Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 78
Filtrar
1.
Prim Care Diabetes ; 13(2): 170-175, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30545795

RESUMO

AIM: To describe quality management processes and appropriate interpretation with respect to HbA1c point-of-care (POC) testing in a national diabetes and cardiovascular risk screening programme. METHODS: We compared HbA1c results from capillary blood, measured by the cobas b 101 (Roche Diagnostics) POC testing system, with results from venous blood measured by accredited laboratory analysers to inform national screening practice and a (separately-reported) randomised controlled trial. Difference plots and regressions were used to aid interpretation around 40 and 50mmol/mol, the cut-offs used to identify "pre-diabetes" and diabetes in New Zealand. RESULTS: After initial acceptable tests, subsequent batches delivered POC results that varied from laboratory HbA1c by +6 to -14mmol/mol around the clinical cut-offs. Ten faulty batches of discs were recalled worldwide. POC testing was suspended in one region, as was the planned trial. The manufacturing defect was rectified, accuracy of the new batches was confirmed, and testing resumed. CONCLUSION: POC testing must be conducted within stringent quality assurance processes prior to and while in use. Within such a system, POC testing for HbA1c can be sufficiently accurate for screening and diagnosis of diabetes.


Assuntos
Serviços de Saúde Comunitária/normas , Diabetes Mellitus/diagnóstico , Hemoglobina A Glicada/análise , Programas de Rastreamento/normas , Sistemas Automatizados de Assistência Junto ao Leito/normas , Testes Imediatos/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Biomarcadores/sangue , Diabetes Mellitus/sangue , Humanos , Nova Zelândia , Variações Dependentes do Observador , Valor Preditivo dos Testes , Controle de Qualidade , Melhoria de Qualidade/normas , Reprodutibilidade dos Testes
2.
Clin Microbiol Rev ; 31(4)2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30158301

RESUMO

SUMMARYResearch in visceral leishmaniasis in the last decade has been focused on how better to use the existing medicines as monotherapy or in combination. Systematic research by geographical regions has shown that a universal treatment is far from today's reality. Substantial progress has been made in the elimination of kala-azar in South Asia, with a clear strategy on first- and second-line therapy options of single-dose liposomal amphotericin B and a combination of paromomycin and miltefosine, respectively, among other interventions. In Eastern Africa, sodium stibogluconate (SSG) and paromomycin in combination offer an advantage compared to the previous SSG monotherapy, although not exempted of limitations, as this therapy requires 17 days of painful double injections and bears the risk of SSG-related cardiotoxicity. In this region, attempts to improve the combination therapy have been unsuccessful. However, pharmacokinetic studies have led to a better understanding of underlying mechanisms, like the underexposure of children to miltefosine treatment, and an improved regimen using an allometric dosage. Given this global scenario of progress and pitfalls, we here review what steps need to be taken with existing medicines and highlight the urgent need for oral drugs. Furthermore, it should be noted that six candidates belonging to five new chemical classes are reaching phase I, ensuring an optimistic near future.

3.
N Z Med J ; 131(1478): 21-31, 2018 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-30001303

RESUMO

AIM: To examine trends in ischaemic heart disease (IHD) events by ethnicity. METHODS: All IHD deaths and hospitalisations from 2006-2015 were identified using individual-linkage of national hospitalisation and mortality data. Age-standardised IHD rates and average annual age-adjusted percent changes were estimated by ethnic group. Ratios of non-fatal to fatal events were calculated by dividing age-standardised hospitalisation by death rates. RESULTS: IHD mortality rates declined by 3.1-5.4% per year for most groups, except Pacific women, who experienced a non-significant decline of 1.3% per year. IHD hospitalisation rates declined significantly by 3.6-8.8% per year in all groups. IHD mortality rates were highest in Maori and Pacific people, but hospitalisation rates highest in Indians. Indians also had the highest ratio of hospitalisations to deaths. For every person who died from IHD in 2014/15, 7-8 Indians, but only 3-4 Maori or Pacific people, were hospitalised with IHD. CONCLUSION: Fatal and non-fatal IHD rates are declining in all groups, but Maori and Pacific people have disproportionately high rates of IHD mortality. The much lower ratio of IHD hospitalisations to deaths among Maori and Pacific people compared to others suggests there are still important barriers to preventive interventions and acute care for Maori and Pacific men and women.

4.
J Virol Methods ; 259: 60-65, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29874550

RESUMO

Real-time PCR assays for nucleic acid testing (NAT) of hepatitis viruses A-E and for HIV-1 and HIV-2 have been developed; however, a multiplex assay that can simultaneously detect all of these agents is not yet available. Standardized TaqMan assays for detection of hepatitis viruses A-E have been described and applied to TaqMan Array Cards (TAC) which are capable of multiple pathogen detection using a single set of optimized PCR conditions. Assays for three gene regions of HIV-1 (long-terminal repeat (LTR), gag, and polymerase) and HIV-2 (overlap of LTR and gag, protease and integrase) were designed using the hepatitis assay conditions. Nucleic acid extracts of HIV-1-infected samples (44 plasma, 41 whole blood, 20 HIV-1 viral stocks) were tested on the TAC cards; 98 were reactive (92%) with 70 in multiple gene regions. Twenty-four of the 27 (89%) HIV-2 specimens (10 plasma, 1 PBMC lysate, 6 whole blood and 10 plasmids containing HIV-2 polymerase) were detected on TAC. No HIV or hepatitis virus sequences were detected in 30 HIV-negative samples (specificity 100%). Three HBV and 18 HCV co-infections were identified in the HIV-1-infected specimens. Multi-pathogen detection using TAC could provide a rapid, sensitive and more efficient method of surveying for a variety of infectious disease nucleic acids.


Assuntos
Infecções por HIV/diagnóstico , HIV-1/isolamento & purificação , HIV-2/isolamento & purificação , Vírus de Hepatite/isolamento & purificação , Hepatite Viral Humana/diagnóstico , Análise em Microsséries/métodos , Reação em Cadeia da Polimerase em Tempo Real/métodos , Infecções por HIV/virologia , HIV-1/genética , HIV-2/genética , Vírus de Hepatite/genética , Hepatite Viral Humana/virologia , Sensibilidade e Especificidade , Fatores de Tempo
5.
Injury ; 49(9): 1680-1686, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29853326

RESUMO

A national health target for length of stay in emergency departments (ED) was introduced in 2009 to reduce crowding and improve quality of care. We aimed to determine whether the target was associated with changes in time to CT and appropriateness of CT imaging, as markers of care quality for suspected acute traumatic brain injury (TBI). We undertook a retrospective review of the case records of a random sample of people aged ≥15 years presenting to the ED with TBI from 2006 to 2013. General linear models were used to investigate changes in outcomes along with routine process times before and after the introduction of the target. Among 501 eligible cases the median (IQR) time to CT was 136 (76-247) pre target versus 119 (59-209) minutes post target, p = 0.014. The proportion of appropriate imaging was similar between periods: 77.9% (95% CI 71-83%) versus 76.6% (95%CI 72-81%), p = 0.825. Interactions suggested that the time to CT and appropriateness of imaging before and after the introduction of the target varied by ethnicity, although the changes were not clinically important. Time to assessment and length of stay did not change importantly. We found no evidence of a clinically important change in time to CT or appropriateness of imaging for suspected TBI in association with the introduction of the SSED time target. Additional research with larger cohorts of Maori and Pacific participants is recommended to understand our observed patterns by ethnicity.

6.
Emerg Med Australas ; 30(2): 214-221, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28941074

RESUMO

OBJECTIVE: Despite extensive literature, how crowding in EDs should be measured is still debated. The present study aimed to describe crowding metrics used in Australasia, what they were used for, the perceived extent and frequency of crowding and the challenges faced when trying to measure crowding. METHODS: A survey of ED clinical directors was undertaken between December 2014 and July 2015. Free-text responses were categorised and thematically coded. Quantitative data were analysed descriptively and with logistic regression. RESULTS: There were 113 of 145 responses (78%). Crowding was considered a major problem by 84 of 113 (74%) and not rare by 88 of 111 participants (79%). These constructs were correlated; G = -0.851, P < 0.001. Levels 1-3 EDs were less likely to report crowding as a major problem than Level 4 EDs; odds ratio 0.15 (0.03-0.69), P = 0.02. Sixteen current metrics were identified and categorised into 'time', 'occupancy' and 'workload' metrics. These categories of metric were used differently, and multiple metrics had more uses than single metrics. Previously described complex crowding metrics were infrequently recognised (<20%). Common challenges to measuring crowding were lack of an agreed metric (40%) and lack of buy-in by inpatient teams or hospital management (35%). CONCLUSION: ED crowding remains a common and important problem in Australasia. Crowding is multifaceted, so a single metric might not capture all important elements of crowding or be relevant to all stakeholders. However, a metric like Access Block, which encompasses elements of time, occupancy and workload and is relevant to stakeholders outside the ED, might hold the most promise.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Carga de Trabalho/normas , Australásia , Serviço Hospitalar de Emergência/organização & administração , Prática Clínica Baseada em Evidências/métodos , Prática Clínica Baseada em Evidências/normas , Humanos , Modelos Logísticos , Razão de Chances , Estudos Prospectivos , Inquéritos e Questionários , Carga de Trabalho/psicologia
7.
Heart ; 104(1): 51-57, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28663363

RESUMO

OBJECTIVES: To examine recent trends in first and recurrent ischaemic heart disease (IHD) deaths and hospitalisations. METHODS: Using anonymous patient-linkage of routinely collected data, all New Zealanders aged 35-84 years who experienced an International Statistical Classification of Diseases and Related Health Problems I(CD)-coded IHD hospitalisation and/or IHD death between 1 January 2005 and 31 December 2015 were identified. A 10-year look-back period was used to differentiate those experiencing first from recurrent events. Age-standardised hospitalisation and mortality rates were calculated for each calendar year and trends compared by sex and age. RESULTS: 160 109 people experienced at least one IHD event (259 678 hospitalisations and 35 548 deaths) over the 11-year study period, and there was a steady decline in numbers (from almost 24 000 in 2005 to just over 16 000 in 2015) and in age-standardised rates each year. With the exception of deaths in younger (35-64 years) women with prior IHD, there was a significant decline in IHD events in men and women of all ages, with and without a history of IHD. The decline in IHD mortality was greater for those experiencing a first rather than recurrent IHD event (3.8%-5.2% vs 0%-3.7% annually on average). In contrast, the decline in IHD hospitalisations was greater for those experiencing a recurrent compared with a first IHD event (5.6%-7.3% vs 3.2%-5.7% annually on average). CONCLUSIONS: The substantial decline in IHD hospitalisations and mortality observed in New Zealanders with and without prior IHD between 2005 and 2015 suggests that primary and secondary prevention efforts have been effective in reducing the occurrence of IHD events.


Assuntos
Previsões , Isquemia Miocárdica/epidemiologia , Sistema de Registros , Medição de Risco , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Nova Zelândia , Prognóstico , Recidiva , Estudos Retrospectivos , Distribuição por Sexo , Fatores Sexuais
8.
BMJ Qual Saf ; 27(3): 226-240, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29055899

RESUMO

BACKGROUND: Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness. METHOD: We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards. RESULTS: Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study's primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline. CONCLUSIONS: QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

9.
N Z Med J ; 130(1466): 45-52, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-29197900

RESUMO

AIM: To describe how we incorporate experiential quality improvement (QI) learning at the University of Auckland by integrating a clinical audit project into the Year 6 obstetrics and gynaecology clinical attachment. METHODS: Students gain insight into the relevance of QI while engaged in day-to-day clinical work. Students work with a clinical supervisor to identify an area for potential improvement, set a standard of care, measure current practice, investigate reasons for deviation from the standard and make real-world suggestions to close the gap between best evidence and observed practice. RESULTS: Since 2004, over 1,250 projects have been completed, and two journal articles published. Many of the student projects result in actual improvements to clinical processes of care, and lead to strengthening of academic and service provider learning networks and partnerships. CONCLUSIONS: Performing a hands-on project within the constraints and context of a busy women's health service is a feasible and effective method of teaching QI. Medical schools have an integral role to play in ensuring future healthcare professionals are equipped with QI knowledge, skills and attitudes. Experiential QI learning enhances clinical teaching and training, and is important in preparing future clinicians to incorporate QI into their daily practice.


Assuntos
Currículo , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Estudantes de Medicina , Educação Médica , Humanos , Nova Zelândia , Faculdades de Medicina , Serviços de Saúde da Mulher
10.
N Z Med J ; 130(1463): 28-38, 2017 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-28981492

RESUMO

AIM: Cardiovascular disease (CVD) risk assessment is commonly recommended in guidelines, but there is uncertainty about how clinicians use this information. Our objective was to understand how New Zealand primary care clinicians use CVD risk assessment estimates to inform new statin prescribing. METHODS: We used a cohort of patients seen in primary care who have had a CVD risk estimated on the basis of a New Zealand modified Framingham risk equation. These patients were linked to national pharmaceutical dispensing records to determine new statin use in the following six months. Regression discontinuity and logistic regression analysis, and graphical approaches, were used to explore associations between estimated CVD risk and primary clinicians' decisions to initiate statin treatment. RESULTS: There were 76,571 patients aged 35 to 75 who were not on a statin, had a first recorded CVD risk assessment between July 2007 and June 2011, and for whom national guidelines recommended management on the basis of estimated CVD risk. Statin dispensing increased with increasing CVD risk. There was no evidence of sudden jumps in the proportions of patients dispensed statins at guideline recommended treatment threshold values of 15% and 20% CVD risk (P=0.314 and 0.731). A logistic regression model using the CVD risk score predicted statin initiation better than models using lipid measures (Area Under the Curve 0.725 versus 0.682). However, further modelling and graphical analysis suggested clinicians were using a range of other information to inform the initiation of statins. CONCLUSION: New Zealand primary care clinicians' statin prescribing decisions appear to be influenced by patients' predicted CVD risk. However, other factors are associated with increased statin dispensing independent of CVD risk score.


Assuntos
Doenças Cardiovasculares , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Conduta do Tratamento Medicamentoso/organização & administração , Adulto , Idoso , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Tomada de Decisão Clínica/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Medição de Risco/métodos , Fatores de Risco
11.
N Z Med J ; 130(1464): 13-24, 2017 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-29073653

RESUMO

AIM: To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. METHODS: All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. RESULTS: Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. CONCLUSIONS: Although the building blocks for improving the quality and safety of healthcare are present, this national study of multiple health professional pre-registration education programmes has identified teaching gaps in patient safety and improvement science methods and tools. Failure to address these gaps will compromise the ability of new graduates to successfully implement and sustain improvements.


Assuntos
Currículo , Pessoal de Saúde/educação , Segurança do Paciente/normas , Melhoria de Qualidade , Comunicação , Prática Clínica Baseada em Evidências/normas , Humanos , Liderança , Informática Médica , Nova Zelândia , Cultura Organizacional , Equipe de Assistência ao Paciente/normas , Assistência Centrada no Paciente/normas , Pesquisa Qualitativa , Análise de Sistemas
12.
BMC Med Educ ; 17(1): 91, 2017 May 26.
Artigo em Inglês | MEDLINE | ID: mdl-28549464

RESUMO

BACKGROUND: Teaching clinical audit skills to nascent health professionals is one strategy to improve frontline care. The undergraduate medical curriculum at the University of Auckland provides improvement science theory and skills in Year 5 teaching, and the opportunity to put this into practice during an Obstetrics and Gynaecology (O&G) clinical attachment in Year 6. In 2015, a revised medical school curriculum at the university resulted in a planned reduction of the O&G attachment from five weeks to four, necessitating revision of the Year 6 Quality Improvement (QI) project. The aim of this study was to evaluate if the revised programme provided an important experiential learning opportunity for medical students without imposing an unsustainable burden on clinical services. METHODS: Based on a CIPP (Context/Input/Process/Product) evaluation model, the study was conducted in several stages to get a sense of the context as the new programme was being planned (Context evaluation), the feasibility of an alternative approach to meet the educational need (Input evaluation), the implementation of the revised programme (Process evaluation) and finally, the programme outcomes (Product evaluation). We used multiple data sources (supervisors, students, academic administrators, and hospital staff) and data collection methods (questionnaires, focus groups, individual interviews, consultative workshops, student reports and oral presentations). RESULTS: The context evaluation revealed the Year 6 QI programme to be valuable and contributed to O&G service improvements, however, the following concerns were identified: time to complete the project, timely topic selection and access to data, recognition of student achievement, and staff workload. The evaluation of the revised QI project indicated improvement in student perceptions of their QI knowledge and skills, and most areas previously identified as challenging, despite the concurrent reduction in the duration of the O&G attachment. CONCLUSIONS: Applying the CIPP model for evaluation to our revised QI programme enabled streamlining of procedures to achieve greater efficiency without compromising the quality of the learning experience, or increasing pressure on staff. A four week clinical rotation is adequate for medical educators to consider opportunities for including QI projects as part of student experiential learning.


Assuntos
Educação Médica/normas , Ginecologia/educação , Obstetrícia/educação , Melhoria de Qualidade , Estudantes de Medicina , Estudos Transversais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Inquéritos e Questionários
13.
N Z Med J ; 130(1455): 15-34, 2017 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-28494475

RESUMO

AIM: The impact of national targets for emergency department (ED) length of stay (LOS) on patient care is unclear. This study aimed to determine the effect of New Zealand's six-hour time target (95% of ED patients discharged or admitted to hospital within six hours) on a range of quality indicators. METHODS: A nationwide observational study from 2006 to 2012 modelled differences in changes over time before and after target introduction in 2009. The observed model estimates in 2012 were compared to those predicted if pre-target trends had continued. Differences are absolute values except for morality, which is presented as a relative change. RESULTS: There were 5,793,767 ED presentations and 2,082,374 elective admissions from 18 out of a possible 20 district health boards included in the study. There were clinically important reductions in hospital LOS (-0.29 days), EDLOS (-1.1 hours), admitted patients EDLOS (-2.9 hours), ED crowding (-26.8%), ED mortality (-57.8%), elective inpatient mortality (-42.2%) and the proportion not waiting for assessment (-2.8%). Small changes were seen in time to assessment in the ED (-3.4 minutes), re-presentation to ED within 48 hours of the index ED discharge (-0.7%), re-presentation to ED within 48 hours from ward discharge (+0.4%) and acute admissions (+3.9%). An increase was observed in re-admission to a ward within 30 days of discharge (1.0%). These changes were all statistically significant (p<0.001). CONCLUSION: Most outcomes we investigated either improved or were unchanged after the introduction of the time target policy in New Zealand. However, attention is required to ensure that reductions in hospital length of stay are not at the expense of subsequent re-admissions.


Assuntos
Serviço Hospitalar de Emergência/normas , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Avaliação de Resultados (Cuidados de Saúde) , Fatores de Tempo , Adulto Jovem
14.
N Z Med J ; 130(1455): 35-44, 2017 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-28494476

RESUMO

AIM: To determine whether implementation of a national health target called Shorter Stays in Emergency Departments impacted on clinical markers of quality of care. METHOD: A retrospective pre- and post-intervention study from 2006 to 2012 examined quality of care metrics for five different indicators at different sites in relation to the implementation of the target using a general linear model for times to treatment. Explanatory variables included period (pre- or post-target), ethnicity, age, deprivation and severity of condition. Back transformed least square means were used to describe the outcomes. RESULTS: The times to treatment for ST elevation myocardial infarction; 36.9 (28-49) vs 47.6 (36-63) minutes p=0.14, antibiotics for severe sepsis; 105.9 (73-153) vs 104.3 (70-155) minutes p=0.93, analgesia for moderate or severe pain; 48 (31-75) vs 46 (32-66) minutes p =0.77, theatre for fractured neck of femur; 35.4 (32.1-39.1) vs 32.4 (29.2-36.1) hours, and to theatre for appendicitis; 14.1 (12-17) vs 16.4 (14-20) hours were unchanged after implementation of the target. Treatment adequacy was also unchanged for these indicators. CONCLUSION: Introduction of the Shorter Stays in Emergency Departments target was not associated with any clinically important or statistically significant changes in the time to treatment and adequacy of care for five different clinical indicators of quality of care in Aotearoa New Zealand. For those indicators measured at one site only, it is unknown whether these results can be generalised to other sites.


Assuntos
Serviço Hospitalar de Emergência/normas , Tempo de Internação/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/normas , Tempo para o Tratamento/estatística & dados numéricos , Política de Saúde , Hospitais , Humanos , Nova Zelândia , Estudos Retrospectivos
15.
PLoS One ; 12(4): e0173170, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28384217

RESUMO

BACKGROUND: Many national cardiovascular disease (CVD) risk factor management guidelines now recommend that drug treatment decisions should be informed primarily by patients' multi-variable predicted risk of CVD, rather than on the basis of single risk factor thresholds. To investigate the potential impact of treatment guidelines based on CVD risk thresholds at a national level requires individual level data representing the multi-variable CVD risk factor profiles for a country's total adult population. As these data are seldom, if ever, available, we aimed to create a synthetic population, representing the joint CVD risk factor distributions of the adult New Zealand population. METHODS AND RESULTS: A synthetic population of 2,451,278 individuals, representing the actual age, gender, ethnicity and social deprivation composition of people aged 30-84 years who completed the 2013 New Zealand census was generated using Monte Carlo sampling. Each 'synthetic' person was then probabilistically assigned values of the remaining cardiovascular disease (CVD) risk factors required for predicting their CVD risk, based on data from the national census national hospitalisation and drug dispensing databases and a large regional cohort study, using Monte Carlo sampling and multiple imputation. Where possible, the synthetic population CVD risk distributions for each non-demographic risk factor were validated against independent New Zealand data sources. CONCLUSIONS: We were able to develop a synthetic national population with realistic multi-variable CVD risk characteristics. The construction of this population is the first step in the development of a micro-simulation model intended to investigate the likely impact of a range of national CVD risk management strategies that will inform CVD risk management guideline updates in New Zealand and elsewhere.


Assuntos
Doenças Cardiovasculares/terapia , Gestão de Riscos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fumar/epidemiologia
16.
J Paediatr Child Health ; 53(7): 685-690, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28407334

RESUMO

AIM: Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI. METHODS: We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009. RESULTS: Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006). CONCLUSION: Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Serviço Hospitalar de Emergência , Tempo de Internação , Tomografia Computadorizada por Raios X , Criança , Pré-Escolar , Aglomeração , Feminino , Política de Saúde , Hospitais Pediátricos , Humanos , Masculino , Auditoria Médica , Nova Zelândia , Estudos Retrospectivos
17.
BMC Health Serv Res ; 17(1): 8, 2017 01 05.
Artigo em Inglês | MEDLINE | ID: mdl-28056967

RESUMO

BACKGROUND: Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery. METHODS: MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients. RESULTS: Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group. CONCLUSIONS: Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.


Assuntos
Competência Cultural , Transtornos Mentais/terapia , Serviços de Saúde Mental/organização & administração , Afro-Americanos/etnologia , Grupos de Populações Continentais/etnologia , Aconselhamento , Cultura , Grupos Étnicos/psicologia , Humanos , Transtornos Mentais/etnologia , Transtornos Mentais/psicologia , Satisfação do Paciente/etnologia
18.
PLoS Negl Trop Dis ; 10(9): e0004880, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27627654

RESUMO

BACKGROUND: SSG&PM over 17 days is recommended as first line treatment for visceral leishmaniasis in eastern Africa, but is painful and requires hospitalization. Combination regimens including AmBisome and miltefosine are safe and effective in India, but there are no published data from trials of combination therapies including these drugs from Africa. METHODS: A phase II open-label, non-comparative randomized trial was conducted in Sudan and Kenya to evaluate the efficacy and safety of three treatment regimens: 10 mg/kg single dose AmBisome plus 10 days of SSG (20 mg/kg/day), 10 mg/kg single dose AmBisome plus 10 days of miltefosine (2.5mg/kg/day) and miltefosine alone (2.5 mg/kg/day for 28 days). The primary endpoint was initial parasitological cure at Day 28, and secondary endpoints included definitive cure at Day 210, and pharmacokinetic (miltefosine) and pharmacodynamic assessments. RESULTS: In sequential analyses with 49-51 patients per arm, initial cure was 85% (95% CI: 73-92) in all arms. At D210, definitive cure was 87% (95% CI: 77-97) for AmBisome + SSG, 77% (95% CI 64-90) for AmBisome + miltefosine and 72% (95% CI 60-85) for miltefosine alone, with lower efficacy in younger patients, who weigh less. Miltefosine pharmacokinetic data indicated under-exposure in children compared to adults. CONCLUSION: No major safety concerns were identified, but point estimates of definitive cure were less than 90% for each regimen so none will be evaluated in Phase III trials in their current form. Allometric dosing of miltefosine in children needs to be evaluated. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov, number NCT01067443.


Assuntos
Anfotericina B/administração & dosagem , Gluconato de Antimônio e Sódio/administração & dosagem , Antiprotozoários/administração & dosagem , Leishmaniose Visceral/tratamento farmacológico , Fosforilcolina/análogos & derivados , Adolescente , Adulto , Anfotericina B/efeitos adversos , Gluconato de Antimônio e Sódio/efeitos adversos , Antiprotozoários/farmacocinética , Criança , Quimioterapia Combinada , Feminino , Humanos , Quênia , Leishmania donovani , Masculino , Pessoa de Meia-Idade , Carga Parasitária , Fosforilcolina/administração & dosagem , Fosforilcolina/efeitos adversos , Fosforilcolina/farmacocinética , Sudão , Resultado do Tratamento , Adulto Jovem
19.
J Prim Health Care ; 8(2): 172-8, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27477560

RESUMO

INTRODUCTION Run charts are quality improvement tools. AIM To investigate the feasibility and acceptability of run charts displaying weekly cardiovascular disease (CVD) risk assessments in general practice and assess their impact on CVD risk assessments. METHODS A controlled non-randomised observational study in nine practices using run charts and nine control practices. We measured the weekly proportion of eligible patients with completed CVD risk assessments for 19 weeks before and after run charts were introduced into intervention practices. A random coefficients model determined changes in CVD risk assessment rates (slope) from pre- to post- intervention by aggregating and comparing intervention and control practices' mean slopes. We interviewed staff in intervention practices about their use of run charts. RESULTS Seven intervention practices used their run chart; six consistently plotting weekly data for >12 weeks and positioning charts in a highly visible place. Staff reported that charts were easy to use, a visual reminder for ongoing team efforts, and useful for measuring progress. There were no significant differences between study groups: the mean difference in pre- to post-run chart slope in the intervention group was 0.03% more CVD risk assessments per week; for the control group the mean difference was 0.07%. The between group difference was 0.04% per week (95% CI: -0.26 to 0.35, P = 0.77). DISCUSSION Run charts are feasible in everyday general practice and support team processes. There were no differences in CVD risk assessment between the two groups, likely due to national targets driving performance at the time of the study.


Assuntos
Recursos Audiovisuais , Doenças Cardiovasculares/diagnóstico , Medicina Geral/organização & administração , Medição de Risco/métodos , Humanos
20.
Trans R Soc Trop Med Hyg ; 110(6): 321-3, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27268714

RESUMO

Visceral leishmaniasis is a neglected tropical disease endemic in East Africa where improved patient-adapted treatments are needed. The Leishmaniasis East Africa Platform (LEAP) was created in 2003 to strengthen clinical research capacity, serve as a base for training, and evaluate and facilitate implementation of new treatments. Major infrastructure upgrades and personnel training have been carried out. A short course of Sodium Stibogluconate and Paramomycin (SSG&PM) was evaluated and is now first-line treatment in the region; alternative treatments have also been assessed. LEAP can serve as a successful model of collaboration between different partners and countries when conducting clinical research in endemic countries to international standards.


Assuntos
Gluconato de Antimônio e Sódio/uso terapêutico , Antiprotozoários/uso terapêutico , Pesquisa Biomédica , Fortalecimento Institucional , Comportamento Cooperativo , Leishmaniose Visceral/terapia , Paromomicina/uso terapêutico , África Oriental , Pesquisa Biomédica/educação , Doenças Endêmicas , Humanos , Doenças Negligenciadas
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA