no significant volume-outcome relations were found between annual hospital or operator PCI volume and risk-adjusted 1-year outcomes for any practical volume cutoff values including 2013 Guidelines' recommended hospital/operator minimal annual PCI volumes. Providers in the highest annual volume quartile, however, were associated with lower adverse outcome rates than providers in the lowest volume quartile.


Asunto(s)
Cardiólogos/estadística & datos numéricos , Estenosis Coronaria/cirugía , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Mortalidad , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Grupos Étnicos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , New York/epidemiología , Infarto del Miocardio sin Elevación del ST/cirugía , Evaluación de Resultado en la Atención de Salud , Infarto del Miocardio con Elevación del ST/cirugía
5.
Obstet Gynecol ; 135(2): 328-339, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31923082

RESUMEN

OBJECTIVE: To validate the observed/expected ratio for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care, and to identify patient characteristics associated with disparities in access to high-performing hospitals. METHODS: This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to the California Cancer Registry between 1996 and 2014. A fit logistic regression model, which was risk-adjusted for patient and disease characteristics, was used to calculate the observed/expected ratio for each hospital, stratified by hospital annual case volume. A Cox proportional hazards model was used for survival analyses, and a multivariable logistic regression model was used to identify independent predictors of access to high-performing hospitals. RESULTS: The study population included 30,051 patients who were treated at 426 hospitals: low observed/expected ratio (n=304) 23.5% of cases; intermediate observed/expected ratio (n=92) 57.8% of cases; and high observed/expected ratio (n=30) 18.7% of cases. Hospitals with high observed/expected ratios were significantly more likely to deliver guideline-adherent care (53.3%), compared with hospitals with intermediate (37.8%) and low (27.5%) observed/expected ratios (P<.001). Median disease-specific survival time ranged from 73.0 months for hospitals with high observed/expected ratios to 48.1 months for hospitals with low observed/expected ratios (P<.001). Treatment at a hospital with a high observed/expected ratio was an independent predictor of superior survival compared with hospitals with intermediate (hazard ratio [HR] 1.06, 95% CI 1.01-1.11, P<.05) and low (HR 1.10, 95% CI 1.04-1.16, P<.001) observed/expected ratios. Being of Hispanic ethnicity (odds ratio [OR] 0.85, 95% CI 0.78-0.93, P<.001, compared with white), having Medicare insurance (OR 0.74, 95% CI 0.68-0.81 P<.001, compared with managed care), having a Charlson Comorbidity Index score of 2 or greater (OR 0.91, 95% CI 0.83-0.99, P<.05), and being of lower socioeconomic status (lowest quintile OR 0.41, 95% CI 0.36-0.46, P<.001, compared with highest quintile) were independent negative predictors of access to a hospital with a high observed/expected ratio. CONCLUSION: Ovarian cancer care at a hospital with a high observed/expected ratio is an independent predictor of improved survival. Barriers to high-performing hospitals disproportionately affect patients according to sociodemographic characteristics. Triage of patients with suspected ovarian cancer according to a performance-based observed/expected ratio hospital classification is a potential mechanism for expanded access to expert care.


Asunto(s)
Carcinoma Epitelial de Ovario/mortalidad , Carcinoma Epitelial de Ovario/terapia , Adhesión a Directriz/estadística & datos numéricos , Disparidades en Atención de Salud , Hospitales de Alto Volumen/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , California/epidemiología , Carcinoma Epitelial de Ovario/patología , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Hispanoamericanos/estadística & datos numéricos , Humanos , Modelos Logísticos , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Tasa de Supervivencia , Adulto Joven
6.
Ann R Coll Surg Engl ; 102(1): 36-42, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31660752

RESUMEN

INTRODUCTION: The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training. METHODS: We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship. RESULTS: There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times. CONCLUSIONS: Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.


Asunto(s)
Educación de Postgrado en Medicina/métodos , Cirugía General/educación , Admisión del Paciente/estadística & datos numéricos , Traumatología/educación , Heridas y Traumatismos/etiología , Adulto , Anciano , Anciano de 80 o más Años , Inglaterra , Femenino , Hospitales de Alto Volumen , Humanos , Irlanda , Masculino , Persona de Mediana Edad , Admisión y Programación de Personal/organización & administración , Admisión y Programación de Personal/estadística & datos numéricos , Estudios Retrospectivos , Horario de Trabajo por Turnos/estadística & datos numéricos , Factores de Tiempo , Centros Traumatológicos/organización & administración , Centros Traumatológicos/estadística & datos numéricos , Gales , Lugar de Trabajo/organización & administración , Lugar de Trabajo/estadística & datos numéricos , Heridas y Traumatismos/cirugía
7.
Surgery ; 167(2): 468-474, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31515123

RESUMEN

BACKGROUND: Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery. METHODS: Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility. RESULTS: There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003). CONCLUSION: Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.


Asunto(s)
Servicios de Salud para Ancianos/estadística & datos numéricos , Hospitales de Alto Volumen/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/mortalidad , Anciano , Femenino , Humanos , Masculino , Estados Unidos
8.
Am J Obstet Gynecol ; 222(1): 58.e1-58.e10, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31344350

RESUMEN

BACKGROUND: Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE: To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN: We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS: We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION: The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.


Asunto(s)
Neoplasias Endometriales/terapia , Accesibilidad a los Servicios de Salud/tendencias , Hospitales/tendencias , Viaje/tendencias , Adulto , Anciano , Grupos Étnicos/estadística & datos numéricos , Femenino , Geografía , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Humanos , Histerectomía , Histerectomía Vaginal , Seguro de Salud/estadística & datos numéricos , Laparoscopía , Persona de Mediana Edad , New York , Regionalización , Procedimientos Quirúrgicos Robotizados
9.
J Cardiovasc Surg (Torino) ; 61(2): 183-190, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-31755677

RESUMEN

BACKGROUND: Accumulated endovascular aneurysm repair (EVAR) procedures will increase number of patients requiring conversion to open repair of abdominal aortic aneurysms (AAA). In most cases, patients undergo late open surgical conversion (LOSC), many months, or years, after initial EVAR. The aim of this study is to analyze results of LOSC after EVAR in elective and urgent setting, including presenting features, surgical techniques, as well as to review the clinical outcomes and their predictors. METHODS: Retrospective review of all consecutive patients undergoing LOSC after EVAR was performed at three distinct, high volume, vascular centers. Patients that required primary conversion within 30 days after EVAR have not been included in this study. Between January 1st 2010 and January 1st 2017 total of 31 consecutive patients were treated. LOSC were performed either in elective or in urgent setting, thus dividing patients in two groups. Primary outcome was 30-day mortality and secondary postoperative complications. RESULTS: LOSC rate after EVAR was 4.51%. Most common indication for LOSC was type I endoleak (N.=20, 64.51%). All patients that presented with ruptured AAA had some form of endoleak (type I endoleak was present in five from six cases). Most common site for aortic cross-clamping was infrarenal (51.61%). Stent-graft was removed completely in 18 patients (58.06%) and partially in 13 (41.93%). 30-day mortality rate was 16.12% (5 patients) and most common cause of death was myocardial infarction (60%). Following univariate factors were isolated as predictors for 30-day mortality: preoperative coronary artery disease, chronic obstructive pulmonary disease, urgent LOSC, prolonged time until LOSC, ruptured AAA, supraceliac clamp, higher number of red blood cell transfusion, postoperative myocardial infarction, and prolonged intubation (more than 48 hours). CONCLUSIONS: LOSC seems to be safe and effective procedure when preformed in elective manner. On the other side, urgent LOSC after EVAR is associated with very high postoperative mortality and morbidity. Endoleak remains the main indication for open conversion. Further studies are necessary to standardize timing and treatment options for failing EVAR.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Causas de Muerte , Conversión a Cirugía Abierta/métodos , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Conversión a Cirugía Abierta/mortalidad , Bases de Datos Factuales , Procedimientos Endovasculares/métodos , Femenino , Mortalidad Hospitalaria , Hospitales de Alto Volumen , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Pronóstico , Reoperación/métodos , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento
10.
J Urol ; 203(5): 926-932, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-31846391

RESUMEN

PURPOSE: Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy. MATERIALS AND METHODS: We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates. RESULTS: A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p <0.001 for very high), prolonged length of stay (OR 0.25, p <0.001 for very high), 30-day readmission (OR 0.53, p <0.001 for very high) and positive surgical margins (OR 0.61, p <0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p <0.001 for very high). CONCLUSIONS: Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.


Asunto(s)
Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Prostatectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Estudios de Seguimiento , Humanos , Incidencia , Tiempo de Internación/tendencias , Masculino , Readmisión del Paciente/tendencias , Neoplasias de la Próstata/cirugía , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología
11.
Ann Vasc Surg ; 62: 1-7, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31207399

RESUMEN

BACKGROUND: Volume-outcome relationships exist for many complex surgical procedures, prompting institutions to adopt surgical volume standards for credentialing. The current Leapfrog Group Hospital volume standard for open abdominal aortic aneurysm repair (OAR) is 15 per year. However, this is primarily based on data from the 1990s and may not be appropriate given the dramatic decline in OAR. We sought to quantify the proportion of hospitals meeting volume standards, the difference in perioperative outcomes between low-volume and high-volume hospitals, and the potential travel burden of volume credentialing on patients. METHODS: We identified Medicare beneficiaries for individuals aged ≥65 years undergoing OAR in 2013-2014. Hospital "all-payer" annual volume was estimated based on the national proportion of patients undergoing OAR covered by Medicare in the Vascular Quality Initiative. Hospital annual OAR volume was characterized as <5/year, 5-9/year, 10-14/year, and ≥15/year (high volume). Adjusted rates of postoperative morbidity, reoperation, failure to rescue, and mortality in 2014 were compared across volume cohorts. Distance between patients' home zip code and high-volume hospitals was calculated. RESULTS: A total of 21,191 OARs were performed at 1,445 hospitals between 2013 and 2014. The average hospital OAR annual volume was 7.8 (standard deviation [SD] ± 9.3) with a median of 4.5. Among the 1,445 hospitals, only 190 (13.1%) performed ≥15 OARs per year whereas 756 hospitals (53.3%) performed <5 per year. Among patients who underwent OAR in 2014, 5,395 (53.3%) received care at a hospital that performed <15 per year. There was no difference in complication, reoperation, or failure to rescue rates between high-volume and low-volume hospitals. Mortality did not significantly differ among OAR volume cohorts. Hospitals performing <5 OARs per year had a mortality rate of 5.7% compared with 5.6% at high-volume hospitals (P = 0.817). One-quarter of patients who received care at a low-volume hospital would have had to travel more than 60 miles to reach a high-volume hospital. CONCLUSIONS: By conservative estimates, only 13% of hospitals performing OAR meet current volume standards. Triaging all patients to high-volume hospitals would require shifting over 5,000 patients annually with no associated improvement in perioperative outcomes. Implementation of the current OAR hospital volume standard may significantly burden patients and hospitals without improving surgical outcomes.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Habilitación Profesional/normas , Hospitales de Alto Volumen/normas , Hospitales de Bajo Volumen/normas , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Procedimientos Quirúrgicos Vasculares/normas , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Bases de Datos Factuales , Fracaso de Rescate en Atención a la Salud/normas , Femenino , Accesibilidad a los Servicios de Salud/normas , Humanos , Masculino , Medicare , Derivación y Consulta/normas , Reoperación/normas , Factores de Tiempo , Viaje , Resultado del Tratamiento , Estados Unidos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad
12.
Ann Vasc Surg ; 62: 248-257, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31449931

RESUMEN

BACKGROUND: This study aims to identify potential risk factors for becoming symptomatic in patients with radiographic celiac artery compression (CAC) as well as prognostic factors for patients with median arcuate ligament syndrome (MALS) who underwent surgical ligament release. METHODS: This is a retrospective cohort study of patients with findings of CAC on computed tomography or magnetic resonance angiography (CT/MRA) who were asymptomatic and who were diagnosed with MALS at a single university hospital between January 2001 and 2018. RESULTS: Following a review of 1,330 CT/MRA reports, a total of 109 patients were identified as having radiographically apparent CAC. Among these, 48 (44.0%) patients were symptomatic. Univariate comparison between those with and without symptoms showed that symptomatic patients were more commonly younger than 30 years old [17/48 (35.4%) vs. 8/61 (13.1%), P = 0.006], had a history of prior abdominal surgery [25/48 (52.1%) vs. 18/61 (29.5%), P = 0.017], and had high-grade stenosis [32/43 (74.4%) vs. 25/61 (41.0%), P = 0.001]. Among 41 included patients who underwent surgical release of the median arcuate ligament including open, laparoscopic, and robotic approaches, 82.9% reported overall clinical improvement, 5/41 (12.2%) reported persistent pain, and 13/36 (36.0%) experienced pain recurrence. The only identified risk factor associated with symptom recurrence was American Society of Anesthesiologists class III [7/13 (53.8%) vs. 4/23 (17.4%), P = 0.029]. CONCLUSIONS: The severity of stenosis and prior abdominal surgery both contributed to symptom development in patients with radiographically apparent CAC from the median arcuate ligament.


Asunto(s)
Arteria Celíaca , Descompresión Quirúrgica , Síndrome del Ligamento Arcuato Medio/cirugía , Adulto , Anciano , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/fisiopatología , Angiografía por Tomografía Computarizada , Descompresión Quirúrgica/efectos adversos , Femenino , Hospitales de Alto Volumen , Hospitales Universitarios , Humanos , Los Angeles , Angiografía por Resonancia Magnética , Masculino , Síndrome del Ligamento Arcuato Medio/diagnóstico por imagen , Síndrome del Ligamento Arcuato Medio/fisiopatología , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
13.
Artículo en Inglés | MEDLINE | ID: mdl-31817294

RESUMEN

Fragility fractures pose a serious threat to patient health, quality of life, and healthcare sustainability. In order to reduce their clinical, social, and economic burden, a Fracture Liaison Service (FLS) was introduced in a high volume orthopedic hospital in 2017. The purpose of this retrospective observational study is to describe the FLS protocol, introduce its preliminary outcomes, and provide an early evaluation in light of international guidelines and recommendations. All the performances suggested by the International Osteoporosis Foundation (IOF) are provided under the same institution by which a patient is admitted for surgery. Clinical indicators from patient history and administrative indicators from the hospital database have been used to estimate the spread of fragility fracture prevention and the degree of patient compliance to these programs. The research included 403 patients. Although, almost 1/3 were admitted for the second fragility fracture, only half received anti-osteoporotic treatment before it. The degree of prevention was even lower in the case of patients admitted for the first fragility fracture. The risk of being affected by a secondary fracture was seven times higher when patients did not attend any follow-up or diagnostic exam. In order to identify the main determinants of compliance with FLS and perform a cost-effectiveness analysis on a larger sample, it is fundamental to integrate data from different providers.


Asunto(s)
Hospitales de Alto Volumen , Fracturas Osteoporóticas/prevención & control , Prevención Secundaria/métodos , Anciano , Anciano de 80 o más Años , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Fracturas Osteoporóticas/diagnóstico , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Calidad de Vida , Estudios Retrospectivos , Prevención Secundaria/organización & administración , Resultado del Tratamiento
14.
J Orthop Surg Res ; 14(1): 468, 2019 Dec 27.
Artículo en Inglés | MEDLINE | ID: mdl-31881918

RESUMEN

BACKGROUND: A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA. MATERIALS AND METHODS: We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis. RESULTS: Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies. CONCLUSIONS: These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required. TRIAL REGISTRATION: PROSPERO CRD42019123776.


Asunto(s)
Artroplastia de Reemplazo de Cadera , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Humanos , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento
15.
Medicine (Baltimore) ; 98(44): e17712, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31689806

RESUMEN

Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.


Asunto(s)
Mortalidad Hospitalaria , Hospitales/estadística & datos numéricos , Cirujanos/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/mortalidad , Femenino , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Humanos , Masculino , Metaanálisis como Asunto , Estudios Observacionales como Asunto , Oportunidad Relativa
16.
Int J Colorectal Dis ; 34(12): 2121-2127, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31720828

RESUMEN

BACKGROUND: The influence of hospital-related factors on outcomes following colorectal surgery is not well-established. The aim of our study was to evaluate the relationship between hospital factors on outcomes in surgically managed colorectal cancer patients. METHODS: We performed a 2-year (2014-2015) analysis of the NIS database. Adult (> 18 years) patients who underwent open or laparoscopic colorectal resection were identified using ICD-9 codes. Patients were stratified based on hospital: volume (low vs. high), teaching status, and location (urban vs. rural). Outcome measures were complications and mortality. Multivariate logistic regression was performed. RESULTS: A total of 153,453 patients with CRC were identified of which 35.3% underwent surgical management. Mean age was 69 ± 13 years, 51.6% were female, and 67% were white. Twenty-seven percent of the patients were managed at a high-volume center, 48% at intermediate-volume center while 25% at a low-volume center. Complications and mortality rates were lower in patients who were managed at high-volume centers and urban hospitals, while no difference was noticed based on teaching status. On regression analysis, patients managed at high-volume centers (OR 0.76 [0.56-0.89]) and urban hospitals (OR 0.83 [0.64-0.91]) have lower odds of complications; similarly, high-volume centers (OR 0.79 [0.65-0.90]) and urban facility (OR 0.87 [0.70-0.92]) were associated with lower odds of mortality. However, there was no association between teaching status and outcomes. CONCLUSION: Hospital factors significantly influence outcomes in patients with CRC managed surgically. High-volume centers and urban facilities have relatively better outcomes. Regionalization of care along with the appropriate availability of resources may improve outcomes in patients with CRC. LEVEL OF EVIDENCE: Level III, Retrospective Observational Study.


Asunto(s)
Colectomía , Neoplasias Colorrectales/cirugía , Hospitales de Alto Volumen , Hospitales Urbanos , Anciano , Anciano de 80 o más Años , Colectomía/efectos adversos , Colectomía/mortalidad , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Bases de Datos Factuales , Femenino , Hospitales de Bajo Volumen , Hospitales Rurales , Hospitales de Enseñanza , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología
17.
Am Heart J ; 218: 75-83, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31707331

RESUMEN

BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30 days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (P < .001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, P = .24; mortality: 0% vs. 0.07%, P = .99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Angina Estable/cirugía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/estadística & datos numéricos , Anciano , Procedimientos Quirúrgicos Ambulatorios/economía , Procedimientos Quirúrgicos Ambulatorios/mortalidad , Ahorro de Costo , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/mortalidad , Femenino , Hospitales de Alto Volumen/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/economía , Alta del Paciente/tendencias , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Intervención Coronaria Percutánea/economía , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Factores de Tiempo , Estados Unidos , United States Department of Veterans Affairs
18.
World J Surg Oncol ; 17(1): 180, 2019 Nov 04.
Artículo en Inglés | MEDLINE | ID: mdl-31684956

RESUMEN

BACKGROUND: Guidelines recommend treatment of retroperitoneal sarcomas (RPS) at high-volume centers. However, high-volume centers may not be accessible locally. This national study compared outcomes of RPS resection between local low-volume centers and more distant high-volume centers. METHODS: Patients treated for RPS were identified from the National Cancer Database (1998-2012). Travel distance and annual hospital volume were divided into quartiles. Two groups were identified: (1) short travel to low-volume hospitals (ST/LV), (2) long travel to high-volume hospitals (LT/HV). Outcomes were adjusted for clinical, tumor, and treatment characteristics. RESULTS: Two thousand five hundred ninety-nine patients met the inclusion criteria. The LT/HV cohort was younger and more often white (p < 0.01). The LT/HV group had more comorbidities, higher tumor grade, and more often radical resections and radiotherapy (all p < 0.05). The ST/LV group underwent significantly more R2 resections (4.4% vs. 2.6%, p = 0.003). Thirty-day mortality was significantly lower in the LT/HV group (1.2% vs. 2.8%, p = 0.0026). Five-year survival was better among the LT/HV group (63% vs. 53%, p < 0.0001). After adjustment, the LT/HV group had a 27% improvement in overall survival (HR 0.73, p = 0.0009). CONCLUSIONS: This national study suggests that traveling to high-volume centers for the treatment of RPS confers a significant short-term and long-term survival advantage, supporting centralized care for RPS.


Asunto(s)
Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Neoplasias Retroperitoneales/cirugía , Sarcoma/cirugía , Viaje/estadística & datos numéricos , Anciano , Bases de Datos Factuales/estadística & datos numéricos , Supervivencia sin Enfermedad , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , North Carolina/epidemiología , Readmisión del Paciente/estadística & datos numéricos , Pronóstico , Neoplasias Retroperitoneales/mortalidad , Estudios Retrospectivos , Sarcoma/mortalidad
19.
J Stroke Cerebrovasc Dis ; 28(12): 104455, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31680032

RESUMEN

BACKGROUND: Perioperative cerebral infarction is one of the concerning complications after transcatheter aortic valve implantation in patients with aortic stenosis. Several studies have reported on this complication; however, those included only Caucasians and analyzed a small number of cases. Here, we report on the characteristics and risk factors of symptomatic cerebral infarction after transcatheter aortic valve implantation in a single, high-volume center in Japan. METHODS: We included 308 consecutive patients who underwent transcatheter aortic valve implantation in our facility between 2013 and 2016. We retrospectively analyzed the occurrence, characteristics, and prognoses of symptomatic cerebral infarction within 7 days after the procedure and statistically compared the risk factors between patients with or without cerebral infarction. RESULTS: Five patients (1.6%) suffered from symptomatic cerebral infarction, which was usually recognized just after the procedure, with mild symptoms. Long-term prognoses tended to be good unless other factors influenced disability. Comorbidities, such as carotid artery stenosis and peripheral artery disease, were significantly higher in patients with cerebral infarction (P = .036 and .002, respectively); in addition, coronary artery disease and longer anesthesia duration (indicating challenging catheter procedures) tended to be associated with cerebral infarction (P = .080 and .069, respectively). CONCLUSIONS: Symptomatic cerebral infarction occurred in 1.6% of patients after transcatheter aortic valve implantation in a single, high-volume center in Japan; the infarctions were of mild severity tending toward good long-term prognoses. We speculate arterial embolism from atherosclerotic large arteries, especially from the aortic arch, during catheter procedures might be the mechanistic basis of cerebral infarction.


Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Infarto Cerebral/etiología , Hospitales de Alto Volumen , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano de 80 o más Años , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/terapia , Comorbilidad , Femenino , Humanos , Masculino , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tokio , Resultado del Tratamiento
20.
J Surg Oncol ; 120(8): 1318-1326, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31701535

RESUMEN

BACKGROUND: While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care. METHODS: The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. RESULTS: Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital. CONCLUSION: Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.


Asunto(s)
Conducta de Elección , Hospitales de Alto Volumen , Pancreaticoduodenectomía/estadística & datos numéricos , Viaje , Centros Médicos Académicos , Anciano , California/epidemiología , Femenino , Accesibilidad a los Servicios de Salud , Capacidad de Camas en Hospitales , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Análisis Multivariante , Personal de Enfermería en Hospital/estadística & datos numéricos , Quirófanos/estadística & datos numéricos
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