Sustentabilidad hospitalaria, calidad y seguridad del paciente en el Hospital Clínico Universidad de Chile / Hospital sustainability, quality and patient safety in Hospital Clínico Universidad de Chile

The sustainability of the Universidad de Chile Clinical Hospital must be understood comprehensively; providing higher quality and safety for our patients, ensuring highest standards of medical care. The quality of care must be understood not only in complying with the minimum standards to accredit and grant GES benefits, establish agreements with health insurers and be financially competitive; It must be incorporated into its management the dimensions of quality - effectiveness, efficiency, accessibility, safety, equity and patient-centered care- minimizing the costs of non-quality work. Our Clinical Hospital, as our country's main training center in healthcare professions, must include training at the undergraduate students' curriculum in quality and patient safety issues. (AU)

States' use of Medicaid to meet the needs of autistic individuals.

OBJECTIVE: To assess the use of Medicaid programs, including waivers, to address the needs of aging autistic individuals. DATA SOURCES: We gathered data on Medicaid programs in place between 2004 and 2015 for 50 states and the District of Columbia from the Centers for Medicare and Medicaid Services website, by contacting state Medicaid administrators and advocacy groups, and by reviewing the Medicaid Analytic eXtract Waiver Crosswalk. STUDY DESIGN: This retrospective analysis classified each Medicaid program and documented state changes over time in eligibility criteria: those serving autism spectrum disorder only, autism spectrum disorder or intellectual disability, and intellectual disability only. DATA COLLECTION/EXTRACTION METHODS: We captured age and diagnosis eligibility criteria for Medicaid programs serving any of the three target groups. PRINCIPAL FINDINGS: A total of 269 Medicaid programs met our criteria and most programs (51%) were 1915(c) waivers. The number of autism-specific 1915(c) waivers grew more than fivefold during the study period, outpacing increases in waivers serving individuals with intellectual disability. CONCLUSIONS: States varied in their use of Medicaid to address the needs of the aging autism population. Further study of characteristics of states that changed their Medicaid programs, and of the health care use and outcomes associated with these changes, are needed to identify opportunities to replicate effective approaches to meeting the needs of this population.

Twenty years of International Council of Ophthalmology fellowships: description of the programme and the impact on more than 1100 awardees.

BACKGROUND/AIMS: The International Council of Ophthalmology (ICO) offers fellowship programmes to help young ophthalmologists, mainly from low-resource countries, improve their practical or research skills in ophthalmology subspecialty areas. Using questionnaires, the objective of the present study was to evaluate how the ICO Fellowship Programme has impacted on improving knowledge, skills and the careers of young ophthalmologists from low-resource countries. METHODS: From 2001 to 2019 overall 1140 ICO fellowships were awarded. A questionnaire was sent to ICO fellows after the conclusion of their fellowship and another 3 years later. Part 1 contained 26 questions, while Part 2 had 21 questions. The answers were collected through an online platform and analysed descriptively thereafter. RESULTS: 1101 Part 1 questionnaires had been sent to former fellows, with a return rate of 47% (516 responses) and 829 Part 2 questionnaires with a return rate of 47% (390 responses). Overall, 98.3% strongly or somewhat agreed that knowledge in their subspecialty has improved considerably. Whereas only 19% of them held a lecturer, senior lecturer or head of subspecialty department position prior to the fellowship, 46% of them held such a position 3 years after the fellowship was completed. CONCLUSIONS: The ICO Fellowship Programmes aim to promote the enhancement of eye care delivery and eye health in low-resource countries, the professional development of young leaders and the improvement of eye care. The results of the current study confirm the expectation of such a positive impact. Moreover, almost half of the responding participants have been appointed to a local leadership position in their home country.

Interruption of the European Association of Cardiothoracic Anaesthesiology (EACTA) Fellowship Program During the Coronavirus Disease 2019 Pandemic: Consequences and Solutions.

This article discusses the impact of the COVID-19 pandemic on the EACTA fellowship program. The authors present three points that in their view are important and give cause for concern because they could make it difficult or impossible to achieve the original goals of the fellowship program. Corresponding points are discussed and possible solutions are presented. An implementation in the fellowship curriculum is planned.

Using patient-reported outcome measures for program evaluation: Design and findings on intention-to-treat outcomes from the Veterans Outcome Assessment survey.

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation.

The past, present and future impact of HIV prevention and control on HPV and cervical disease in Tanzania: A modelling study.

BACKGROUND: Women with HIV have an elevated risk of HPV infection, and eventually, cervical cancer. Tanzania has a high burden of both HIV and cervical cancer, with an HIV prevalence of 5.5% in women in 2018, and a cervical cancer incidence rate among the highest globally, at 59.1 per 100,000 per year, and an estimated 9,772 cervical cancers diagnosed in 2018. We aimed to quantify the impact that interventions intended to control HIV have had and will have on cervical cancer in Tanzania over a period from 1995 to 2070. METHODS: A deterministic transmission-dynamic compartment model of HIV and HPV infection and natural history was used to simulate the impact of voluntary medical male circumcision (VMMC), anti-retroviral therapy (ART), and targeted pre-exposure prophylaxis (PrEP) on cervical cancer incidence and mortality from 1995-2070. FINDINGS: We estimate that VMMC has prevented 2,843 cervical cancer cases and 1,039 cervical cancer deaths from 1995-2020; by 2070 we predict that VMMC will have lowered cervical cancer incidence and mortality rates by 28% (55.11 cases per 100,000 women in 2070 without VMMC, compared to 39.93 with VMMC only) and 26% (37.31 deaths per 100,000 women in 2070 without VMMC compared to 27.72 with VMMC), respectively. We predict that ART will temporarily increase cervical cancer diagnoses and deaths, due to the removal of HIV death as a competing risk, but will ultimately further lower cervical cancer incidence and mortality rates by 7% (to 37.31 cases per 100,000 women in 2070) and 5% (to 26.44 deaths per 100,000 women in 2070), respectively, relative to a scenario with VMMC but no ART. A combination of ART and targeted PrEP use is anticipated to lower cervical cancer incidence and mortality rates to 35.82 and 25.35 cases and deaths, respectively, per 100,000 women in 2070. CONCLUSIONS: HIV treatment and control measures in Tanzania will result in long-term reductions in cervical cancer incidence and mortality. Although, in the near term, the life-extending capability of ART will result in a temporary increase in cervical cancer rates, continued efforts towards HIV prevention will reduce cervical cancer incidence and mortality over the longer term. These findings are critical background to understanding the longer-term impact of achieving cervical cancer elimination targets in Tanzania.

Sustaining Programs: Lessons Learned from Former Federal Grantees.

INTRODUCTION: A common concern of federal funders and grant recipients is how to sustain program activities once their federal funding period ends. Federal funding can be intended to develop or seed a program but not necessarily to continue its activities indefinitely. Understanding the importance of programmatic sustainability, the Office of Population Affairs (OPA) conducted research in 2015 on the elements that contribute to sustainability. As part of the Sustainability Study, OPA collected information from former Pregnancy Assistance Fund (PAF) program grantees. METHODS: Grantees that were awarded cohort 1 PAF program funding (2010-2014) but not awarded cohort 2 funding (2014-2017) were eligible for study inclusion because their OPA funding ended more than 1 year prior to the Sustainability Study, allowing for an assessment of sustainability after federal funding. Seven former PAF grantees were identified as eligible. Interviews were conducted with six of these grantees; grant applications and interim final reports from all seven were reviewed. RESULTS: Five lessons emerged from interviews and review of grant documentation. Programs successfully continuing beyond the federal grant period tended to (1) diversify funding sources, (2) communicate regularly with key stakeholders, (3) form partnerships with like-minded programs, (4) consider implementing evidence-based interventions, and (5) begin planning for sustainability early. DISCUSSION: By considering these lessons learned from the research, grantees can be well positioned to continue beyond a federal grant period. The lessons garnered from the Sustainability Study have informed, expanded, and affirmed OPA's sustainability toolkit, sustainability framework, and technical assistance.

Establishing Psychological Safety to Obtain Feedback for Training Programs: A Novel Cross-Specialty Focus Group Exchange.

BACKGROUND: Formative feedback from residents is essential to improve residency programs, and focus groups may provide rich information. However, residents may withhold information due to fear of retaliation or speak less candidly to please focus group moderators. OBJECTIVE: We assessed participant perceptions and utility of feedback obtained from a confidential focus group exchange between 2 residency programs. METHODS: Anesthesiology and pediatric programs at the same institution participated in 2017. Residents voluntarily provided program feedback during 1 of 2 confidential focus groups for each program. Each focus group was moderated by the program director (PD) of the other specialty. The PDs used thematic analysis to identify themes for use by the respective programs in improvement efforts. An anonymous survey was distributed after the focus groups to collect participant perceptions (quantitative and narrative) on this approach. RESULTS: Thirteen residents of 140 (9.3%) participated (7 anesthesiology, 6 pediatrics). Thematic feedback from focus groups was largely consistent with known issues, although novel information was also obtained (eg, pediatric interns wanted earlier one-on-one meetings with their PD). Survey data suggest that residents were able to share more meaningful feedback than they would otherwise, and they did not feel that having an external moderator (a PD who may have been unfamiliar with the specialty) was a barrier to discussion. The approach required 6 hours of time for each PD and approximately $200 for dinners. CONCLUSIONS: The focus group exchange required modest resources, was perceived as safe by residents, and generated robust, actionable feedback for the programs.

Medicaid and CHIP Child Health Beneficiary Incentives: Program Landscape and Stakeholder Insights.

OBJECTIVES: To describe the landscape of Medicaid and the Children's Health Insurance Program beneficiary incentive programs for child health and garner key stakeholder insights on incentive program rationale, child and family engagement, and program evaluation. METHODS: We identified beneficiary health incentive programs from 2005 to 2018 through a search of peer-reviewed and publicly available documents and through semistructured interviews with 80 key stakeholders (Medicaid and managed-care leadership, program evaluators, patient advocates, etc). This study highlights insights from 23 of these stakeholders with expertise on programs targeting child health (<18 years old) to understand program rationale, beneficiary engagement, and program evaluation. RESULTS: We identified 82 child health-targeted beneficiary incentive programs in Medicaid and the Children's Health Insurance Program. Programs most commonly incentivized well-child checks (n = 77), preventive screenings (n = 30), and chronic disease management (n = 30). All programs included financial incentives (eg, gift cards, premium incentives); some also offered incentive material prizes (n = 12; eg, car seats). Loss-framed incentives were uncommon (n = 1; eg, lost benefits) and strongly discouraged by stakeholders. Stakeholders suggested family engagement strategies including multigenerational incentives or incentives addressing social determinants of health. Regarding evaluation, stakeholders suggested incentivizing evidence-based preventive services (eg, vaccinations) rather than well-child check attendance, and considering proximal measures of child well-being (eg, school functioning). CONCLUSIONS: As the landscape of beneficiary incentive programs for child health evolves, policy makers have unique opportunities to leverage intergenerational and social approaches for family engagement and to more effectively increase and evaluate programs' impact.

Cross-cultural Comparison of Pharmacy Students' Attitudes, Knowledge, Practice, and Barriers Regarding Evidence-based Medicine.

Objective. To explore cultural influences on US and Japanese pharmacy students' evidence-based medicine (EBM) attitudes, knowledge, and behavior. Methods. A cross-sectional study was conducted using a self-administered survey. Senior students in one pharmacy school in the United States and two pharmacy schools in Japan were invited to complete a 33-item survey instrument. Results. Students in both countries reported having positive attitudes and understanding of EBM concepts. In their self-evaluation, American students rated their current EBM practice, EBM skills, and access to EBM resources higher than Japanese students rated themselves in these areas. The most common barriers to EBM for American students were lack of time (84.5%), lack of statistical knowledge (63.9%), and lack of critical appraisal skills (53.1%). The most common barriers to EBM for Japanese students were lack of training (92.6%), lack of clinical knowledge (90.4%), and lack of opportunity (88.8%). Conclusion. Although barriers to implementing EBM and confidence levels in using EBM differed between US and Japanese pharmacy students, both cohorts recognized EBM as an important skillset for the pharmacy profession. Culturally specific approaches to teaching EBM to pharmacy students are needed to improve EBM use in practice.

The financing of stand-alone palliative Care Services in Uganda: analysis of the implications for sustainability.

BACKGROUND: Sustainable funding is key for ensuring the quality and coverage of palliative care services. This study examined the sources of funding for stand-alone palliative care services in Uganda as well as their services financial sustainability plans. METHODS: Researchers conducted a cross sectional survey of all stand-alone palliative care organizations that have operated for five or more years. Researchers administered a questionnaire survey and interviews on the audited financial statements, services provided and sustainability plans. RESULTS: Nine of the stand-alone palliative care organizations surveyed had operated for five to 25 years. 93% of the funding for palliative care services comes from donations; while 7% is from income generating activities. 94% of the donations are from external sources. The Government of Uganda's major contribution is in the form of medicines, training and payment of taxes. All the organizations had good financial records. Six of the fifteen Hospices/palliative care providers had sustainability plans included in their operational manuals. The older organizations (those that had been operational for more than 10 years) had better resource mobilization capacity and strategies. CONCLUSION: The majority of stand-alone palliative care organizations in Uganda are largely donor funded. They have considerable financial sustainability and fund-raising capacity. Government support is in the form of medicines and training. Based on this study findings, the capacity of the stand-alone palliative care services to raise funds should be increased. The Government of Uganda should include palliative care in the national health system and increase funding for these services.

Development and assessment of an academic performance enrichment program for low-performing, first-year pharmacy students.

Pharmacy school applications have steadily declined over the past several years. Thus pharmacy schools are not only searching for effective means to increase enrollment of qualified candidates, but are also focusing on the development of programs to improve academic performance and retention of enrolled students. To address the needs of struggling first-year pharmacy students enrolled in an Integrated Biological Sciences (BSI) course, an academic performance enrichment program (APEP) was developed. The program was designed to improve academic success by engaging low-performing students with the aims of improving their time management skills, study skills, metacognition, and understanding of BSI course material. The APEP consisted of structured tutoring sessions twice per week, which were required for all students with a course grade ≤73.5% at any point during the semester. To assess program effectiveness, performance improvement on BSI exams by the APEP students were compared with that of non-APEP students in the same class and to those in the previous 3 yr. Student perceptions of the program were also evaluated via an online survey. The APEP was deemed effective in that a greater percentage of students were able to improve their exam scores and to a greater extent by attending the APEP sessions compared with non-APEP students in the same class and with low-performing students in previous years when the APEP did not exist. Furthermore, APEP students believed the program was effective in meeting its aims. In conclusion, the APEP was effective in improving academic performance of low-performing students in BSI.

Implementation of a Stewardship Initiative on Respiratory Viral PCR-based Antibiotic Deescalation.

OBJECTIVE: Respiratory viral polymerase chain reaction (RV PCR) tests assist in rapidly identifying viral pathogens and differentiating viral versus bacterial causes of pneumonia. Studies evaluating the use of RV PCR tests on antibiotic use in adults have demonstrated mixed results. We implemented an antimicrobial stewardship (ASP) intervention for patients with a positive RV PCR test result who were receiving broad-spectrum antibiotics and aimed to assess the impact on antibiotic usage. METHODS: Retrospective quasi-experimental study of adult hospitalized patients comparing time to antibiotic deescalation, duration of antibiotic therapy, and antiviral use preintervention (January-March 2016) and postintervention (January-March 2017). RESULTS: Of 172 ASP alerts reviewed, 55 (32%) were considered actionable. Of these, 47% of interventions were accepted. No significant difference was observed in median time to antibiotic deescalation (pre: 2.7 days vs post: 2.3 days, p=0.88). Time to discontinuation of antimicrobial therapy pre- and postintervention was reduced from 4 to 1.9 days (p=0.057) for piperacillin-tazobactam, from 2.7 to 1.8 days (p=0.75) for ceftriaxone, and from 3.6 to 2 days (p=0.4) for levofloxacin, respectively. Time to initiation of oseltamivir for influenza was significantly shorter in the postintervention group (pre: 11.3 hrs vs post: 3.6 hrs, p=0.02). CONCLUSION: A third of patients receiving broad-spectrum antibiotics with a positive RV PCR had an opportunity for antimicrobial optimization, although this did not translate into a significant impact on the time to antibiotic deescalation or overall antibiotic use. Combination of RV PCR results with biomarkers to rule out bacterial coinfections and chest radiographic findings may help enhance the likelihood of accepted antibiotic deescalation recommendations and represents an area of future research.

Examination of Factors Relating to Student Performance on the Pharmacy Curriculum Outcomes Assessment.

Objective. To examine relationships between students' demographic and academic performance factors and their scores on the Pharmacy Curriculum Outcomes Assessment (PCOA). Methods. Students' PCOA scores and demographics (eg, age, race/ethnicity, sex), preadmission data [eg, cumulative and science grade point average (GPA), Pharmacy College Admissions Test (PCAT)], and academic performance variables (eg, pharmacy GPA, academic standing) were analyzed for one class of third-year pharmacy students (N=159). Independent t-tests and Analysis of Variance (ANOVA) were used to compare scores by demographic variables. Pearson's r correlations were used to assess relationships between PCOA scores and age, PCAT scores, and GPA. Stepwise linear regression was conducted to determine the predictive ability of variables with significant correlations to PCOA performance. Results. Significant correlations were found between sex and PCOA scores with males scoring higher than females. Significant correlations with PCOA scores were also found for PCAT scores, pre-pharmacy science GPA, and pharmacy didactic GPA. Significant differences were found by academic standing, where students in academic difficulty who were allowed to proceed without repeating curricular content scored significantly lower on the PCOA than those who did not experience academic difficulty. Conversely, there were no statistical differences between those who repeated courses and those who never experienced academic difficulty. PCOA performance predictors in the final regression model included PCAT composite score, pharmacy GPA and sex. Conclusion. New findings included differences in PCOA scores by sex and by academic standing, a variable not previously explored in published studies. Findings have implications for remediation decisions in pharmacy curricula.

Development of Guiding Principles for a New Era in Graduate Education.

Many external drivers may be influencing a paradigm shift in graduate education. Workforce dynamics are driving a re-examination of what is instructed in graduate programs as well as how curricula are delivered. Most graduate programs have made incremental changes in their philosophical approaches, but new and more dramatic paradigms may be needed to sufficiently address the future needs of employers and students alike.

A National Survey of Internal Medicine Primary Care Residency Program Directors.

BACKGROUND: The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE: We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN: Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES: Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS: Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS: IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.