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1.
Addiction ; 2020 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-32045046
2.
Addiction ; 115(3): 493-504, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31691390

RESUMO

AIMS: To examine how the risks of incident opioid use disorder (OUD), non-fatal and fatal overdose have changed over time among opioid-naive individuals receiving an initial opioid prescription. DESIGN: Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non-fatal and fatal overdose among the opioid-naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. SETTING: Massachusetts, USA. PARTICIPANTS: Massachusetts residents aged ≥ 11 years in 2011-15 who were opioid-naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance. MEASUREMENTS: Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non-fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. FINDINGS: Among opioid-naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1-year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19-2.29 for duration of 3 or more months], non-fatal (HR = 1.67, 95% CI = 1.53-1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91-2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12-1.17), non-fatal (HR = 1.20, 95% CI = 1.10-1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61-2.16). CONCLUSIONS: Among opioid-naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.

3.
JAMA Intern Med ; : 1-9, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31682713

RESUMO

Importance: Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. Objective: To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. Design, Setting, and Participants: This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. Exposures: Time (year) as a continuous variable. Main Outcomes and Measures: The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. Results: The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). Conclusions and Relevance: Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

4.
Healthc (Amst) ; : 100378, 2019 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-31708403

RESUMO

BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure developed in conjunction with the Medicare Payment Advisory Commission. METHODS: We identified beneficiary age, sex, race, and Medicaid eligibility, death date, chronic conditions and healthcare utilization among a 20% sample of Medicare beneficiaries in 2016. For each beneficiary we calculated HDAH for the year by subtracting the following measure components from 365 days: mortality days, the total number of days spent in inpatient, observation, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation and long-term hospital settings as well as the number of outpatient emergency department and home health visits. We examined how HDAH and its components varied by beneficiary demographic characteristics and chronic condition burden as well as by healthcare market (Hospital Referral Region). We specified a patient-level linear regression adjustment model with HDAH as the outcome and incorporated market fixed effects as well as beneficiary age, sex, and Chronic Conditions Warehouse categories as covariates. We examined the impact of including home health visits in the measure, as well as the association between market demographics and health system characteristics and mean market HDAH. We examined how HDAH changed from 2013 to 2016. RESULTS: The 6,637,568 beneficiaries age 65 and older in our sample had a mean of 347.2 HDAH, those 80 and older had a mean of 325.3 while those with three or more chronic conditions had a mean of 333.7. The components that led to the largest reduction in HDAH were mortality (7.4 days), home health (2.7 visits), SNF utilization (2.4 days) and inpatient care (1.5 days). The worst performing market had 5.8 fewer adjusted HDAH on average compared to the national mean, while beneficiaries in the best-performing market had 5.0 more HDAH on average compared to the national mean, among all beneficiaries age 65 and older. CONCLUSIONS: HDAH is a population-based quality measure with substantial market-level variation. IMPLICATIONS: HDAH recognizes the multidimensional nature of healthcare and may afford providers greater flexibility to tailor quality-improvement initiatives to the unique needs of their patients. LEVEL OF EVIDENCE: Level II.

7.
JAMA Netw Open ; 2(6): e195229, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31173121

RESUMO

Importance: Little empirical work has been performed on whether teaching hospitals are more expensive when considering total costs of care for an acute care episode. Objective: To compare total standardized costs at 30 days by hospital teaching status for common conditions. Design, Setting, and Participants: This cross-sectional study assessed the costs of hospitalizations among US Medicare beneficiaries 65 years and older at major, minor, and nonteaching hospitals from January 1, 2014, to November 30, 2015, for 15 medical conditions and 6 surgical procedures. Data analysis was performed from February 26, 2019, to April 16, 2019. Exposures: Hospital teaching status (major, minor, and nonteaching hospitals). Main Outcomes and Measures: The primary outcome was 30-day total standardized costs to Medicare for hospitalizations for all 21 conditions in aggregate as well as stratified by medical and surgical condition categories. Secondary outcomes included 30-day spending for individual components of care (index hospitalization, physician services, readmission, and outpatient and post-acute care services) as well as total standardized costs at 90 days. Results: The sample consisted of 1 249 006 hospitalizations at 3064 hospitals (232 [7.6%] major teaching, 837 [27.3%] minor teaching, and 1995 [65.1%] nonteaching hospitals). Treatment at a major teaching hospital was associated with lower total 30-day adjusted standardized costs ($18 605 vs $18 793 at minor teaching hospitals and $18 873 at nonteaching hospitals; difference between major and nonteaching hospitals: -$268; 95% CI, -$456 to -$80; P = .005). Treatment at a major teaching hospital was associated with higher spending for the index hospitalization ($8529 vs $8370 at minor teaching hospitals and $8180 at nonteaching hospitals; difference between major and nonteaching hospitals: $349; 95% CI, $308-$390; P < .001) but lower physician costs ($677 vs $725 at minor teaching hospitals and $728 at nonteaching hospitals; difference: -$50; 95% CI, -$60 to -$41; P < .001). Furthermore, post-acute care costs at 30 days were lowest at major teaching hospitals ($6015 vs $6239 for minor teaching hospitals and $6260 for nonteaching hospitals; difference: -$245; 95% CI, -$375 to -$115; P < .001). Thirty-day total costs were lower at major teaching hospitals compared with nonteaching hospitals for 12 of the 21 individual conditions examined. There was no difference in costs by teaching status at 90 days ($24 982 at major teaching hospitals vs $24 959 at minor teaching hospitals vs $25 044 at nonteaching hospitals; difference: -$61; 95% CI, -$310 to $188; P = .63). Conclusions and Relevance: Medicare patients treated at major teaching hospitals had lower Medicare spending at 30 days and similar costs at 90 days compared with Medicare patients at nonteaching hospitals. These findings appear to raise doubts that care at teaching hospitals is necessarily more expensive than care at nonteaching hospitals.


Assuntos
Hospitalização/economia , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Gastos em Saúde/estatística & dados numéricos , Custos Hospitalares , Hospitais de Ensino/economia , Humanos , Masculino , Estados Unidos
8.
J Nurs Adm ; 48(10): 508-518, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30239447

RESUMO

OBJECTIVES: The aims of this study are (1) to describe the division, organizational strengths, and improvement opportunities of self-reported behaviors indicative of the multidimensional construct of professional practice and (2) to understand demographic characteristics that contributed to these strengths and improvement opportunities. BACKGROUND: Prior to implementing a system-wide interdisciplinary shared governance structure, ProHealth Care measured staff attitudes toward the multidimensional construct of professional practice as proposed within the Clinical Practice Model framework using the Professional Practice Framework Assessment Survey (PPFA-S). METHODS: Clinical and support staff were invited to share their views toward professional practice using the previously validated, reliable tool, the PPFA-S. RESULTS: Partnering relationships, scope of practice, and shared purpose were strengths. Strategies were initiated to strengthen networking councils, integrated competency, evidence-based practice, transformative capacity, and clinical tools. CONCLUSIONS: The survey identified professional practice strengths and improvement opportunities across the organization as well as factors contributing to these strengths and opportunities. These findings were useful to help guide system integration.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Equipes de Administração Institucional/organização & administração , Assistência Centrada no Paciente/organização & administração , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Atitude do Pessoal de Saúde , Comportamento Cooperativo , Enfermagem Baseada em Evidências , Prática Clínica Baseada em Evidências , Humanos , Inovação Organizacional , Inquéritos e Questionários , Estados Unidos
9.
Health Aff (Millwood) ; 37(6): 864-872, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29863940

RESUMO

Academic medical centers are widely considered to have higher costs than nonteaching hospitals, which has led some policy makers to suggest that the centers should be reserved for patients with the most complex conditions. While prior studies have shown lower mortality at the centers, it is unclear how this varies by patient severity. We examined more than 11.8 million hospitalizations in the period 2012-14 for Medicare beneficiaries ages sixty-five and older and found that, after adjustment for patient and hospital characteristics, high-severity patients had 7 percent lower odds, medium-severity patients had 13 percent lower odds, and low-severity patients had 17 percent lower odds of thirty-day mortality when treated at an academic medical center for common medical conditions, compared to similar patients treated at a nonteaching hospital. For surgical procedures, high-severity patients had 17 percent lower odds of mortality, medium-severity patients had 10 percent lower odds, and there was no difference for low-severity patients. The availability of technology explained some, but not all, of these differences. Taken together, these findings suggest that efforts to limit care at academic medical centers have the potential to lead to worse outcomes, as mortality rates for even low-severity patients seem to be lower at the centers.


Assuntos
Centros Médicos Acadêmicos/economia , Estado Terminal/mortalidade , Estado Terminal/terapia , Disparidades em Assistência à Saúde , Mortalidade Hospitalar/tendências , Medicare/economia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Feminino , Avaliação Geriátrica , Política de Saúde , Hospitais de Ensino/economia , Humanos , Revisão da Utilização de Seguros , Masculino , Seleção de Pacientes , Formulação de Políticas , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Estados Unidos
10.
Healthc (Amst) ; 6(1): 46-51, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29398469

RESUMO

BACKGROUND: A small proportion of patients account for the majority of health care spending. Of this group, little is known about what proportion have a cancer diagnosis and how their spending pattern compares to those without cancer. METHODS: Using national Medicare data of enrollees 65 or older, we identified patients in the top decile of spending in 2014 and designated them as high-cost. We used ICD-9 codes to identify patients with a cancer diagnosis and examined cancer prevalence among both high-cost and non-high-cost patients. We examined patterns of spending for high-cost patients with and without cancer. RESULTS: While 14.8% of all Medicare beneficiaries have a cancer diagnosis, we found that the prevalence of a cancer diagnosis was much higher among high-cost patients (32.5% versus 12.9% of non-high-cost patients). Thus, having a cancer diagnosis was associated with a 3.1 times greater odds of being high-cost, even after accounting for age (odds ratio 3.09, 95% CI 3.07-3.11; P < 0.001). High-cost patients with cancer had higher total annual spending than high-cost patients without cancer ($66,685 vs. $59,427; p < 0.0001); costs among high-cost cancer patients were driven by greater use of outpatient treatments (19.2% of total spending vs. 13.6% among non-cancer high-cost patients, p < 0.0001) and more prescription drugs (11.9% vs. 9.9%; p < 0.0001). CONCLUSIONS: There is a high prevalence of cancer diagnoses among high-cost Medicare patients. IMPLICATIONS: Programs that target high-cost patients may need to customize interventions based on whether the patient has a cancer diagnosis.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Medicare/economia , Neoplasias/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Classificação Internacional de Doenças/estatística & dados numéricos , Modelos Logísticos , Masculino , Medicare/estatística & dados numéricos , Razão de Chances , Prevalência , Estados Unidos
11.
BMJ Open ; 8(1): e019357, 2018 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-29382680

RESUMO

OBJECTIVE: There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012. OUTCOMES MEASURES: Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling. RESULTS: High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to -0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2 of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148). CONCLUSIONS: Increases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.


Assuntos
Codificação Clínica/tendências , Serviço Hospitalar de Emergência/tendências , Preços Hospitalares/tendências , Hospitalização/economia , Unidades de Terapia Intensiva/tendências , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/economia , Honorários Médicos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Sensibilidade e Especificidade , Estados Unidos
12.
Pediatr Emerg Care ; 2018 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-29346238

RESUMO

OBJECTIVE: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions. METHODS: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model. RESULTS: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years. CONCLUSIONS: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

13.
Ann Rheum Dis ; 77(2): 212-220, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29066464

RESUMO

OBJECTIVES: Assess the efficacy and safety of tocilizumab in patients with systemic sclerosis (SSc) in a phase II study. METHODS: Patients with SSc were treated for 48 weeks in an open-label extension phase of the faSScinate study with weekly 162 mg subcutaneous tocilizumab. Exploratory end points included modified Rodnan Skin Score (mRSS) and per cent predicted forced vital capacity (%pFVC) through week 96. RESULTS: Overall, 24/44 (55%) placebo-tocilizumab and 27/43 (63%) continuous-tocilizumab patients completed week 96. Observed mean (SD (95% CI)) change from baseline in mRSS was -3.1 (6.3 (-5.4 to -0.9)) for placebo and -5.6 (9.1 (-8.9 to-2.4)) for tocilizumab at week 48 and -9.4 (5.6 (-8.9 to -2.4)) for placebo-tocilizumab and -9.1 (8.7 (-12.5 to -5.6)) for continuous-tocilizumab at week 96. Of patients who completed week 96, any decline in %pFVC was observed for 10/24 (42% (95% CI 22% to 63%)) placebo-tocilizumab and 12/26 (46% (95% CI 27% to 67%)) continuous-tocilizumab patients in the open-label period; no patients had >10% absolute decline in %pFVC. Serious infection rates/100 patient-years (95% CI) were 10.9 (3.0 to 27.9) with placebo and 34.8 (18.0 to 60.8) with tocilizumab during the double-blind period by week 48 and 19.6 (7.2 to 42.7) with placebo-tocilizumab and 0.0 (0.0 to 12.2) with continuous-tocilizumab during the open-label period. CONCLUSIONS: Skin score improvement and FVC stabilisation in the double-blind period were observed in placebo-treated patients who transitioned to tocilizumab and were maintained in the open-label period. Safety data indicated increased serious infections in patients with SSc but no new safety signals with tocilizumab. TRIAL REGISTRATION NUMBER: NCT01532869; Results.


Assuntos
Anticorpos Monoclonais Humanizados/administração & dosagem , Antirreumáticos/administração & dosagem , Escleroderma Sistêmico/tratamento farmacológico , Pele/patologia , Adulto , Idoso , Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Injeções Subcutâneas , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Pele/efeitos dos fármacos , Resultado do Tratamento , Capacidade Vital/efeitos dos fármacos
14.
Rheumatology (Oxford) ; 57(1): 152-157, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29077900

RESUMO

Objectives: Patient acceptable symptom state (PASS) as an absolute state of well-being has shown promise as an outcome measure in many rheumatologic conditions. We aimed to assess whether PASS may be effective in active diffuse cutaneous SSc differentiating active from placebo. Methods: Data from the phase 2 Safety and Efficacy of Subcutaneous Tocilizumab in Adults with Systemic Sclerosis (faSScinate) trial were used, which compared tocilizumab (TCZ) vs placebo over 48 weeks followed by an open-label TCZ period to 96 weeks. Three different types of PASS questions were evaluated at weeks 8, 24, 48 and 96, including if a current state would be acceptable over time as a yes vs no response and Likert scales about how acceptable a current state is if remaining over time. Additional outcomes assessed included modified Rodnan skin score, HAQ disability index (HAQ-DI), physician and patient global assessments on a visual analogue scale, CRP and ESR. Results: The placebo group consisted of 44 patients and the TCZ group had 43 patients. At baseline, 33% achieved a PASS for all three PASS questions, with the proportion increasing to 69, 71 and 78%, respectively, at 96 weeks. Changes in PASS scores showed a moderately negative correlation with HAQ-DI and patient and physician global assessments visual analogue scales, which indicates expected improvements as PASS improved. The PASS question, 'Considering all of the ways your scleroderma has affected you, how acceptable would you rate your level of symptoms?' showed significant correlations with patient-reported outcomes and differentiating placebo vs TCZ at 48 weeks (P = 0.023). Conclusion: PASS may be used as a patient-centred outcome in SSc, especially as a 7-point Likert scale. Further validation is required to determine the utility as an outcome measure in trials and clinical practice.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Esclerodermia Difusa/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerodermia Difusa/fisiopatologia , Resultado do Tratamento
15.
JAMA ; 317(20): 2105-2113, 2017 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-28535236

RESUMO

Importance: Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals. Objective: To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions. Design, Setting, and Participants: Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older. Exposures: Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals). Main Outcomes and Measures: Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions. Results: The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P = .003). Among small (≤99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P = .01). Conclusions and Relevance: Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.


Assuntos
Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Medicare , Idoso , Feminino , Número de Leitos em Hospital , Hospitalização , Humanos , Masculino , Qualidade da Assistência à Saúde , Estados Unidos
16.
Head Neck ; 39(7): 1291-1295, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28452157

RESUMO

BACKGROUND: Anaplastic thyroid cancer (ATC) is a highly aggressive thyroid cancer. Several treatment trials are available, but the number of eligible patients to participate is very low because of the rarity and aggressiveness of the disease. METHODS: Facilitating Anaplastic Thyroid Cancer Specialized Treatment (FAST) is a quality improvement project aimed at decreasing time from referral to disposition (scheduling of first appointment) to our institution. After identifying reasons for delays, we created a new process flow specifically for patients with ATC allowing patients to be scheduled immediately. RESULTS: Historical data revealed a mean referral to disposition time for patients with ATC of 8.7 days before our intervention. After the intervention, the mean referral to disposition time was reduced to 0.5 days. Participation in treatment trials for all patients with ATC was 34%. CONCLUSION: Since the implementation of FAST, the access time has decreased and the number of successful referrals for ATC has increased significantly.


Assuntos
Planejamento de Assistência ao Paciente/organização & administração , Carcinoma Anaplásico da Tireoide/patologia , Carcinoma Anaplásico da Tireoide/terapia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/terapia , Centros Médicos Acadêmicos , Biópsia por Agulha , Terapia Combinada , Procedimentos Clínicos , Intervalo Livre de Doença , Feminino , Humanos , Imuno-Histoquímica , Comunicação Interdisciplinar , Masculino , Melhoria de Qualidade , Radioterapia Adjuvante , Medição de Risco , Análise de Sobrevida , Carcinoma Anaplásico da Tireoide/mortalidade , Neoplasias da Glândula Tireoide/mortalidade , Tireoidectomia/métodos , Tireoidectomia/mortalidade , Resultado do Tratamento , Estados Unidos
17.
Am J Manag Care ; 23(1): e24-e30, 2017 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-28141937

RESUMO

OBJECTIVES: To address concerns that expanding insurance coverage without expanding provider supply can lead to worse access for the previously insured, we examined whether previously insured Medicaid beneficiaries faced greater difficulties accessing primary care after statewide insurance expansion in Massachusetts. STUDY DESIGN: We used the Medicaid Analytic eXtract databases for Massachusetts and 3 New England control states for 2006 and 2009. We calculated rates of overall, acute, and chronic preventable admissions (or Prevention Quality Indicators [PQIs]) and a composite of control conditions for adults aged 21 to 64 years. METHODS: We used multivariate Poisson regression models, adjusting for age, race, gender, reason for Medicaid eligibility, and state-level physician supply, as well as a difference-in-differences (DID) approach to compare the change in the rate of PQIs and control admissions in Massachusetts versus control states before and after health reform. RESULTS: Massachusetts and control states had increases in unadjusted rates of overall, acute, and chronic PQIs. When adjusting for age, race, gender, reason for eligibility, and physician supply, this increase persisted for overall and chronic PQIs in control states, with no significant difference in the relative increase between the 2 groups for any of the PQI measures. For the within-Massachusetts analysis, low-uptake counties had a significant increase in admission for chronic PQIs that was greater than that observed for high-uptake counties (+148.0 vs +36.0; P = .045 for DID). There was no significant DID for acute or overall PQIs between the 2 groups. CONCLUSIONS: We found no evidence that insurance expansion in Massachusetts, compared with control states, reduced access to primary care for vulnerable Medicaid beneficiaries.


Assuntos
Reforma dos Serviços de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Adulto , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Humanos , Cobertura do Seguro/economia , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Análise Multivariada , Distribuição de Poisson , Medição de Risco , Estados Unidos , Adulto Jovem
18.
Ann Emerg Med ; 70(2): 193-202.e16, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28063614

RESUMO

STUDY OBJECTIVE: Prolonged boarding times in the emergency department (ED) disproportionately affect mental health patients, resulting in patient and provider dissatisfaction and increased patient morbidity and mortality. Our objective is to quantify the burden of mental health boarding and to elucidate the effect of insurance together with demographic, social, and comorbid factors on length of stay. METHODS: We conducted a cross-sectional observational study of 871 consecutive patients requiring an ED mental health evaluation at one of 10 unaffiliated Massachusetts hospitals. Demographics; insurance; length of stay; medical, psychiatric, and social history; and disposition data were collected. We evaluated the effect of these characteristics on boarding time. RESULTS: ED median length of stay varied greatly by disposition, driven primarily by ED boarding time. Admitted and transferred patients had longer delays than discharged patients (5.63, 9.32, and 1.23 hours, respectively). Medical clearance time (1.40 hours) composed only 10.5% of total ED length of stay and varied little by insurance. In our multivariate analyses, patients with Medicaid and the uninsured had significantly longer total lengths of stay and were more than twice as likely to remain in the ED for 24 hours or greater compared with privately insured patients. CONCLUSION: Mental health patients in Massachusetts have lengthy ED visits, particularly those requiring inpatient admission. Boarding time accounts for the majority of total ED length of stay and varies by insurance, even when other factors known to affect ED length of stay are controlled. Efforts to improve timeliness of care for mental health emergencies should focus on reducing ED boarding and eliminating disparities in care by insurance status.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Transtornos Mentais/terapia , Adolescente , Adulto , Estudos Transversais , Serviço Hospitalar de Emergência/economia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Massachusetts/epidemiologia , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Medicare , Transtornos Mentais/economia , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Transferência de Pacientes , Estados Unidos , Adulto Jovem
19.
J Invest Dermatol ; 136(12): 2436-2443, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27476724

RESUMO

Mounting evidence suggests that copy number variations (CNVs) can contribute to cancer susceptibility. The main goal of this study was to evaluate the role of germline CNVs in melanoma predisposition in high-risk melanoma families. We used genome-wide tiling comparative genomic hybridization and single nucleotide polymorphism arrays to characterize CNVs in 335 individuals (240 melanoma cases) from American melanoma-prone families (22 with germline CDKN2A or CDK4 mutations). We found that the global burden of overall CNVs (or deletions or duplications separately) was not significantly associated with case-control or CDKN2A/CDK4 mutation status after accounting for the familial dependence. However, we identified several rare CNVs that either involved known melanoma genes (e.g., PARP1, CDKN2A) or cosegregated with melanoma (duplication on 10q23.23, 3p12.2 and deletions on 8q424.3, 2q22.1) in families without mutations in known melanoma high-risk genes. Some of these CNVs were correlated with expression changes in disrupted genes based on RNASeq data from a subset of melanoma cases included in the CNV study. These results suggest that rare cosegregating CNVs may influence melanoma susceptibility in some melanoma-prone families and genes found in our study warrant further evaluation in future genetic analyses of melanoma.


Assuntos
Variações do Número de Cópias de DNA/genética , Predisposição Genética para Doença/epidemiologia , Mutação em Linhagem Germinativa , Melanoma/genética , Neoplasias Cutâneas/genética , Feminino , Estudo de Associação Genômica Ampla , Humanos , Incidência , Masculino , Melanoma/patologia , Linhagem , Reação em Cadeia da Polimerase em Tempo Real/métodos , Medição de Risco , Análise de Sequência de RNA , Neoplasias Cutâneas/patologia
20.
PLoS One ; 10(12): e0144075, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26636324

RESUMO

OBJECTIVE: To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings. RESEARCH DESIGN AND METHODS: We used data from the 2005-2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures. RESULTS: Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs. CONCLUSIONS: These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.


Assuntos
Centros Comunitários de Saúde/economia , Diabetes Mellitus/economia , Qualidade da Assistência à Saúde/economia , Adolescente , Adulto , Idoso , Custos e Análise de Custo , Diabetes Mellitus/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
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