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1.
BMC Med ; 17(1): 184, 2019 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-31570106

RESUMEN

BACKGROUND: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS). METHODS: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement. RESULTS: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals. CONCLUSIONS: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Parto Obstétrico/estadística & datos numéricos , Servicios de Salud Materna/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Adulto , Brasil/epidemiología , Cesárea/estadística & datos numéricos , Ciudades/epidemiología , Ciudades/estadística & datos numéricos , Vías Clínicas/organización & administración , Vías Clínicas/normas , Estudios Transversales , Prestación de Atención de Salud/organización & administración , Prestación de Atención de Salud/normas , Parto Obstétrico/métodos , Parto Obstétrico/normas , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Servicios de Salud Materna/organización & administración , Servicios de Salud Materna/normas , Transferencia de Pacientes/organización & administración , Embarazo , Indicadores de Calidad de la Atención de Salud , Derivación y Consulta/estadística & datos numéricos , Análisis de Sistemas , Transporte de Pacientes/estadística & datos numéricos
2.
Recenti Prog Med ; 110(4): 188-194, 2019 04.
Artículo en Italiano | MEDLINE | ID: mdl-31066364

RESUMEN

The approval of clinical pathways (CPWs) represents a key step to focus the care management on the patient. The PDTA Net project, by ReS Foundation and CINECA, aims to create a reference tool to study how the local organizational models influence healthcare and clinical outcomes. The article shows the analysis of all CPWs approved by Italian Regions and Autonomous Provinces until 31/12/2018. The search for documents was performed on the institutional websites through specific keywords. CPWs were filled into a database, according to the Region, publication year, disease of interest (distinguishing between chronic diseases with high epidemiological impact and rare diseases) and relevant clinical area. All documents were analyzed by geographical and temporal distribution, the latter also according to ministerial measures. From 2005 to 2018, 536 Regional CPWs were approved (316 for chronic diseases with a high epidemiological impact and 220 for rare diseases). The Regions with the highest number of CPWs of chronic diseases were Umbria (34 CPWs) and Piemonte (33). The most addressed clinical areas were: oncology (72), neurology (60), cardiology (34) and metabolic disorders (22). The most issued diseases were: diabetes (17), trauma/polytrauma (15), chronic obstructive pulmonary disease and multiple sclerosis (12 each), stroke (11), rheumatoid arthritis, breast cancer and colorectal neoplasms (10 each). The publication of the documents was affected by ministerial measures (Balduzzi Law, National Chronicity Plan, Diabetic Disease Plan and National Dementia Plan). The majority of CPWs on rare diseases was retrieved in Regions with activated Rare Disease Networks: Lombardia (110 CPWs), Lazio (64) and Toscana (17). This study showed that, to date, in Italy there are several CPWs published at Regional level, nevertheless their structure and application are heterogeneous and strongly influenced by the National Plans. All analyzed documents are available through the web platform of the project https://fondazioneres.it/pdta/. This project could be useful for health system stakeholders, in order to encourage the transition to new health governance and making CPWs effective governance tools.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Prestación de Atención de Salud/estadística & datos numéricos , Bases de Datos Factuales , Humanos , Italia
3.
Neth J Med ; 77(3): 109-115, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31012428

RESUMEN

BACKGROUND: The seasonal influenza epidemic poses a significant burden on hospitals, both in terms of capacity and costs. Beds that are occupied by isolated influenza patients result in hospitals temporary being closed to admissions and elective operations being cancelled. Improving hospital and emergency department (ED) patient flow during the influenza season could solve these problems. Microbiological point-of-care-testing (POCT) could reduce unnecessary patient isolation by providing a positive/negative result before admission, but has not yet broadly been implemented. METHODS: A clinical pathway for patients with acute respiratory tract infection presenting at the ED was implemented, including a PCR-based POCT for influenza, operated by nurses and receptionists. In parallel, a temporary ward equipped with 15 beds for influenza-positive patients was established. In this retrospective observational study, we describe the results of implementing this pathway by comparison with the previous epidemic. RESULTS: Clinical performance of the POCT within the clinical pathway was good with strongly decreased time from ED presentation to sample collection (194 vs 47 min) and time from sample collection to result (1094 vs 62 min). Hospital patient flow was improved by a decreased percentage of admitted influenza-positive patients (91% vs 73%) and shorter length of subsequent stay (median 5.86 vs 4.61 days) compared to the previous influenza epidemic. In addition, 430 patient-days of unnecessary isolation have been prevented within a time span of 18 weeks. Roughly estimated savings were almost 400,000 euros. CONCLUSION: We recommend that hospitals explore possibilities for improving patient flow during an influenza epidemic.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Gripe Humana/diagnóstico , Pruebas en el Punto de Atención , Infecciones del Sistema Respiratorio/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Epidemias , Femenino , Implementación de Plan de Salud , Hospitalización/estadística & datos numéricos , Humanos , Gripe Humana/epidemiología , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Estudios Retrospectivos
4.
West J Emerg Med ; 20(2): 250-255, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30881544

RESUMEN

Introduction: In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions. Methods: This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher's exact test. Results: In the "before" phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001). Conclusion: A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.


Asunto(s)
Unidades de Observación Clínica/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Síncope/terapia , Boston , Unidades de Observación Clínica/organización & administración , Estudios de Cohortes , Vías Clínicas/estadística & datos numéricos , Utilización de Instalaciones y Servicios , Femenino , Hospitalización/estadística & datos numéricos , Hospitales de Enseñanza/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Estudios Prospectivos , Estados Unidos
5.
Soc Psychiatry Psychiatr Epidemiol ; 54(8): 955-963, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30843086

RESUMEN

BACKGROUND: Poor transitions to adult care from child and adolescent mental health services may increase the risk of disengagement and long-term negative outcomes. However, studies of transitions in mental health care are commonly difficult to administer and little is known about the determinants of successful transition. The persistence of health inequalities related to access, care, and outcome is now well accepted including the inverse care law which suggests that those most in need of services may be the least likely to obtain them. We sought to examine the pathways and determinants of transition, including the role of social class. METHOD: A retrospective systematic examination of electronic records and case notes of young people eligible to transition to adult care over a 4-year period across five Health and Social Care NHS Trusts in Northern Ireland. RESULTS: We identified 373 service users eligible for transition. While a high proportion of eligible patients made the transition to adult services, very few received an optimal transition process and many dropped out of services or subsequently disengaged. Clinical factors, rather than social class, appear to be more influential in the transition pathway. However, those not in employment, education or training (NEET) were more likely (OR 3.04: 95% CI 1.34, 6.91) to have been referred to Adult Mental Health Services (AMHS), as were those with a risk assessment or diagnosis (OR 4.89: 2.45, 9.80 and OR 3.36: 1.78, 6.34), respectively. CONCLUSIONS: Despite the importance of a smoother transition to adult services, surprisingly, few patients experience this. There is a need for stronger standardised policies and guidelines to ensure optimal transitional care to AMHS. The barriers between different arms of psychiatry appear to persist. Joint working and shared arrangements between child and adolescent and adult mental health services should be fostered.


Asunto(s)
Servicios de Salud del Adolescente/estadística & datos numéricos , Vías Clínicas/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Determinantes Sociales de la Salud/estadística & datos numéricos , Transición a la Atención de Adultos/estadística & datos numéricos , Adolescente , Femenino , Humanos , Masculino , Irlanda del Norte , Participación del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Adulto Joven
6.
World J Gastroenterol ; 25(8): 1002-1011, 2019 Feb 28.
Artículo en Inglés | MEDLINE | ID: mdl-30833805

RESUMEN

BACKGROUND: A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation. AIM: To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS: This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196). RESULTS: At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones (P < 0.001) and incidence of cholangitis complication (P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials (P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) (P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups. CONCLUSION: Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.


Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/estadística & datos numéricos , Coledocolitiasis/cirugía , Vías Clínicas/estadística & datos numéricos , Análisis de Datos , Complicaciones Posoperatorias/epidemiología , Anciano , Macrodatos , Colangiopancreatografia Retrógrada Endoscópica/economía , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitiasis/economía , Conducto Colédoco/cirugía , Vías Clínicas/economía , Femenino , Gastos en Salud/estadística & datos numéricos , Precios de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Resultado del Tratamiento
7.
Bull Cancer ; 106(4): 293-303, 2019 Apr.
Artículo en Francés | MEDLINE | ID: mdl-30827485

RESUMEN

INTRODUCTION: Management of elderly patients with cancer is challenging worldwide. Improvement of their care pathway should focus on unplanned hospitalizations. This study aimed to compare the geriatric and oncologic profiles of elderly patients with cancer, hospitalized for an acute pathology either in medical oncology or acute geriatric medicine units. METHODS: Epidemiological, analytical, monocentric, transversal study performed in the geriatric and oncological short-stay units of the university hospital of Poitiers (France) from 07/01/2014 to 06/30/2015. Only patients with diagnosed cancer prior to hospitalization were included. The geriatric, oncological and hospitalization data were collected and analyzed. RESULTS: In total, 230 patients were included (156 in geriatrics, 74 in oncology). Alteration of the general condition was the most frequent reason for admission. In multivariate age-adjusted analyses, factors associated with admission to a geriatric unit were co-morbidities (OR=0.18 [95% CI: 0.07-0.46], P<0.01) and dependence (OR=0.07 [95% CI: 0.01-0.36], P<0.01). Ongoing antineoplastic treatment (OR=2.60 [95%CI: 1.14-5.89], P=0.02) and metastatic cancer (OR=2.63 [95%CI: 1.18-5.86], P=0.02) influenced hospitalization in the oncology unit. During the hospital stay there was more frequent psychological support in oncology (OR=45.59 [95%CI: 9.79-212.23], P<0.01) and social support in Geriatrics (OR=0.13 [95% CI: 0.04-0.40], P<0.01). CONCLUSION: This first comparative study showed a significant difference in profiles of elderly patients with cancer hospitalized for an acute problem, depending on the hospital unit. This finding paves the way of improvement of care pathway by formalizing links between these two departments to optimize care and referrals to the most appropriate care unit, according to patients condition, in case of unscheduled hospitalization.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Geriatría/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Oncología Médica/estadística & datos numéricos , Neoplasias , Cuidados Posteriores , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Estudios Transversales , Femenino , Humanos , Masculino , Análisis Multivariante , Metástasis de la Neoplasia , Neoplasias/tratamiento farmacológico , Neoplasias/patología , Estudios Retrospectivos
8.
Recenti Prog Med ; 110(1): 33-41, 2019 Jan.
Artículo en Italiano | MEDLINE | ID: mdl-30720015

RESUMEN

INTRODUCTION: Heart failure (HF) is a main issue of modern healthcare system. Patient affected are continuously growing in number and age; therefore, an integrated management between different parts of healthcare system is crucial to optimize outcome and sustainability. So far, little is known about clinical pathways of HF patients in Sicily. METHODS: On initiative of the Regional HF Group of the Italian Association of Hospital Cardiologists (ANMCO), we decided to census all the Cardiology Unit of Sicily. A simple questionnaire elaborated by the group and exploring clinical and organizational matters of HF was sent to the Units. The answer arrived on a voluntary basis. RESULTS: 41/46 Units sent back the filled questionnaire. Five typologies of units were represented, based on complexity [1. Outpatient units; 2. Units without Intensive Care Unit (ICU); 3. Units with ICU; 4. Units with ICU and Cath Lab; 5. Units with ICU, Cath lab and Cardiac Surgery). A dedicated HF unit is present only in half centers, but it is formally recognized solely in 22% of Units. These Units have scarce dedicated staff and activity is predominantly based on personal initiative. Diagnostic and therapeutic tools are used appropriately in most of them, even though congestion is judged mainly through physical exam and echocardiography. Differently from the indications of the guidelines, post discharge titration of therapy lacks in almost 30% of centers. DISCUSSION AND CONCLUSIONS: In Sicily, HF is managed on a plan mainly based on personal initiative. The quality is sufficiently good but a more appropriate and structured organization in particular of the follow-up seems a necessary and improvable requirement in view of quality measurers and economic sustainability of health care.


Asunto(s)
Servicio de Cardiología en Hospital/estadística & datos numéricos , Unidades de Cuidados Coronarios/estadística & datos numéricos , Prestación de Atención de Salud/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Servicio de Cardiología en Hospital/organización & administración , Unidades de Cuidados Coronarios/organización & administración , Vías Clínicas/estadística & datos numéricos , Prestación de Atención de Salud/organización & administración , Encuestas de Atención de la Salud , Humanos , Sicilia
9.
J Med Syst ; 43(3): 46, 2019 Jan 19.
Artículo en Inglés | MEDLINE | ID: mdl-30661117

RESUMEN

In order to improve medical quality, shorten hospital stays, and reduce redundant treatment, an optimization of diagnosis and treatment of chronic diseases based on association analysis under the background of regional integration in the paper was proposed, which was to expand the scope of application of the clinical pathway standard diagnosis and treatment program in the context of regional medical integration and mass medical data, so that it had a larger group of patients within the region. In the context of regional medical integration, owing to the types of medical data were diverse, the preprocessing requirements and process specifications for diagnosis and treatment data were firstly proposed. At the stage of diagnosis and treatment unit optimization, the correlation between clinical behaviors was analyzed by using association rules of the FP-growth and Apriori algorithm. Through the optimization and combination of diagnosis and treatment units, the optimized clinical pathway was finally achieved. Experiments showed that after the optimization strategy by the paper proposed, the clinical path diagnosis and treatment achieved obvious improvement in medical quality under the condition that the medical cost was basically flat.


Asunto(s)
Enfermedad Crónica/terapia , Toma de Decisiones Clínicas/métodos , Vías Clínicas/estadística & datos numéricos , Registros Electrónicos de Salud/estadística & datos numéricos , Salud Poblacional/estadística & datos numéricos , Algoritmos , Macrodatos , Minería de Datos/métodos , Eficiencia Organizacional , Humanos , Mejoramiento de la Calidad
10.
Support Care Cancer ; 27(4): 1215-1222, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30310988

RESUMEN

PURPOSE: Physical activity (PA) is central to self-management for people with colorectal cancer (CRC) to support health behaviour and function secondary to cancer treatment. However, there is limited evidence on how health professionals (HPs) promote PA during cancer treatment. This study aimed to investigate how and when PA is promoted throughout the chemotherapy pathway among colorectal cancer survivors. METHODS: A qualitative study was conducted with adults with CRC receiving chemotherapy at a large cancer centre. Cross-sectional observation of clinical consultations was conducted at four points during the chemotherapy pathway: prior, midpoint, final cycle, and 8 weeks following chemotherapy. Following completion of treatment, audio-recorded, semi-structured interviews were conducted with patients and HPs and transcribed verbatim. Codes and themes were identified and triangulated from all the data using framework analysis. Observational themes are reported and complimented by interview data. RESULTS: Throughout the chemotherapy pathway (pre, midpoint, end), many opportunities were missed by HPs to promote PA as a beneficial means to maintain functioning and ameliorate cancer treatment side effects. When discussed, PA levels were used only to determine fitness for future oncological treatment. No PA promotion was observed despite patients reporting low PA levels or treatment side effects. Post-treatment, PA promotion was more routinely delivered by HPs, as evidenced by problem-solving and onward referrals to relevant HPs. CONCLUSION: PA promotion was largely absent during treatment despite it being a key component of patient self-management following treatment. This suggests considerable missed opportunities for HPs to provide cancer survivors with PA evidence-based interventions. Further research is necessary to identify how best to ensure PA is promoted throughout the cancer journey. IMPLICATION FOR CANCER SURVIVORS: These findings suggest many may not be receiving support to be physically active during treatment.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Supervivientes de Cáncer/estadística & datos numéricos , Neoplasias Colorrectales/terapia , Vías Clínicas , Terapia por Ejercicio , Ejercicio/fisiología , Promoción de la Salud , Anciano , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/rehabilitación , Terapia Combinada , Vías Clínicas/organización & administración , Vías Clínicas/normas , Vías Clínicas/estadística & datos numéricos , Estudios Transversales , Terapia por Ejercicio/organización & administración , Terapia por Ejercicio/normas , Terapia por Ejercicio/estadística & datos numéricos , Femenino , Conductas Relacionadas con la Salud , Promoción de la Salud/métodos , Promoción de la Salud/organización & administración , Promoción de la Salud/normas , Accesibilidad a los Servicios de Salud/organización & administración , Accesibilidad a los Servicios de Salud/normas , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Autocuidado/métodos , Autocuidado/normas , Autocuidado/estadística & datos numéricos , Reino Unido/epidemiología
11.
J Arthroplasty ; 34(2): 206-210, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30448324

RESUMEN

BACKGROUND: Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS: We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS: Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION: Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.


Asunto(s)
Artroplastia de Reemplazo de Cadera/normas , Artroplastia de Reemplazo de Rodilla/normas , Vías Clínicas/normas , Paquetes de Atención al Paciente/normas , Reoperación/normas , Anciano , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Vías Clínicas/economía , Vías Clínicas/estadística & datos numéricos , Episodio de Atención , Gastos en Salud , Hospitales , Humanos , Persona de Mediana Edad , Paquetes de Atención al Paciente/economía , Paquetes de Atención al Paciente/estadística & datos numéricos , Alta del Paciente , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos
12.
Ann R Coll Surg Engl ; 101(2): 103-106, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30372125

RESUMEN

INTRODUCTION: Primary care patients with a suspected head and neck cancer are referred through the urgent suspicion of cancer referral pathway. Rates of cancer detection through this pathway are low. Evidence surrounding the pathway of these patients is lacking. This study aimed to determine the outcome of urgent suspicion of cancer referrals for head and neck cancer. METHODS AND METHODS: All head and neck cancer urgent suspicion of cancer referrals in NHS Greater Glasgow and Clyde between June 2015 and May 2016 were analysed in regard to their clinical pathway. RESULTS: There were 2116 urgent suspicion of cancer referrals in the one-year period. The overall cancer rate was 235 (11.8%), compared with 152 (7.6%) that resulted in a primary head and neck cancer diagnosis. Of the total, 851 (42.6%) were reassured and discharged after one clinic appointment; 536 (26.8%) were followed up for suspected benign pathology and 436 (21.8%) were actively investigated for cancer. CONCLUSION: A significant proportion of patients attending urgent suspicion of cancer clinic appointments can be seen and discharged in one clinic appointment, provided there is same day imaging available. Cancer identification rates through urgent suspicion of cancer pathways remain low.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Neoplasias de Cabeza y Cuello/diagnóstico , Derivación y Consulta/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Auditoría Clínica , Vías Clínicas/organización & administración , Femenino , Neoplasias de Cabeza y Cuello/terapia , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud , Derivación y Consulta/organización & administración , Estudios Retrospectivos , Reino Unido , Adulto Joven
13.
J Fr Ophtalmol ; 42(1): 32-36, 2019 Jan.
Artículo en Francés | MEDLINE | ID: mdl-30554873

RESUMEN

Little data concerning the management of eye disease in general medical practice is reported in the literature. The main objective of the study was the description and management of ophthalmologic symptoms encountered by the general practitioner. The study was a quantitative, longitudinal, prospective, multi-center trial conducted in 3 departments in France, with data gathered from medical residents' consultation results. The inclusion criteria were: any new ophthalmologic problem with or without complaint, regardless of the patient's age. The resident filled in an observatory questionnaire collecting data on: the complaint within its context ; specific and non-specific reasons for the complaint ; identification of the medical problem and the management offered. The consultation data were classified according to the CISP-2. From May 1, 2015 to April 30, 2016, 674 of the 53,463 consultations held by resident investigators were for an ophthalmologic problem, corresponding to a 1.3% incidence. In over 70% of the cases, the ocular complaint was the main reason for the consultation. The majority of the conditions were benign and managed without specialty consultation. Eighty-six percent of the consultations lead to medication prescription, including 47% topical antibiotics. Eleven percent of the consultations led to referral to a hospital emergency or eye department. Additional multidisciplinary studies could compliment this study and enable a global vision of patients' clinical care pathways.


Asunto(s)
Oftalmopatías/diagnóstico , Oftalmopatías/epidemiología , Médicos Generales/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Vías Clínicas/normas , Vías Clínicas/estadística & datos numéricos , Femenino , Francia/epidemiología , Humanos , Incidencia , Lactante , Recién Nacido , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto Joven
14.
Med Mal Infect ; 49(1): 23-33, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30195462

RESUMEN

OBJECTIVES: To quantify within a cohort of HIV-infected individuals the number of medical visits and procedures to be carried out according to comorbidities and risk factors to implement a personalized care pathway. PATIENTS AND METHODS: Retrospective study of 915 patients consulting from January 1 to December 31, 2016 at an outpatient unit of multidisciplinary consultations, using an electronic patient record. We built an algorithm using parameters required for the application of the national guidelines for the management of HIV-infected individuals. The frequency of comorbidities was measured according to gender, transmission risk group, and nadir CD4 (200/mm3). RESULTS: Patients were mostly men (median age: 52 years), of whom 16% were aged≥60 years. Viral load was<40 copies/mL in 93.5% of treated patients and CD4 cell count≥500/mm3 for 73%. Overall, 74.5% of patients had at least one comorbidity. The number of comorbidities was similar in men and women but was significantly higher in patients with a nadir CD4 <200/mm3 and increased with age (irrespective of gender). The minimum number of consultations to be scheduled per year was 8123: 70% for the management of comorbidities with an average of six consultations/year/patient. Overall, 53% of patients should attend a proctology consultation. The minimum number of paramedical procedures to be performed was 5115. CONCLUSION: The implementation of a personalized multidisciplinary management within a single facility seems to be a suitable care model to address the needs of HIV-infected individuals.


Asunto(s)
Vías Clínicas , Adhesión a Directriz/estadística & datos numéricos , Infecciones por VIH , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Cuidados Posteriores/normas , Cuidados Posteriores/estadística & datos numéricos , Anciano , Vías Clínicas/normas , Vías Clínicas/estadística & datos numéricos , Femenino , Estudios de Seguimiento , VIH , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Infecciones por VIH/terapia , Humanos , Comunicación Interdisciplinaria , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Grupo de Atención al Paciente/normas , Grupo de Atención al Paciente/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Estudios Retrospectivos
15.
BMC Infect Dis ; 18(1): 697, 2018 Dec 27.
Artículo en Inglés | MEDLINE | ID: mdl-30587155

RESUMEN

BACKGROUND: Timely initiation of antibiotics within one hour of prescription is one of the recommended antibiotic stewardship interventions when managing patients with pneumonia in the emergency department. Effective implementation of this intervention depends on effective communication, a well-established coordination process and availability of resources. Understanding what may influence this aspect of care by using process mapping is an important component when planning for improvement interventions. The aim of the study was to identify factors that influence antibiotic initiation following prescription in the Adult Emergency and Trauma Centre of the largest referral hospital in Malawi. METHODS: We conducted a prospective observational case study using process mapping of two purposively selected adult pneumonia patients. One of the investigators CM observed the patient from the time of arrival at the triage area to the time he/she received initial dose of antibiotics. With purposively selected members of the clinical team; we used simple questions to analyze the map and identified facilitators, barriers and potential areas for improvement. RESULTS: Both patients did not receive the first dose of antibiotic within one hour of prescription. Despite the situation being less than ideal, potential facilitators to timely antibiotic initiation were: prompt assessment and triaging; availability of different expertise, timely first review by the clinician; and blood culture collected prior to antibiotic initiation. Barriers were: long waits, lack of communication/coordinated care and competency gap. Improvements are needed in communication, multidisciplinary teamwork, education and leadership/supervision. CONCLUSION: Process mapping can have a significant impact in unveiling the system-related factors that influence timely initiation of antibiotics. The mapping exercise brought together stakeholders to evaluate and identify the facilitators and barriers. Recommendations here focused on improving communication, multidisciplinary team culture such as teamwork, good leadership and continuing professional development.


Asunto(s)
Antibacterianos/administración & dosificación , Vías Clínicas , Neumonía/tratamiento farmacológico , Tiempo de Tratamiento , Adulto , Vías Clínicas/organización & administración , Vías Clínicas/normas , Vías Clínicas/estadística & datos numéricos , Toma de Decisiones , Farmacorresistencia Microbiana , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Comunicación Interdisciplinaria , Malaui/epidemiología , Masculino , Grupo de Atención al Paciente/organización & administración , Grupo de Atención al Paciente/normas , Neumonía/epidemiología , Estudios Prospectivos , Derivación y Consulta/estadística & datos numéricos , Tiempo de Tratamiento/normas
16.
BMC Health Serv Res ; 18(1): 933, 2018 Dec 04.
Artículo en Inglés | MEDLINE | ID: mdl-30514277

RESUMEN

BACKGROUND: The number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints. METHODS: We developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams. RESULTS: Four scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios. CONCLUSIONS: Using new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.


Asunto(s)
Extracción de Catarata/estadística & datos numéricos , Catarata/economía , Anciano , Procedimientos Quirúrgicos Ambulatorios , Presupuestos , Extracción de Catarata/economía , Costos y Análisis de Costo , Vías Clínicas/economía , Vías Clínicas/estadística & datos numéricos , Predicción , Humanos , Masculino , Programas Nacionales de Salud/economía , Programas Nacionales de Salud/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Reino Unido
17.
Cancer ; 124(21): 4181-4191, 2018 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-30475400

RESUMEN

BACKGROUND: Cancer costs should be discussed by patients and providers, but information is not readily available. Results from recently published studies (in the last 5 years) on direct and indirect cancer costs may help guide these discussions. METHODS: The authors reviewed studies published between 2013 and 2017 that reported direct health care costs and indirect (productivity losses) costs. The annual mean total and net costs of cancer were summarized for all payers and for survivors only by age (ages 18-64 and ≥65 years), by phase of care (initial [ie, 12 months from diagnosis], continuing, and end-of-life [ie, 12 months before death]), or for recently diagnosed (within 1-2 years of diagnosis) and longer term survivors. RESULTS: For all payers combined, costs for cancers like breast, prostate, colorectal, and lung cancers were $20,000 to $100,000 in the initial phase, $1000 to $30,000 annually in the continuing phase, and ≥$60,000 in the end-of-life phase. Annual out-of-pocket costs to recently diagnosed survivors were >$1000 for medical care and time costs, approximately $2000 for productivity losses, and from $2500 to >$4000 for employment disability, depending on age. For longer term survivors, the cost of medical care was approximately $1500 for older survivors and $747 for younger survivors, time costs were $831 to $955 for older survivors and $459 to $630 for younger survivors, and productivity losses were approximately $800. Disability among long-term survivors was similar to that among short-term survivors. Limitations of the reviewed studies included older data and under-representation of higher cost cancers. CONCLUSIONS: Frequently updated cost information for all cancer types is needed to guide discussions of anticipated short-term and long-term cancer-related costs with survivors. Cancer 2018;000:000-000. © 2018 American Cancer Society.


Asunto(s)
Continuidad de la Atención al Paciente/economía , Vías Clínicas/economía , Empleo/economía , Costos de la Atención en Salud , Neoplasias/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Supervivientes de Cáncer/estadística & datos numéricos , Continuidad de la Atención al Paciente/estadística & datos numéricos , Costo de Enfermedad , Vías Clínicas/estadística & datos numéricos , Eficiencia , Empleo/estadística & datos numéricos , Femenino , Costos de la Atención en Salud/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/epidemiología , Adulto Joven
18.
Implement Sci ; 13(1): 142, 2018 11 13.
Artículo en Inglés | MEDLINE | ID: mdl-30424818

RESUMEN

BACKGROUND: Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. METHODS: The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. RESULTS: The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. CONCLUSIONS: Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH TRIAL REGISTRATION: ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.


Asunto(s)
Vías Clínicas/normas , Laparotomía/normas , Atención Perioperativa/normas , Mejoramiento de la Calidad/organización & administración , Vías Clínicas/estadística & datos numéricos , Procesos de Grupo , Humanos , Capacitación en Servicio , Laparotomía/mortalidad , Tiempo de Internación/estadística & datos numéricos , Grupo de Atención al Paciente , Readmisión del Paciente , Evaluación de Programas y Proyectos de Salud , Medicina Estatal , Reino Unido
19.
Rev Epidemiol Sante Publique ; 66(6): 385-394, 2018 Nov.
Artículo en Francés | MEDLINE | ID: mdl-30309672

RESUMEN

BACKGROUND: The aim of this study is to analyze and to compare data from 2015, focusing on hospital care for patients with multiple sclerosis from three French regions with different characteristics in terms of prevalence, size and number of multiple sclerosis competencies and resource centers. METHODS: All hospital admissions from the PMSI MCO 2015 database, with a principal or related diagnosis (PD-RD) of G35* ("multiple sclerosis") were extracted. We also extracted chemotherapy treatments administered in hospital, during admissions with a significant associated diagnosis (SAD) of G35*, if the PD or RD was coded Z512 ("non-tumor chemotherapy"). The analyzed regions corresponded to those of 2015, some of which have since merged. RESULTS: There were 95,359 hospital admissions for multiple sclerosis in France in 2015 among a total cohort of 21,102 patients, resulting in a total cost of € 54.1m. Patients with MS were managed mainly in the ambulatory setting, which accounted for 88.5 % of all admissions. The Rhône-Alpes region represented 7.6 % of national admissions for MS, 9.6 % of patients, and 14 % of inpatient days, contributing 10.4 % of the national cost of MS care. 58.4 % of stays were managed by the two main multiple sclerosis centers. The Nord-Pas-de-Calais region represented 9.8 % of national admissions, 10 % of patients, 6.6 % of inpatient days, and 9.1 % of the national cost. 29.8 % of stays were managed by the main multiple sclerosis center. The Centre region represented 2.7 % of stays, 2.8 % of patients, 3.1 % of inpatient days, and 2.8 % of the national cost. 28.4 % of stays were managed by the main multiple sclerosis center. CONCLUSION: This study highlights the diversity of multiple sclerosis hospital management and care between these three regions.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Esclerosis Múltiple/epidemiología , Esclerosis Múltiple/terapia , Pautas de la Práctica en Medicina , Adulto , Competencia Clínica/estadística & datos numéricos , Vías Clínicas/economía , Vías Clínicas/organización & administración , Vías Clínicas/normas , Bases de Datos Factuales , Femenino , Francia/epidemiología , Recursos en Salud/economía , Recursos en Salud/organización & administración , Recursos en Salud/normas , Recursos en Salud/estadística & datos numéricos , Hospitalización/economía , Humanos , Masculino , Martinica/epidemiología , Persona de Mediana Edad , Esclerosis Múltiple/economía , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos
20.
Brachytherapy ; 17(6): 895-898, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30217434

RESUMEN

PURPOSE: Although external beam radiation therapy (EBRT) plus a brachytherapy boost (BB) offers a 20% improvement in biochemical progression-free survival compared with dose-escalated EBRT alone for men with intermediate and high-risk prostate cancer, population studies show a concerning decline in BB utilization. METHODS: We modified our clinical pathway (CP) in January 2016 to indicate EBRT with BB as first-choice modality for high-risk prostate cancer, based on preliminary findings of Androgen Suppression Combined with Elective Nodal and Dose-Escalated Radiation Therapy. A retrospective review was performed on 659 patients with high-risk prostate cancer treated with definitive intent EBRT ± BB within a network of 19 sites between December 2011 and July 2017. χ2 test was used to determine changes in practice pattern before vs. after CP modification. RESULTS: Before CP modification, 25.2% of patients were planned for BB, compared with 45.4% afterward (p < 0.001). Among 23 nonbrachytherapist physicians, utilization of BB increased from 3.4% to 14.8% (p < 0.001) after CP modification. Among nine brachytherapists, utilization increased from 46.4% to 55.6% (p = 0.120). Among patients treated by a nonbrachytherapist who did not receive BB, the reason was physician preference in 59.7%, patient preference in 19.9%, and other in 20.4%. CONCLUSION: Based on recent evidence suggesting improved biochemical progression-free survival with use of BB for high-risk prostate cancer, we modified our CP, after which we observed increased use of a BB across a network, especially among physicians who do not perform brachytherapy. However, physician preference remains the most significant factor in the nonutilization of BB. New mechanisms are needed to overcome this barrier.


Asunto(s)
Braquiterapia/tendencias , Vías Clínicas/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Neoplasias de la Próstata/radioterapia , Humanos , Masculino , Antígeno Prostático Específico , Estudios Retrospectivos
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