RESUMO
BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used by the Centers of Medicare and Medicaid (CMS) to assess inpatient satisfaction. HCAHPS survey results are publicly reported, and performance began to affect CMS reimbursement to hospitals as of FY2013. However, the impact of severity of illness on patients' self-reported inpatient satisfaction as measured by HCAHPS survey scores remains unknown. OBJECTIVE: To determine the impact of severity of illness on patients' self-reported inpatient satisfaction. DESIGN: The All Patient-Refined, Diagnosis Related Group (APR-DRG) classifies every patient into one of four levels of severity of illness. We evaluated the impact of APR-DRG severity of illness on five HCAHPS domains, two reputation and two environmental questions, using linear regression analysis. SETTING: Adult inpatients discharged from a large, academic, tertiary care hospital. PATIENTS: 37,223 patients' HCAHPS survey data were combined with their APR-DRG severity of illness rating over a 39-month period between April 2008 and June 2011. MEASUREMENTS: HCAHPS scores. RESULTS: Higher severity of illness was consistently and inversely associated with lower patients' self-reported perception of inpatient hospital satisfaction as measured by HCAHPS scores. For each one-unit increase in severity of illness, the average HCHAPS scores across all five domains were approximately 3 percent lower. CONCLUSIONS: Hospitals treating patients with a higher severity of illness will have lower HCAHPS scores, potentially leading these hospitals to receive lower reimbursement from CMS. Conversely, hospitals with lower severity of illness will receive greater reimbursement. Failure to adequately adjust for severity of illness is a serious flaw in the current HCAHPS reporting system that should be corrected.
Assuntos
Organizações de Assistência Responsáveis , Assistência Ambulatorial/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Patient Protection and Affordable Care Act , Assistência Centrada no Paciente/organização & administração , Assistência Ambulatorial/economia , Assistência Ambulatorial/tendências , Controle de Custos/métodos , Controle de Custos/normas , Serviços de Assistência Domiciliar/economia , Serviços de Assistência Domiciliar/tendências , Humanos , Assistência Centrada no Paciente/economia , Assistência Centrada no Paciente/tendências , Estados UnidosRESUMO
Medical care in the USA is plagued by high costs, poor quality and fragmented care delivery. In response, new methods of integrated healthcare delivery are needed, including the patient-centered medical home. At the same time, we need to revitalize our approach to the practice of medicine, moving to a personalized approach, even as we increasingly focus on population management. Some aspects of personalized healthcare have the potential to add significant cost to the system, while others can improve value. This article aims to provide an overview of the current healthcare climate, discuss evolving models of care in the era of healthcare reform and describe the increasingly important role of personalized healthcare in this process.
RESUMO
Medical care in the United States is plagued by extremely high costs, poor quality, and fragmented delivery. In response, new concepts of integrated health care delivery have developed, including patient-centered medical homes and accountable care organizations (ACOs). This article reviews these concepts and includes a detailed discussion of the Centers for Medicare and Medicaid Services' ACO and Shared Savings Proposed Rule.
Assuntos
Organizações de Assistência Responsáveis/organização & administração , Reforma dos Serviços de Saúde/métodos , Assistência Centrada no Paciente/métodos , Organizações de Assistência Responsáveis/tendências , Atenção à Saúde , Custos de Cuidados de Saúde , Reforma dos Serviços de Saúde/tendências , Gastos em Saúde , Humanos , Medicare , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados UnidosRESUMO
Studies published during the past year on the treatment of several infectious diseases provide valuable information that should enable us to treat our patients more effectively. Among those findings: Oral vancomycin (Vancocin) is superior to oral metronidazole (Flagyl) for treating patients with severe Clostridium difficile-associated disease. The risk of death from any cause may be higher with the use of cefepime (Maxipime) than with other beta-lactam antibiotics. In patients presenting to primary care physicians with symptoms of acute maxillary sinusitis, antibiotics and topical nasal steroids do not seem to be effective, either alone or in combination. For patients with Bell palsy, early treatment with prednisolone improves the chance of complete recovery; antiviral therapy may be indicated for patients with complete facial nerve paralysis. In patients undergoing chemotherapy for acute myelogenous leukemia or myelodysplasia, posaconazole (Noxafil) prevented fungal infections more effectively than fluconazole (Diflucan) or itraconazole (Sporanox) and improved overall survival. Anidulafungin (Eraxis) was not inferior to fluconazole in the treatment of invasive candidiasis.
Assuntos
Corticosteroides/uso terapêutico , Anti-Infecciosos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Micoses/tratamento farmacológico , Antibacterianos/uso terapêutico , Antifúngicos/uso terapêutico , HumanosRESUMO
Key studies on the prevention of human papillomavirus and hepatitis A published during the past year found that: A quadrivalent vaccine against human papillomavirus prevents cervical intraepithelial neoplasia, vulvar and vaginal intraepithelial neoplasia, and anogenital disease in young women. The vaccine is likely cost-effective when given to girls, but perhaps not when given to boys. Although hepatitis A immune globulin is modestly better than hepatitis A vaccine for postexposure prophylaxis against hepatitis A, both are highly effective. Hepatitis A vaccine is now recommended by the Advisory Committee on Immunization Practices as the preferred agent in healthy individuals between the ages of 2 and 40.
Assuntos
Vacinas contra Hepatite A , Hepatite A/prevenção & controle , Imunoglobulinas Intravenosas , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus , Adolescente , Adulto , Criança , Pré-Escolar , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Feminino , Vírus da Hepatite A/imunologia , Humanos , Masculino , Neoplasias do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/virologia , Neoplasias Vaginais/prevenção & controle , Neoplasias Vaginais/virologiaRESUMO
CONTEXT: Hemosuccus pancreaticus is an uncommon cause of upper gastrointestinal bleeding. Chronic infection of the pancreas with Brucellosis causing hemosuccus pancreaticus has not been previously reported. CASE REPORT: We describe a case of a 75-year-old man presenting with a pancreatic mass and hemosuccus pancreaticus secondary to chronic pancreatic brucellosis. Polymerase chain reaction analysis of the pancreatic tissue was positive for brucella after an initial positive serology. ERCP revealed bleeding from the pancreatic duct. Computed tomography scans of the abdomen demonstrated an enlarging pancreatic mass. Endoscopic ultrasound showed a cystic mass in the body of the pancreas. Fine needle aspiration revealed granulomata. Selective mesenteric angiogram failed to reveal the source of bleeding. The patient eventually underwent pancreatic resection with resolution of symptoms. CONCLUSION: This is the first case of hemosuccus pancreaticus due to chronic pancreatic brucellosis reported in medical literature.
Assuntos
Brucelose/diagnóstico , Hemorragia/diagnóstico , Pancreatopatias/diagnóstico , Pancreatite Crônica/diagnóstico , Pancreatite Crônica/microbiologia , Idoso , Diagnóstico Diferencial , Humanos , MasculinoAssuntos
Corticosteroides/uso terapêutico , Ceftriaxona/uso terapêutico , Meningites Bacterianas/tratamento farmacológico , Vancomicina/uso terapêutico , Doença Aguda , Corticosteroides/administração & dosagem , Adulto , Ceftriaxona/administração & dosagem , Quimioterapia Combinada , Humanos , Meningites Bacterianas/fisiopatologia , Vancomicina/administração & dosagemRESUMO
Severe acute respiratory syndrome (SARS) is probably here to stay, and every health care institution should take precautions against an outbreak. The signs and symptoms of SARS are nonspecific, and there is no early diagnostic test, no specific treatment, and no vaccine. In some parts of the world, including Canada, more than 80% of probable cases were nosocomial.
Assuntos
Síndrome Respiratória Aguda Grave/diagnóstico , Humanos , Controle de Infecções , Mpox/diagnóstico , Mpox/prevenção & controle , Síndrome Respiratória Aguda Grave/terapia , Síndrome Respiratória Aguda Grave/transmissãoRESUMO
Intracardiac devices are increasingly used to correct hemodynamically dysfunctional valves and electrophysiologic abnormalities. These devices become infected at relatively low rates. Nevertheless, when these low rates are applied to widely used devices, significant numbers of infections result. Additionally, these infections have been associated with high degrees of morbidity and high mortality rates. This article reviews the epidemiology, microbiology, clinical presentation, and medical as well as surgical therapy of intracardiac device infections.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Endocardite Bacteriana/etiologia , Endocardite Bacteriana/terapia , Próteses Valvulares Cardíacas/efeitos adversos , Coração Auxiliar/efeitos adversos , Marca-Passo Artificial/efeitos adversos , Infecções Relacionadas à Prótese/complicações , Infecções Relacionadas à Prótese/terapia , Remoção de Dispositivo , HumanosRESUMO
OBJECTIVE: To determine the accuracy and cost-effectiveness of a polymerase chain reaction (PCR) for detecting nasal carriage of Staphylococcus aureus directly from clinical specimens. CROSS-SECTIONAL STUDY: This occurred in a tertiary-care hospital in Cleveland, Ohio, and included 239 consecutive patients who were scheduled for a cardiothoracic surgical procedure. Conventional cultures and a PCR for S. aureus from nasal swabs were used as measurements. COST-EFFECTIVENESS ANALYSIS: Data sources were market prices and Bureau of Labor Statistics. The time horizon was the maximum period for availability of culture results (3 days). Interventions included universal mupirocin therapy without testing; initial therapy, with termination if PCR negative (treat-PCR); initial therapy, with termination if culture negative (treat-culture); treat PCR-positive carriers (PCR-guided treatment); and treat culture-positive carriers (culture-guided treatment). The perspective was institutional and costs and the length of time to treatment were outcome measures. RESULTS: Sixty-seven (28%) of the 239 swabs grew S. aureus. Rapid PCR was 97.0% sensitive and 97.1% specific for the detection of S. aureus. For populations with prevalences of nasal S. aureus carriage of up to 50%, the PCR assay had negative predictive values of greater than 97%. PCR-guided treatment had the lowest incremental cost-effectiveness ratio (1.93 dollars per additional day compared with the culture strategy). Among immediate treatment strategies, treat-PCR was most cost-effective. The universal therapy strategy cost 38.19 dollars more per additional day gained with carrier identification compared with the PCR strategy. CONCLUSION: Rapid real-time PCR is an accurate, rapid, and cost-effective method for identifying S. aureus carriers for preoperative intervention.
Assuntos
Portador Sadio , Cavidade Nasal/microbiologia , Reação em Cadeia da Polimerase/métodos , Cuidados Pré-Operatórios/economia , Staphylococcus aureus/isolamento & purificação , Algoritmos , Sequência de Bases , Análise Custo-Benefício , Primers do DNA , Humanos , Mupirocina/uso terapêutico , Ohio , Reação em Cadeia da Polimerase/economia , Valor Preditivo dos Testes , Prevalência , Sensibilidade e Especificidade , Staphylococcus aureus/efeitos dos fármacos , Staphylococcus aureus/genética , Procedimentos Cirúrgicos TorácicosAssuntos
Endocardite Bacteriana/classificação , Endocardite Bacteriana/cirurgia , Doenças das Valvas Cardíacas/classificação , Doenças das Valvas Cardíacas/cirurgia , Endocardite Bacteriana/mortalidade , Doenças das Valvas Cardíacas/mortalidade , Humanos , Prognóstico , Medição de Risco , Índice de Gravidade de DoençaRESUMO
The increasing prevalence of vancomycin-resistant enterococcal (VRE) infections has necessitated a search for drugs that are effective in treating these infections, and a need to determine whether currently available antimicrobials are effective. 75 consecutive clinical isolates of vancomycin-resistant Enterococcus faecium (VRE faecium) (40 blood and 35 urine isolates) isolated over 1 y at the Cleveland Clinic Foundation were tested for susceptibility to linezolid, quinupristin-dalfopristin, fosfomycin and nitrofurantoin using the Etest. The minimum inhibitory concentrations were read independently by 3 observers and compared, and a final reading was obtained by predetermined criteria. The proportion of isolates susceptible to linezolid, quinupristin-dalfopristin, fosfomycin and nitrofurantoin was 100%, 98.7%, 98.7% and 78.7%, respectively. No single isolate was resistant to more than 1 of the 4 drugs tested. Etest presented significant unexpected difficulties in testing for VRE faecium susceptibility to nitrofurantoin. Fosfomycin may be a useful alternative to linezolid and quinupristin-dalfopristin in the treatment of VRE infections in certain clinical situations, e.g. uncomplicated urinary tract infections. In addition, the use of fosfomycin could limit the use of newer agents, thus reducing the chance of development of further resistance in the enterococci.
Assuntos
Enterococcus faecium/efeitos dos fármacos , Enterococcus faecium/isolamento & purificação , Fosfomicina/farmacologia , Resistência a Vancomicina , Antibacterianos/farmacologia , Sangue/microbiologia , Farmacorresistência Bacteriana , Feminino , Humanos , Masculino , Testes de Sensibilidade Microbiana , Sensibilidade e Especificidade , Urina/microbiologiaRESUMO
Antimicrobial resistance among bacterial pathogens is a global problem, but in Egypt data are sparse. We reviewed the antimicrobial susceptibility patterns of bloodstream isolates of Gram-positive cocci and Gram-negative bacilli in five hospitals in Cairo, Egypt, from 1999 to 2000. In addition, susceptibilities of non-bloodstream isolates of Streptococcus pneumoniae and Enterococcus spp. were analysed. High rates of resistance were found in most of the bacteria studied. In the hospitals, a variety of methods were used for identification and susceptibility testing, but in the laboratories quality controlled strains were utilized routinely, to ensure accurate performance of the assays. Only 29% of Staphylococcus aureus isolates and 23% of coagulase-negative staphylococcal isolates were oxacillin susceptible. Both groups of staphylococci were also highly resistant to erythromycin, co-trimoxazole, clindamycin and doxycycline; all isolates were susceptible to vancomycin. Susceptibility of S. pneumoniae isolates to penicillin, ceftriaxone and fluoroquinolones was 63%, 84% and 82%, respectively. Vancomycin susceptibility of the enterococci was 96%; susceptibility to high-level gentamicin and streptomycin was 54% and 48%, respectively. Resistance to most relevant antimicrobials was commonplace among the Gram-negative bacilli; however, most remained susceptible to imipenem. The percentage of bloodstream isolates of Escherichia coli susceptible to common antimicrobial agents was as follows: ampicillin (6%), ampicillin-sulbactam (38%), co-trimoxazole (38%) and aminoglycosides (52%). The susceptibility of isolates of E. coli, Klebsiella and Enterobacter spp. to ceftazidime was 62%, 40% and 46%, respectively. This suggests a potentially high rate of extended-spectrum beta-lactamase (ESBL) and/or Amp-C enzyme production. These results call for a nationwide surveillance programme to monitor microbial trends and antimicrobial resistance patterns in Egypt.
Assuntos
Infecção Hospitalar/epidemiologia , Farmacorresistência Bacteriana Múltipla , Inquéritos Epidemiológicos , Hospitais/tendências , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/microbiologia , Egito , Humanos , Estudos RetrospectivosAssuntos
Comunicação , Metáfora , Educação de Pacientes como Assunto/métodos , Pneumologia , Adulto , Feminino , Humanos , Pneumopatias , Masculino , Relações Médico-PacienteRESUMO
Intracardiac devices are increasingly used to correct hemodynamically dysfunctional valves and electrophysiologic abnormalities. These devices become infected at relatively low rates. Nevertheless, when these low rates are applied to widely used devices, significant numbers of infections result. Additionally, these infections have been associated with high degrees of morbidity and high mortality rates. This article reviews the epidemiology, microbiology, clinical presentation, and medical as well as surgical therapy of intracardiac device infections.
Assuntos
Endocardite Bacteriana/terapia , Próteses Valvulares Cardíacas/microbiologia , Coração Artificial/microbiologia , Coração Auxiliar/microbiologia , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Bactérias/classificação , Bactérias/efeitos dos fármacos , Bactérias/patogenicidade , Desfibriladores Implantáveis/microbiologia , Gerenciamento Clínico , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/patologia , Coração Artificial/efeitos adversos , Humanos , Marca-Passo Artificial/microbiologiaRESUMO
Peripherally inserted central catheters (PICCs) have become popular for long courses of intravenously administration of antibiotics. Although these devices are generally regarded as safe, thrombotic complications have been associated with their use. In a retrospective review, 51 (2.47%) of 2063 patients who had a PICC placed during 1994-1996 were found to have developed a total of 52 PICC-associated venous thromboses (VTs). Two patients received the diagnosis of pulmonary embolism that was a complication of VT. Risk factors for VT identified by multiple logistic regression analysis were younger age, history of VT, discharge to a skilled-nursing facility, and therapy with amphotericin B. VT is a significant complication of PICC placement. It may occur more frequently than previously recognized and may be complicated by pulmonary embolism. Clinicians should maintain a high index of suspicion, especially for high-risk patients.