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1.
J Ambul Care Manage ; 44(4): 293-303, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34319924

RESUMO

COVID-19 necessitated significant care redesign, including new ambulatory workflows to handle surge volumes, protect patients and staff, and ensure timely reliable care. Opportunities also exist to harvest lessons from workflow innovations to benefit routine care. We describe a dedicated COVID-19 ambulatory unit for closing testing and follow-up loops characterized by standardized workflows and electronic communication, documentation, and order placement. More than 85% of follow-ups were completed within 24 hours, with no observed staff, nor patient infections associated with unit operations. Identified issues include role confusion, staffing and gatekeeping bottlenecks, and patient reluctance to visit in person or discuss concerns with phone screeners.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , COVID-19/terapia , Continuidade da Assistência ao Paciente/organização & administração , Pneumonia Viral/terapia , Unidades de Cuidados Respiratórios/organização & administração , Adulto , Idoso , Boston/epidemiologia , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Encaminhamento e Consulta/estatística & dados numéricos , SARS-CoV-2 , Análise de Sistemas , Fluxo de Trabalho
2.
Mol Biol Cell ; 32(18): 1707-1723, 2021 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-34191528

RESUMO

Interactions between the actin cytoskeleton and the plasma membrane are important in many eukaryotic cellular processes. During these processes, actin structures deform the cell membrane outward by applying forces parallel to the fiber's major axis (as in migration) or they deform the membrane inward by applying forces perpendicular to the fiber's major axis (as in the contractile ring during cytokinesis). Here we describe a novel actin-membrane interaction in human dermal myofibroblasts. When labeled with a cytosolic fluorophore, the myofibroblasts displayed prominent fluorescent structures on the ventral side of the cell. These structures are present in the cell membrane and colocalize with ventral actin stress fibers, suggesting that the stress fibers bend the membrane to form a "cytosolic pocket" that the fluorophores diffuse into, creating the observed structures. The existence of this pocket was confirmed by transmission electron microscopy. While dissolving the stress fibers, inhibiting fiber protein binding, or inhibiting myosin II binding of actin removed the observed pockets, modulating cellular contractility did not remove them. Taken together, our results illustrate a novel actin-membrane bending topology where the membrane is deformed outward rather than being pinched inward, resembling the topological inverse of the contractile ring found in cytokinesis.

3.
Thyroid ; 30(7): 992-998, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31950884

RESUMO

Background: Nondiagnostic results are common following fine-needle aspiration biopsy (FNAB) of thyroid nodules, but recommendations for the management of these patients vary. We sought to determine the outcomes and predictors of nondiagnostic FNABs in a single-center cohort of patients undergoing thyroid nodule evaluation. Methodology: We identified all first time ultrasound-guided FNABs performed between May 2007 and June 2013 at the Beth Israel Deaconess Medical Center Thyroid Nodule Clinic and examined demographic data, follow-up ultrasounds, repeated FNABs, and histopathologic findings. We examined the likelihood of diagnostic findings and of cancer with increasing numbers of nondiagnostic evaluations with their exact binomial confidence intervals [CIs] and potential predictors of nondiagnostic status using generalized estimating equations. Results: During the six-year period, 2234 unique individuals underwent ultrasound-guided FNAB of a thyroid nodule. The probability of obtaining a diagnostic biopsy declined from 84.4% [95% CI 82.8-85.8%] for initial FNABs to 57.6% [CI 50.8-64.2%] for the first re-FNAB and further to 42.4% [CI 25.5-60.8%] for second re-FNABs. Adjusted risk of nondiagnostic FNAB strongly increased with increasing numbers of previous biopsies and was also higher among whites. The overall rate of diagnosis of malignancy after a nondiagnostic FNAB was 8.1% [CI 4.2-13.7%] and was similar regardless of the number of previous nondiagnostic aspirations. Conclusion: Following an initial nondiagnostic FNAB, the probability of yielding a diagnostic result declines with each sequential repeat FNAB. Nonetheless, a tangible possibility of malignancy remains even after repeated nondiagnostic FNABs.


Assuntos
Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/diagnóstico , Nódulo da Glândula Tireoide/diagnóstico , Adulto , Biópsia por Agulha Fina , Feminino , Humanos , Biópsia Guiada por Imagem , Masculino , Pessoa de Meia-Idade , Neoplasias da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/patologia , Ultrassonografia
5.
BMJ Qual Saf ; 27(6): 492-497, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29306903

RESUMO

BACKGROUND: Diagnostic errors result in preventable morbidity and mortality. The outpatient setting may be at increased risk, where time constraints, the indolent nature of outpatient complaints and single decision-maker practice models predominate. METHODS: We developed a self-administered diagnostic pause to address diagnostic error. Clinicians (physicians and nurse practitioners) in an academic primary care setting received the tool if they were seeing urgent care patients who had previously been seen in the past two weeks in urgent care. We used pre-post-intervention surveys, focus groups and chart audits 6 months after the urgent care visit to assess the impact of the intervention on participant perceptions and actions. RESULTS: We piloted diagnostic pauses in two phases (3 months and 6 months, respectively); 9 physicians participated in the first phase, and 16 physicians and 2 nurse practitioners in the second phase. Subjects received 135 alerts for diagnostic pauses and responded to 82 (61% response). Thirteen per cent of alerts resulted in clinicians reporting new actions as a result of the diagnostic pauses. Thirteen per cent of cases at a 6-month chart audit resulted in diagnostic discrepancies, defined as differences in diagnosis from the initial working diagnosis. Focus groups reported that the diagnostic pauses were brief and fairly well integrated into the overall workflow for evaluation but would have benefited as a real-time application for patients at higher risk for diagnostic error. CONCLUSION: This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.


Assuntos
Instituições de Assistência Ambulatorial , Erros de Diagnóstico/prevenção & controle , Garantia da Qualidade dos Cuidados de Saúde/métodos , Tomada de Decisões , Feminino , Grupos Focais , Humanos , Masculino , Projetos Piloto , Atenção Primária à Saúde , Inquéritos e Questionários
6.
Thyroid ; 26(6): 825-30, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27094873

RESUMO

BACKGROUND: There are few published quality metrics relevant to fine-needle aspirations (FNA) of the thyroid and endocrinology. With the development of a Thyroid Nodule Clinic within an academic practice, the Division of Endocrinology, in collaboration with the Department of Medicine Quality Improvement Team, established a system to monitor the results and follow-up of thyroid biopsies to ensure patient safety and to prevent adverse clinical outcomes attributable to delayed or incomplete follow-up. METHODS: All FNA performed are identified using billing data from the Thyroid Nodule Clinic. Results were followed using the Beth Israel Deaconess Online Medical Record (OMR) system, and information is collected on documented follow-up plan and actions taken. Missing data are flagged for review. Over the reporting period, the monitoring process and categories were modified to account for adoption of the Bethesda reporting criteria and implementation of gene expression classifier testing. Specific workflow plans were developed for each cytopathologic classification. RESULTS: Between July 2007 and June 2014, 3895 FNAs were performed. The quality improvement tracking process found that 3856/3895 (99%) biopsy cases had documented follow-up since initiation of the project. CONCLUSION: This monitoring process has ensured quality patient care, with confidence that patients having FNAs are receiving documented necessary follow-up for treatment of their nodular conditions. This system serves as a potential model for others to use in their endocrine practice in managing the results of thyroid nodule biopsies.


Assuntos
Garantia da Qualidade dos Cuidados de Saúde , Melhoria de Qualidade , Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/patologia , Instituições de Assistência Ambulatorial , Biópsia por Agulha Fina/normas , Humanos , Indicadores de Qualidade em Assistência à Saúde
7.
Am J Med ; 129(8): 879.e1-6, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26949003

RESUMO

Obesity is a growing health problem in our society and its treatment has been challenging. In recent decades, several anti-obesity drugs have been withdrawn from the market because of reported and documented adverse effects. After years of interruption, the US Food and Drug Administration (FDA) has recently approved multiple new anti-obesity drugs. The majority of these medications are taken orally, and only one is administered subcutaneously. In this article, we review the efficacy, adverse effects, and mechanism of action of all 5 FDA-approved drugs.


Assuntos
Fármacos Antiobesidade/farmacologia , Aprovação de Drogas , Obesidade/tratamento farmacológico , Perda de Peso/efeitos dos fármacos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Estados Unidos
9.
Eur J Intern Med ; 26(9): 666-9, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26342722

RESUMO

Alzheimer's disease is the most common cause of dementia and occurs commonly in patients 65 and older. There is an urgent need to find an effective management that could help prevent or at least slow down the progress of this major public health problem. Cholesterol related pathways might play a role in the pathogenesis of Alzheimer's disease. Treatment with 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) has been suggested to promote the prevention of Alzheimer's disease. In this review, we discuss potential pathogenetic pathways for the development of Alzheimer's disease and review the evidence regarding the value of statins as a strategy to prevent or delay progression of Alzheimer's disease.


Assuntos
Doença de Alzheimer/prevenção & controle , Doença de Alzheimer/fisiopatologia , Colesterol/sangue , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Idoso , Progressão da Doença , Humanos
10.
J Am Geriatr Soc ; 62(5): 936-42, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24749723

RESUMO

OBJECTIVES: To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications. DESIGN: Pre-post interventional trial. SETTING: Large academic medical center. PARTICIPANTS: Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls. INTERVENTION: The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults. MEASUREMENTS: Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous (IV) morphine in excess of 2 mg, and discharge disposition. RESULTS: Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio (OR) for the difference of differences = 1.23 (95% confidence interval (CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol (OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine (OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities (OR = 1.18, 95% CI = 1.04-1.35, P = .01). CONCLUSION: An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care.


Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Delírio/prevenção & controle , Atenção à Saúde/normas , Geriatria/métodos , Haloperidol/administração & dosagem , Morfina/administração & dosagem , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Técnicas de Apoio para a Decisão , Delírio/diagnóstico , Delírio/epidemiologia , Relação Dose-Resposta a Droga , Feminino , Avaliação Geriátrica , Hospitalização/tendências , Humanos , Injeções Intramusculares , Injeções Intravenosas , Masculino , Massachusetts/epidemiologia , Entrevista Psiquiátrica Padronizada , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Tempo
11.
J Comput Assist Tomogr ; 38(1): 89-95, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24424558

RESUMO

OBJECTIVE: The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance. MATERIALS AND METHODS: A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up. Multivariate logistic regression models determined the factors associated with likelihood of recommended CT surveillance. RESULTS: At least 1 recommended surveillance chest CT was performed on 48% of the patients (148/310). Computed tomographic result communication to the patient (odds ratio [OR], 2.2; P = 0.006; confidence interval [CI], 1.3-4.0) or to the referring physician (OR, 2.8; P = 0.001; CI, 1.7-4.5) and recommendation of a specific surveillance time interval (OR, 1.7; P = 0.023; CI, 1.08-2.72) increased the likelihood of surveillance. Other demographic, radiologic, and clinical factors did not influence surveillance. CONCLUSIONS: Documented physician and patient result communication as well as the recommendation of a specific surveillance time interval increased the likelihood of CT surveillance of incidentally detected lung nodules.


Assuntos
Fidelidade a Diretrizes , Neoplasias Pulmonares/diagnóstico por imagem , Vigilância da População , Nódulo Pulmonar Solitário/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Comunicação , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Clin Gastroenterol Hepatol ; 11(10): 1288-93, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23669305

RESUMO

BACKGROUND & AIMS: Few studies have analyzed the safety of endoscopy in patients with inflammatory bowel disease (IBD). We aimed to determine the prevalence of procedure-related complications among these patients, compared with the general population, and estimate the lifetime risk of colonoscopy-related complications. METHODS: We collected data on complications in 685 patients with IBD and 17,000 patients without IBD (controls) using an automated system to track all emergency department visits to the Beth Israel Deaconess Medical Center within 14 days of an endoscopic procedure, from March 1, 2007, to November 30, 2007. We reviewed charts of all IBD patients to determine health care use (telephone calls or visits to a gastroenterologist or primary care physician and visits to other emergency departments or hospitals) after endoscopy. The lifetime risk of procedure-related complications was estimated using a Markov Monte Carlo model. RESULTS: Rates of complications were 1.17% among patients with IBD and 0.96% among controls (P = .55). The chart review showed that 3.8% of the IBD cohort received medical care within 14 days of the endoscopic procedure. Based on a Markov Monte Carlo simulation model, the lifetime risk of complications after a surveillance colonoscopy protocol was 12.7% among patients with IBD and 2.0% in the general population undergoing screening colonoscopy (P < .001). CONCLUSIONS: Although the risk of adverse events after each endoscopic procedure was similar for patients with IBD and the general population, IBD patients have an increased lifetime risk of complications after colonoscopies. A higher percentage of patients with IBD also seek medical care after endoscopic procedures than controls.


Assuntos
Colonoscopia/efeitos adversos , Doença Iatrogênica/epidemiologia , Doenças Inflamatórias Intestinais/diagnóstico , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Medição de Risco
13.
JAMA Intern Med ; 173(9): 771-6, 2013 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-23546303

RESUMO

IMPORTANCE: Methemoglobinemia is a rare but serious disorder, defined as an increase in oxidized hemoglobin resulting in a reduction of oxygen-carrying capacity. Although methemoglobinemia is a known complication of topical anesthetic use, few data exist on the incidence of and risk factors for this potentially life-threatening disorder. OBJECTIVE: To examine the incidence of and risk factors for procedure-related methemoglobinemia to identify patient populations at high risk for this complication. DESIGN AND SETTING: Retrospective study in an academic research setting. PARTICIPANTS: Medical records for all patients diagnosed as having methemoglobinemia during a 10-year period were reviewed. EXPOSURES: All cases of methemoglobinemia that occurred after the following procedures were included in the analysis: bronchoscopy, nasogastric tube placement, esophagogastroduodenoscopy, transesophageal echocardiography, and endoscopic retrograde cholangiopancreatography. MAIN OUTCOMES AND MEASURES: Comorbidities, demographics, concurrent laboratory values, and specific topical anesthetic used were recorded for all cases. Each case was compared with matched inpatient and outpatient cases. RESULTS: In total, 33 cases of methemoglobinemia were identified during the 10-year period among 94,694 total procedures. The mean (SD) methemoglobin concentration was 32.0% (12.4%). The methemoglobinemia prevalence rates were 0.160% for bronchoscopy, 0.005% for esophagogastroduodenoscopy, 0.250% for transesophageal echocardiogram, and 0.030% for endoscopic retrograde cholangiopancreatography. Hospitalization at the time of the procedure was a major risk factor for the development of methemoglobinemia (0.14 cases per 10,000 outpatient procedures vs 13.7 cases per 10,000 inpatient procedures, P < .001). CONCLUSIONS AND RELEVANCE: The overall prevalence of methemoglobinemia is low at 0.035%; however, an increased risk was seen in hospitalized patients and with benzocaine-based anesthetics. Given the potential severity of methemoglobinemia, the risks and benefits of the use of topical anesthetics should be carefully considered in inpatient populations.


Assuntos
Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Metemoglobinemia/induzido quimicamente , Metemoglobinemia/epidemiologia , Adulto , Idoso , Antídotos/uso terapêutico , Benzocaína/administração & dosagem , Benzocaína/efeitos adversos , Broncoscopia , Estudos de Casos e Controles , Colangiopancreatografia Retrógrada Endoscópica , Comorbidade , Ecocardiografia Transesofagiana , Endoscopia do Sistema Digestório , Feminino , Humanos , Incidência , Pacientes Internados/estatística & dados numéricos , Intubação Gastrointestinal , Masculino , Massachusetts/epidemiologia , Registros Médicos , Metemoglobinemia/tratamento farmacológico , Azul de Metileno/uso terapêutico , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
15.
Crit Care Med ; 40(9): 2562-8, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22732285

RESUMO

OBJECTIVE: Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient's usual care providers, not a critical-care-trained rapid-response team, would improve patient outcomes. DESIGN, SETTING, AND PATIENTS: An interrupted time-series analysis of over a 59-month period. SETTING: Urban, academic hospital. PATIENTS: One hundred seven-one thousand, three hundred forty-one consecutive adult admissions. INTERVENTION: In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient's existing care providers was assembled. MEASUREMENTS AND MAIN RESULTS: The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%-83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%-89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82-1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2). CONCLUSIONS: A primary-team-based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient's usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.


Assuntos
Causas de Morte , Estado Terminal/mortalidade , Estado Terminal/terapia , Mortalidade Hospitalar/tendências , Equipe de Respostas Rápidas de Hospitais/organização & administração , Adulto , Idoso , Estudos de Coortes , Intervalos de Confiança , Bases de Dados Factuais , Emergências , Feminino , Implementação de Plano de Saúde/organização & administração , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente/organização & administração , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento
17.
Am J Med Qual ; 27(4): 321-8, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22326983

RESUMO

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.


Assuntos
Centros Médicos Acadêmicos/normas , Infecções por HIV/terapia , Garantia da Qualidade dos Cuidados de Saúde , Terapia Antirretroviral de Alta Atividade/normas , Contagem de Linfócito CD4/normas , Bases de Dados Factuais , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Serviço de Farmácia Hospitalar , Atenção Primária à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde
18.
Gastrointest Endosc ; 75(3): 554-60, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22341102

RESUMO

BACKGROUND: Adenoma detection rate is an important measure of colonoscopy quality; however, factors including procedure order that contribute to adenoma detection are incompletely understood. OBJECTIVE: The aim of this study was to prospectively evaluate factors associated with adenoma detection rate. DESIGN: Prospective cohort study. Data were collected on patient and physician characteristics, trainee participation, time of day, and case rank. SETTING: Outpatient tertiary-care center. PATIENTS: This study involved consecutive patients presenting for first screening colonoscopies. MAIN OUTCOME MEASUREMENTS: Adenoma and polyp detection rates (proportion of cases with one or more lesion detected) and ratios (mean number of lesions detected per case). RESULTS: A total of 2139 colonoscopies were performed by 32 gastroenterologists. Detection rates were 42.7% for all polyps, 25.4% for adenomas, and 5.0% for advanced adenomas. Adenoma detection was associated with male sex and increasing age on multivariate analysis. In the overall study cohort, time of day and case rank were not significantly associated with detection rates. In post hoc analysis, polyp and adenoma detection rates appeared lower after the fifth case of the day for endoscopists with low volumes of cases and after the tenth case of the day for endoscopists with high volumes of cases. LIMITATION: Single center. CONCLUSION: Overall, time of day and case rank did not influence adenoma detection rate. We observed a small but significant decrease in detection rates in later procedures, which was dependent on physician typical procedure volume. These findings imply that colonoscopy quality in general is stable throughout the day; however, there may be a novel "stamina effect" for some endoscopists, and interventions aimed at improving colonoscopy quality need to take individual physician practice styles into consideration.


Assuntos
Adenoma/epidemiologia , Adenoma/patologia , Pólipos do Colo/epidemiologia , Pólipos do Colo/patologia , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes/classificação , Estudos Prospectivos , Fatores de Tempo
19.
Int J Qual Health Care ; 24(4): 357-64, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22190587

RESUMO

QUALITY PROBLEM: Patients often do not fully understand medical information discussed during office visits. This can result in lack of adherence to recommended treatment plans and poorer health outcomes. CHOICE OF SOLUTION: We developed and implemented a program utilizing an encounter form, which provides structure to the medical interaction and facilitates bidirectional communication and informed decision-making. IMPLEMENTATION: We conducted a prospective quality improvement intervention at a large tertiary-care academic medical center utilizing the encounter form and studied the effect on patient satisfaction, understanding and confidence in communicating with physicians. The intervention included 108 patients seen by seven physicians in five sub-specialties. EVALUATION: Ninety-eight percent of patients were extremely satisfied (77%) or somewhat satisfied (21%) with the program. Ninety-six percent of patients reported being involved in decisions about their care and treatments as well as high levels of understanding of medical information that was discussed during visit. Sixty-nine percent of patients reported that they shared the encounter form with their families and friends. Patients' self-confidence in communicating with their doctors increased from a score of 8.1 to 8.7 post-intervention (P-value = 0.0018). When comparing pre- and post-intervention experiences, only 38% of patients felt that their problems and questions were adequately addressed by other physicians' pre-intervention, compared with 94% post-intervention. LESSONS LEARNED: We introduced a program to enhance physician-patient communication and found that patients were highly satisfied, more informed and more actively involved in their care. This approach may be an easily generalizable approach to improving physician-patient communication at outpatient visits.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Comunicação , Visita a Consultório Médico , Relações Médico-Paciente , Melhoria de Qualidade/organização & administração , Adulto , Idoso , Competência Clínica , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Participação do Paciente , Satisfação do Paciente , Estudos Prospectivos , Fatores Socioeconômicos
20.
J Am Geriatr Soc ; 59(2): 291-6, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21288231

RESUMO

OBJECTIVES: To design, implement, and assess an educational intervention for providers focused on osteoporosis screening and management in older patients with chronic obstructive pulmonary disease or asthma who have been prescribed prolonged courses of oral or high-dose inhaled corticosteroids or both and are therefore at high risk for bone loss and fractures. DESIGN: One-group pretest-posttest. SETTING: Academic outpatient pulmonary practice. PARTICIPANTS: Nineteen pulmonary specialists at an academic medical center. INTERVENTION: Educational theory and a needs assessment and attitude survey guided the development of a multicomponent educational intervention. MEASUREMENTS: Change in provider behavior was assessed by auditing the electronic medical records for adherence to osteoporosis management guidelines in high-risk patients seen by participants at baseline and for 6 months after the educational intervention. Knowledge transfer and changes in attitude were assessed using pre- and posttests and surveys. RESULTS: A 19% increase in overall rate of adherence to osteoporosis management guidelines in high-risk patients was observed: 45% before intervention to 64% after intervention (n=249 patients, P=.003). Postintervention surveys and test scores also showed statistically significant gains from baseline. CONCLUSION: An educational intervention improved adherence to osteoporosis management guidelines of academic pulmonary specialists. The results of this study provide evidence for the positive effect of a multimodal educational program in altering practice behaviors.


Assuntos
Osteoporose/prevenção & controle , Educação de Pacientes como Assunto , Fatores Etários , Idoso , Feminino , Seguimentos , Fidelidade a Diretrizes , Humanos , Masculino , Fatores de Risco
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