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1.
Blood ; 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32092132

RESUMO

Many predictors for venous thromboembolism (VTE) and bleeding in hospitalized medical patients may exist but until now systematic reviews and assessments of the certainty of the evidence do not exist. We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients and searched Medline and EMBASE from inception to May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Of 69,410 citations, we included 17 studies; 14 that reported on VTE and identified 29 candidate prognostic factors and three that reported on bleeding and identified 17 candidate factors. For VTE, moderate certainty evidence shows a probable association with older age, elevated CRP, D-dimer, fibrinogen levels, heart rate, thrombocytosis, leukocytosis, fever, leg edema, lower Barthel Index score, immobility, paresis, previous history of VTE, thrombophilia, malignancy, critical illness and infections. For bleeding, moderate certainty evidence shows a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication and central venous catheter (CVC). Elevated CRP, a lower Barthel Index, history of malignancy and elevated heart rate are not included in most VTE risk assessment models (RAMs). This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding, related research and guidelines for VTE prevention.

2.
Am J Respir Crit Care Med ; 200(6): e31-e43, 2019 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31518182

RESUMO

Rationale: Immune checkpoint inhibitors (ICIs) have revolutionized cancer care but are associated with unique adverse events, including potentially life-threatening pneumonitis. The diagnosis of ICI-pneumonitis is increasing; however, the biological mechanisms, clinical and radiologic features, and the diagnosis and management have not been well defined.Objectives: To summarize evidence, identify knowledge and research gaps, and prioritize topics and propose methods for future research on ICI-pneumonitis.Methods: A multidisciplinary group of international clinical researchers reviewed available data on ICI-pneumonitis to develop and refine research questions pertaining to ICI-pneumonitis.Results: This statement identifies gaps in knowledge and develops potential research questions to further expand knowledge regarding risk, biologic mechanisms, clinical and radiologic presentation, and management of ICI-pneumonitis.Conclusions: Gaps in knowledge of the basic biological mechanisms of ICI-pneumonitis, coupled with a precipitous increase in the use of ICIs alone or combined with other therapies, highlight the importance in triaging research priorities for ICI-pneumonitis.

3.
JAMA Netw Open ; 2(8): e199657, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31418811

RESUMO

Importance: While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival. Objective: To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD. Design, Setting, and Participants: Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities. Interventions: The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation. Main Outcomes and Measures: The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers. Results: All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes. Conclusions and Relevance: Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis. Trial Registration: ClinicalTrials.gov identifier: NCT02478359.

5.
Ann Am Thorac Soc ; 16(12): 1567-1576, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31314549

RESUMO

Small pulmonary nodules are most often managed by surveillance imaging with computed tomography (CT) of the chest, but the optimal frequency and duration of surveillance are unknown. The Watch the Spot Trial is a multicenter, pragmatic, comparative-effectiveness trial with cluster randomization by hospital or health system that compares more- versus less-intensive strategies for active surveillance of small pulmonary nodules. The study plans to enroll approximately 35,200 patients with a small pulmonary nodule that is newly detected on chest CT imaging, either incidentally or by screening. Study protocols for more- and less-intensive surveillance were adapted from published guidelines. The primary outcome is the percentage of cancerous nodules that progress beyond American Joint Committee on Cancer seventh edition stage T1a. Secondary outcomes include patient-reported anxiety and emotional distress, nodule-related health care use, radiation exposure, and adherence with the assigned surveillance protocol. Distinctive aspects of the trial include: 1) the pragmatic integration of study procedures into existing clinical workflow; 2) the use of cluster randomization by hospital or health system; 3) the implementation and evaluation of a system-level intervention for protocol-based care; 4) the use of highly efficient, technology-enabled methods to identify and (passively) enroll participants; 5) reliance on data collected as part of routine clinical care, including data from electronic health records and state cancer registries; 6) linkage with state cancer registries for complete ascertainment of the primary study outcome; and 7) intensive engagement with a diverse group of patient and nonpatient stakeholders in the design and execution of the study.

7.
Ann Emerg Med ; 74(2): 216-223, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30955986

RESUMO

STUDY OBJECTIVE: Professional guidelines recommend 72-hour cardiac stress testing after an emergency department (ED) evaluation for possible acute coronary syndrome. There are limited data on actual compliance rates and effect on patient outcomes. Our aim is to describe rates of completion of noninvasive cardiac stress testing and associated 30-day major adverse cardiac events. METHODS: We conducted a retrospective analysis of ED encounters from June 2015 to June 2017 across 13 community EDs within an integrated health system in Southern California. The study population included all adults with a chest pain diagnosis, troponin value, and discharge with an order for an outpatient cardiac stress test. The primary outcome was the proportion of patients who completed an outpatient stress test within the recommended 3 days, 4 to 30 days, or not at all. Secondary analysis described the 30-day incidence of major adverse cardiac events. RESULTS: During the study period, 24,459 patients presented with a chest pain evaluation requiring troponin analysis and stress test ordering from the ED. Of these, we studied the 7,988 patients who were discharged home to complete diagnostic testing, having been deemed appropriate by the treating clinicians for an outpatient stress test. The stress test completion rate was 31.3% within 3 days and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the ordered test. The 30-day rates of major adverse cardiac events were low (death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid receipt of stress testing was not associated with improved 30-day major adverse cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54). CONCLUSION: Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.

8.
Ann Emerg Med ; 74(2): 171-180, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30797573

RESUMO

STUDY OBJECTIVE: We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). METHODS: We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. RESULTS: A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). CONCLUSION: Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

9.
Chest ; 155(1): 44-52, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30056040

RESUMO

BACKGROUND: Low-dose CT scan reduces lung cancer mortality in high-risk patients fit to undergo surgical resection. Racial disparities in resection of lung cancer in nonscreening populations are well described. We describe surgical resection patterns of patients with early stage non-small cell lung cancer (NSCLC) in the National Lung Screening Trial (NLST) and examine whether racial disparities exist among blacks. METHODS: We identified all NLST participants with clinical stage I NSCLC. Covariates included demographics, smoking history, comorbidities, tumor characteristics, and timing of cancer detection. Using logistic regression, we assessed resection rates of blacks vs whites. RESULTS: Among 752 patients with clinical stage I disease, 692 patients (92%) underwent resection. Unadjusted surgical resection rates for white men, white women, black men, and black women were 92%, 91%, 61%, and 90%, respectively. In adjusted analyses, compared with white men, black men had a 28% lower risk (relative risk, 0.72; 95% CI, 0.50-0.99) of undergoing surgery; however, white women and black women underwent surgery at comparable rates as white men. The odds of undergoing limited resection instead of full resection were 70% greater in white women than white men (OR, 1.69; 95% CI, 1.08-2.65). CONCLUSIONS: Our study shows that disparities in the surgical treatment of lung cancer persist, even among NLST participants who were considered fit to undergo thoracic surgery. As lung cancer screening disseminates into clinical practice, efforts targeting black men should be prioritized.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/cirurgia , Detecção Precoce de Câncer , Disparidades em Assistência à Saúde , Neoplasias Pulmonares/cirurgia , Programas de Rastreamento/métodos , Estadiamento de Neoplasias , Pneumonectomia , Idoso , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Grupos Étnicos , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/etnologia , Masculino , Pessoa de Meia-Idade , Programa de SEER , Taxa de Sobrevida/tendências , Tomografia Computadorizada por Raios X , Estados Unidos/epidemiologia
10.
Support Care Cancer ; 27(5): 1737-1745, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30143893

RESUMO

PURPOSE: Limited understanding of factors affecting uptake and outcomes of different cancer survivorship care models hampers implementation of best practices. We conducted a formative evaluation of stakeholder-perceived acceptability and feasibility of an embedded primary care provider (PCP) survivorship care model. METHODS: We identified clinical, operational, and patient stakeholders within Kaiser Permanente Southern California and conducted semi-structured interviews. Analyses were guided by the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science. Deductive thematic categories were derived a priori from CFIR domains; thematic sub-categories were developed inductively. RESULTS: We interviewed 12 stakeholders; multiple themes were identified. Acceptability: oncologists and operational leaders perceived that the model was an acceptable solution to issues of capacity and efficiency with the potential to improve quality; however, several oncologists perceived negative consequences including "[loss of] the joy of medicine." Patients were less enthusiastic, fearing the introduction of "[someone] who doesn't know me." Feasibility: confidence was high that this model can succeed, although there was concern about finding the right PCP and investment in training and staff support. Culture/climate: numerous system-level facilitators were identified, including encouragement of innovation and familiarity with developing new models. CONCLUSIONS: Formative evaluation is a critical pre-implementation process. Acceptability and feasibility for this model were high among oncologists and operational leaders but patients were ambivalent. Keys to successful implementation include training and support of engaged PCPs and a patient transition plan introduced early in the care trajectory.


Assuntos
Assistência à Saúde/métodos , Ciência da Implementação , Modelos Organizacionais , Neoplasias/reabilitação , Atenção Primária à Saúde/métodos , California , Sobreviventes de Câncer , Assistência à Saúde/organização & administração , Estudos de Viabilidade , Pessoal de Saúde , Humanos , Percepção , Atenção Primária à Saúde/organização & administração
11.
Ann Am Thorac Soc ; 16(1): 124-131, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30272486

RESUMO

RATIONALE: Several randomized trials have compared the efficacy of an indwelling pleural catheter (IPC) versus the more traditional chemical pleurodesis in the management of malignant pleural effusion (MPE). OBJECTIVES: As part of the American Thoracic Society's guidelines for management of MPE, we performed a systematic review and a meta-analysis to compare patient-centered outcomes with the use of a tunneled pleural catheter versus chemical pleurodesis for the first-line treatment of malignant pleural effusions. METHODS: We performed literature searches in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing IPC and pleurodesis in adult patients with symptomatic MPE. Risk of bias was assessed with the Cochrane Risk of Bias tool recommended by the Cochrane Methods Bias Group. The meta-analysis was performed with Review Manager software, using a random effects model. We used risk ratios (RRs) with 95% confidence interval (CI) as the effect measure for dichotomous outcomes and mean differences for continuous outcomes. RESULTS: We identified five randomized trials, involving 545 patients, that compared IPC and pleurodesis. Lack of blinding and the inevitable attrition of patients due to death resulted in an overall high risk of bias among the studies. No differences in survival or measures of dyspnea were observed in any of the studies. Total hospital length of stay was shorter, and repeat pleural interventions were less common in the IPC group (RR, 0.32; 95% CI, 0.18-0.55). However, the risk of cellulitis was higher with IPC (RR, 5.83; 95% CI, 1.56-21.8). No differences were noted in other adverse events. CONCLUSIONS: Compared with chemical pleurodesis, IPC results in shorter hospital length of stay and fewer repeat pleural procedures but carries a higher risk of cellulitis. Careful assessment of individual patient preferences and costs should be considered when choosing between IPC and pleurodesis.

13.
Clin Lung Cancer ; 20(1): e115-e122, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30585165

RESUMO

BACKGROUND: Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality in high-risk patients, most of those eligible are not referred for screening. Tobacco cessation counseling may be an opportune time to educate people about LCS, but little is known about the utilization and perceptions of LCS among people undergoing tobacco cessation treatment. MATERIALS AND METHODS: We surveyed 185 current smokers, including 122 smokers between the ages of 55 and 80 years, who were attending a tobacco cessation class in a large integrated health care system regarding lung cancer risk perception and perceived benefits, harms, and barriers to LCS. We analyzed results according to whether participants had already undergone LCS and also whether they had undergone colorectal cancer screening. RESULTS: A minority (18.9%) of participants had undergone LCS, and no participant who had not undergone LCS was familiar with LCS. Perceived lung cancer risk was high, and screening was believed to be beneficial. Common barriers included being a current smoker (56.6%), worrying about test results (52.5%), lack of knowledge about the test (50.8%), absence of symptoms of lung cancer (40.2%), costs of the study (35.2%), and worrying about being blamed for having smoked (33.6%). Perceived risk and barriers to LDCT were similar among people who had or had not previously undergone colorectal cancer screening. CONCLUSIONS: Utilization of LCS was low, and few smokers were aware of LDCT for LCS. A number of patient-related barriers to screening exist among smokers. Tobacco cessation counseling may be an opportune time to provide education regarding LCS with LDCT.


Assuntos
Neoplasias Pulmonares/diagnóstico , Percepção , Idoso , Idoso de 80 Anos ou mais , Fumar Cigarros/efeitos adversos , Aconselhamento , Detecção Precoce de Câncer , Feminino , Humanos , Neoplasias Pulmonares/psicologia , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Fatores de Risco , Abandono do Hábito de Fumar , Inquéritos e Questionários
15.
Am J Respir Crit Care Med ; 198(7): 839-849, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30272503

RESUMO

BACKGROUND: This Guideline, a collaborative effort from the American Thoracic Society, Society of Thoracic Surgeons, and Society of Thoracic Radiology, aims to provide evidence-based recommendations to guide contemporary management of patients with a malignant pleural effusion (MPE). METHODS: A multidisciplinary panel developed seven questions using the PICO (Population, Intervention, Comparator, and Outcomes) format. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the Evidence to Decision framework was applied to each question. Recommendations were formulated, discussed, and approved by the entire panel. RESULTS: The panel made weak recommendations in favor of: 1) using ultrasound to guide pleural interventions; 2) not performing pleural interventions in asymptomatic patients with MPE; 3) using either an indwelling pleural catheter (IPC) or chemical pleurodesis in symptomatic patients with MPE and suspected expandable lung; 4) performing large-volume thoracentesis to assess symptomatic response and lung expansion; 5) using either talc poudrage or talc slurry for chemical pleurodesis; 6) using IPC instead of chemical pleurodesis in patients with nonexpandable lung or failed pleurodesis; and 7) treating IPC-associated infections with antibiotics and not removing the catheter. CONCLUSIONS: These recommendations, based on the best available evidence, can guide management of patients with MPE and improve patient outcomes.


Assuntos
Derrame Pleural Maligno/terapia , Pleurodese/métodos , Guias de Prática Clínica como Assunto , Sociedades Médicas , Cateteres de Demora , Tratamento Conservador/métodos , Drenagem/métodos , Medicina Baseada em Evidências , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Derrame Pleural Maligno/diagnóstico por imagem , Prognóstico , Radiografia Torácica/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Talco/uso terapêutico , Toracentese/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
16.
West J Emerg Med ; 19(5): 842-848, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30202497

RESUMO

Introduction: The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge. Methods: We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009-2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission. Results: Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models. Conclusion: Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.


Assuntos
Serviço Hospitalar de Emergência , Pacientes Internados/estatística & dados numéricos , Transferência de Pacientes , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco
17.
J Gen Intern Med ; 33(12): 2171-2179, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30182326

RESUMO

BACKGROUND: High-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population. OBJECTIVE: To define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Within a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010. MAIN MEASURES: We used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients. RESULTS: Among 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups. CONCLUSIONS: Data-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly.


Assuntos
Doença Aguda/economia , Doença Crônica/economia , Prestação Integrada de Cuidados de Saúde/economia , Pesquisa Empírica , Custos de Cuidados de Saúde , Doença Aguda/epidemiologia , Doença Aguda/terapia , Adulto , Idoso , Doença Crônica/epidemiologia , Análise por Conglomerados , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
18.
Nurs Outlook ; 66(5): 455-463, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30144938

RESUMO

BACKGROUND: Observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD). Despite practice guidelines recommending regular physical activity (PA), there are no large-scale experimental studies to confirm that patients at high risk for COPD exacerbations can increase their PA and consequently, have improved outcomes. PURPOSE: The purpose of this case study is to describe the use of a widely accepted pragmatic trials framework for the design and implementation of a pragmatic clinical trial (PCT) of PA coaching for COPD in a real-world setting. METHOD: The aim of the trial was to determine the effectiveness of a 12-month PA coaching intervention (Walk On!) compared to standard care for 2,707 patients at high risk for COPD exacerbations from a large integrated health care system. The descriptions of our implementation experiences are anchored within the pragmatic-explanatory continuum indicator summary (PRECIS-2) framework. DISCUSSION: Facilitators of PCT implementation include early and ongoing engagement and support of multiple stakeholders including patients, health system leaders, administrators, physician champions, and frontline clinicians, an organizational/setting that prioritizes positive lifestyle behaviors, and a flexible intervention that allows for individualization. Pragmatic challenges include reliance on electronic data that are not complete or available in real-time for patient identification, timing of outreach may not synchronize with patients' readiness for change, and high turnover of clinical staff drawn from the existing workforce. DISCUSSION: PRECIS-2 is a useful guide for organizing decisions about study designs and implementation approaches to help diverse stakeholders recognize the compromises between internal and external validity with those decisions.


Assuntos
Exercício/fisiologia , Tutoria/métodos , Ensaios Clínicos Pragmáticos como Assunto/métodos , Doença Pulmonar Obstrutiva Crônica/psicologia , Estudos de Casos e Controles , Humanos , Tutoria/normas , Seleção de Pacientes , Ensaios Clínicos Pragmáticos como Assunto/normas , Doença Pulmonar Obstrutiva Crônica/complicações
19.
Am J Respir Crit Care Med ; 198(2): e3-e13, 2018 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-30004250

RESUMO

BACKGROUND: Lung cancer screening (LCS) has the potential to reduce the risk of lung cancer death in healthy individuals, but the impact of coexisting chronic illnesses on LCS outcomes has not been well defined. Consideration of the complex relationship between baseline risk of lung cancer, treatment-related harms, and risk of death from competing causes is crucial in determining the balance of benefits and harms of LCS. OBJECTIVES: To summarize evidence, identify knowledge and research gaps, prioritize topics, and propose methods for future research on how best to incorporate comorbidities in making decisions regarding LCS. METHODS: A multidisciplinary group of international clinicians and researchers reviewed available data on the effects of comorbidities on LCS outcomes, focusing on the juxtaposition of lung cancer risk and competing risks of death, consideration of benefits and risks in patients with chronic obstructive pulmonary disease, communication of risk, and treatment of screen-detected lung cancer. RESULTS: This statement identifies gaps in knowledge regarding how comorbidities and competing causes of death impact outcomes in LCS, and we have developed questions to help guide future research efforts to better inform patient selection, education, and implementation of LCS. CONCLUSIONS: There is an urgent need for further research that can help guide clinical decision-making with patients who may not benefit from LCS owing to coexisting chronic illness. This statement establishes a research framework to address essential questions regarding how to incorporate and communicate risks of comorbidities into patient selection and decisions regarding LCS.


Assuntos
Doença Crônica , Comorbidade , Detecção Precoce de Câncer/normas , Neoplasias Pulmonares/diagnóstico , Programas de Rastreamento/normas , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sociedades Médicas
20.
Am J Manag Care ; 24(6): e196-e199, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29939510

RESUMO

OBJECTIVES: An epidemic of opioid overuse has resulted in nationwide efforts to decrease prescribing, but there is concern that implementing these recommendations will cause patients who are accustomed to opioids for chronic pain to be dissatisfied with care. STUDY DESIGN: Retrospective cohort study of satisfaction scores for patients prescribed opioids for noncancer chronic pain for at least 6 consecutive months from 2009 to 2014. METHODS: We used mixed effects regression to examine the association between opioid dose reduction and the frequency of unfavorable patient satisfaction scores. Subgroup analysis compared the effect of dose reduction on satisfaction scores for encounters between patients and their assigned primary care provider (PCP) versus encounters between patients and an unassigned provider. RESULTS: Included were 2492 encounters involving patients with high-dose chronic opioid use for noncancer pain. A reduction in opioid prescribing occurred in 29% of encounters, and most of these resulted in favorable satisfaction scores (86.4%). After adjustment, the odds of an unfavorable score in the dose reduction group were just marginally higher and not significant (odds ratio [OR], 1.31; 95% CI, 1.00-1.73). Stratified by different encounter types, opioid dose reduction was not associated with unfavorable scores for visits with an assigned PCP (OR, 1.16; 95% CI, 0.79-1.70), but the odds of an unfavorable score were higher for encounters with an unassigned provider (OR, 1.50; 95% CI, 1.01-2.23). CONCLUSIONS: Overall, reducing opioid use for chronic pain is not associated with lower patient satisfaction scores, but encounters with unassigned providers may be associated with slightly lower satisfaction when opioids are reduced.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Satisfação do Paciente , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , California , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
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