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1.
Harv Rev Psychiatry ; 27(6): 342-353, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31714465

RESUMO

BACKGROUND: As an alternative to co-located integrated care, off-site integration (partnerships between primary care and non-embedded specialty mental health providers) can address the growing need for pediatric mental health services. Our goal is to review the existing literature on implementing off-site pediatric integrated care. METHODS: We systematically searched the literature for peer-reviewed publications on off-site pediatric integrated care interventions. We included studies that involved systematic data collection and analysis, both qualitative and quantitative, of implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability). RESULTS: We found 39 original articles from 24 off-site programs with a variety of study designs, most with secondary implementation outcomes. Models of off-site integration varied primarily along two dimensions: direct vs. indirect, and in-person vs. remote. Overall, off-site models were acceptable to providers, particularly when the following were present: strong interdisciplinary communication, timely availability and reliability of services, additional support beyond one-time consultation, and standardized care algorithms. Adoption and penetration were facilitated by enhanced program visibility, including on-site champions. Certain clinical populations (e.g., school-age, less complicated ADHD) seemed more amenable to off-site integrated models than others (e.g., preschool-age, conduct disorders). Lack of funding and inadequate reimbursement limited sustainability in all models. CONCLUSIONS: Off-site interventions are feasible, acceptable, and often adopted widely with adequate planning, administrative support, and interprofessional communication. Studies that focus primarily on implementation and that consider the perspectives of specialty providers and patients are needed.


Assuntos
Serviços de Saúde da Criança/normas , Bem-Estar da Criança , Serviços de Saúde Mental/normas , Criança , Centros Comunitários de Saúde/normas , Acesso aos Serviços de Saúde/normas , Humanos , Pediatria/normas , Encaminhamento e Consulta/normas
2.
Rev Bras Enferm ; 72(5): 1258-1264, 2019 Sep 16.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31531649

RESUMO

OBJECTIVE: To analyze the length of stay of the professionals who work in the Tuberculosis Control Program in Basic Health Units of the city of Rio de Janeiro/RJ. METHOD: Sectional study, developed in eight Health Units of the Maré Complex/RJ. Physicians, nurses, nursing technicians and Community Health Agents of the Family Health Teams were interviewed. The Kruskal-Wallis test was used to verify the existence of groups with the same distribution, and Dunn's multiple comparison test with Bonferroni correction, to identify which group presented a difference. RESULTS: Among Health Units, a significant difference was observed in the length of work (p-value = 0.0005909) and in the dwell time (p-value = 0.0003598). CONCLUSION: It was observed low length of stay of the professionals that work in the Basic Health Units. This result points to challenges inherent in the control of tuberculosis at the local level.


Assuntos
Pessoal de Saúde/psicologia , Reorganização de Recursos Humanos/estatística & dados numéricos , Tuberculose/enfermagem , Brasil , Centros Comunitários de Saúde/organização & administração , Centros Comunitários de Saúde/normas , Pessoal de Saúde/estatística & dados numéricos , Humanos , Satisfação no Emprego
3.
Sex Reprod Healthc ; 19: 78-83, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30928139

RESUMO

OBJECTIVE: To investigate the quality of intrapartum care provided at Rwandan healthcare facilities to women undergoing normal pregnancy and spontaneous full-term labour. METHODS: A cross-sectional study was conducted over eight weeks during 2014-2015 in 18 healthcare facilities in Kigali City and the Northern Province: eight health centres, seven district hospitals, one provincial hospital, one private hospital, and one referral hospital. Data were collected from medical records and a questionnaire including the Bologna score with its five variables: presence of a companion, use of partograph, no augmentation of labour, birth in a non-supine position, and skin-to skin contact. RESULTS: Among the 435 women who fulfilled the inclusion criteria during the study period, mean age was 27.4 years and 41.8% were primiparous. The assisting healthcare professionals were midwives (49.4%), nurses (28.8%), and physicians (22%), and birth occurred at health centres (29%), district hospitals (40%), and the referral hospital (31%). Mean Bologna score was 2.03 of the maximum 5 (range: 0-4). Only one woman (0.2%) had a companion present (her husband). A partograph was used for the majority (84.8%), and 88.0% had no augmentation of labour with oxytocin. Few (6.2%) gave birth in a non-supine position, and few (12.4%) had early skin-to-skin contact with their newborn. CONCLUSION: There are several areas for improving childbirth care according to the Bologna score. Healthy newborns should be placed skin-to-skin with their mothers shortly after birth, non-supine birthing positions should be encouraged, and the importance of a companion during labour and birth should be considered.


Assuntos
Parto Obstétrico/normas , Instalações de Saúde/normas , Assistência Perinatal/normas , Nascimento a Termo , Adulto , Entorno do Parto , Centros Comunitários de Saúde/normas , Estudos Transversais , Parto Obstétrico/métodos , Feminino , Hospitais de Distrito/normas , Hospitais Privados/normas , Humanos , Início do Trabalho de Parto , Relações Mãe-Filho , Posicionamento do Paciente , Gravidez , Ruanda , Adulto Jovem
4.
J Gen Intern Med ; 34(1): 150-153, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30291603

RESUMO

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.


Assuntos
Centros Comunitários de Saúde/normas , Acesso aos Serviços de Saúde/normas , Hospitais de Veteranos/normas , Serviços Terceirizados/normas , United States Department of Veterans Affairs/organização & administração , Saúde dos Veteranos , Veteranos/estatística & dados numéricos , Humanos , Estados Unidos
6.
Afr J Prim Health Care Fam Med ; 10(1): e1-e11, 2018 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-30198287

RESUMO

BACKGROUND:  Research consistently demonstrates the importance of effective team work for improving the quality of health care. We conducted a baseline measure of primary health care (PHC) team effectiveness and overall PHC performance at a primary care facility. AIM:  To improve PHC team effectiveness and ultimately the quality and user experience of primary care at a community health centre (CHC). SETTING:  Du Noon CHC in the southern and western substructure of the Cape Town Metro district services (MDHS). METHODS:  A cross-sectional study using a combination of the Nominal Group Technique (NGT) consensus method and the South African Primary Care Assessment Tool (ZA PCAT) to assess PHC team effectiveness and PHC organisation and performance. RESULTS:  The ZA PCAT was administered to 110 CHC users (patients) and 12 providers (doctors and clinical nurse practitioners). Data from 20 PHC team members showed they perceived their team as well functioning (70% agreement on a 7-item PHC team assessment tool incorporated into the ZA PCAT). The NGT method achieved participant (20) consensus on communication and leadership as the main challenges to effective team functioning and on ideas to overcome the challenges. The ZA PCAT user data showed 18.2% of users rated first contact access as acceptable to good; 47.3% of users rated ongoing care as acceptable to good. Provider data showed that 33% of providers rated first contact access as acceptable to good; 25% of providers rated ongoing care as acceptable to good. First contact access received the lowest acceptable to good score (18.2%) and comprehensiveness (services available) the highest score (88.2%) from users. For the providers, the lowest acceptable to good score was for ongoing care (25%) and the highest acceptable to good score was for primary health care team availability (100%). The ZA PCAT total primary scores were good (above 60%) for both users and providers but moderately higher for the providers. CONCLUSION:  Knowledge of how teams perceive their effectiveness can motivate them to generate ideas for improving performance. There were discrepancies between providers' assessment of team functioning using the ZA PCAT measure and the NGT method results. The ZA PCAT also showed differences between providers' and users' perceptions of PHC performance - consistent with the findings of the multi-CHC Western Cape ZA PCAT study. These findings should encourage and support CHC and district level staff in their efforts to improve the quality and user experience of primary care, as well as PHC team performance.


Assuntos
Centros Comunitários de Saúde/normas , Equipe de Assistência ao Paciente/normas , Atenção Primária à Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Adolescente , Adulto , Centros Comunitários de Saúde/organização & administração , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Profissionais de Enfermagem/organização & administração , Profissionais de Enfermagem/normas , Equipe de Assistência ao Paciente/organização & administração , Médicos de Atenção Primária/organização & administração , Médicos de Atenção Primária/normas , Atenção Primária à Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/normas , África do Sul , Adulto Jovem
7.
S Afr Med J ; 108(9): 748-755, 2018 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-30182900

RESUMO

BACKGROUND: Poor emergency obstetric care has been shown by national confidential enquiries into maternal deaths to contribute to a number of maternal deaths in South Africa. OBJECTIVES: To assess whether a structured training course can improve knowledge and skills and whether this can influence the capacity of a healthcare facility to provide basic and comprehensive emergency obstetric care signal functions. METHODS: A baseline survey was conducted to assess the seven basic emergency obstetric and neonatal care signal functions in 51 community health centres (CHCs) and the nine comprehensive emergency care signal functions in 62 district hospitals (DHs). A re-assessment was conducted 1 year after saturation training had been provided in each district. The delegates were trained using a structured training programme (Essential Steps in Managing Obstetric Emergencies, ESMOE) and their knowledge and skills were tested before and after the training. Saturation training was considered to have been achieved once 80% of the healthcare professionals involved in maternity care had been trained. RESULTS: There was a significant improvement in the knowledge and skills of doctors, namely by 16.8% and 32.8%, respectively, of advanced midwives by 13.7% and 29.0%, and of professional nurses with midwifery by 16.1% and 31.2%. The seven basic emergency care functions improved from 60.8% to 67.8% in the CHCs and from 90.7% to 92.5% in the DHs before and after training. If the two signal functions that are not within the scope of practice of professional nurses with midwifery are excluded (viz. assisted delivery and manual vacuum aspiration), the functionality of CHCs increased from 85.1% to 94.9%. CONCLUSIONS: The ESMOE training programme improved knowledge and skills, but there was a modest improvement in the functionality of the facilities. Improvement in functionality requires changes in the structure of the health system, including changing the scope of practice of professional nurses with midwifery and employing more advanced midwives in CHCs.


Assuntos
Competência Clínica , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde Materna/normas , Obstetrícia/normas , Médicos/normas , Centros Comunitários de Saúde/normas , Parto Obstétrico/estatística & dados numéricos , Emergências , Feminino , Pessoal de Saúde/educação , Pessoal de Saúde/normas , Hospitais de Distrito , Humanos , Recém-Nascido , Morte Materna/prevenção & controle , Serviços de Saúde Materna/estatística & dados numéricos , Tocologia/normas , Tocologia/estatística & dados numéricos , Obstetrícia/educação , Médicos/organização & administração , Médicos/estatística & dados numéricos , Gravidez , África do Sul
8.
BMC Pediatr ; 18(1): 145, 2018 04 30.
Artigo em Inglês | MEDLINE | ID: mdl-29712552

RESUMO

BACKGROUND: The Republic of Malawi is creating a country-wide system of 28 One-Stop Centres (known as 'Chikwanekwanes' - 'everything under one roof') to provide medical, legal and psychosocial services for survivors of child maltreatment and adult intimate partner violence. No formal evaluation of the utility of such services has ever been undertaken. This study focused on the experiences of the families served at the country's first Chikwanekwane in the large, urban city of Blantyre. METHODS: One hundred seven families were surveyed in their home three months after their initial evaluation for sexual abuse at the Blantyre One Stop Centre, and 25 families received a longer interview. The survey was designed to inquire what types of initial evaluation and follow-up services the children received from the medical, legal and social welfare services. RESULTS: All 107 received an initial medical exam and HIV testing, and 83% received a follow-up HIV test by 3 months; 80.2% were seen by a social welfare worker on the initial visit, and 29% had a home visit by 3 months; 84% were seen by a therapist at the initial visit, and 12% returned for further treatment; 95.3% had an initial police report and 27.1% ended in a criminal conviction for child sexual abuse. Most of the families were satisfied with the service they received, but a quarter of the families were not satisfied with the law enforcement response, and 2% were not happy with the medical assessment. CONCLUSIONS: Although a perception of corruption or negligence by police may discourage use of service, we believe that the One-Stop model is an appropriate means to deliver high quality care to survivors of abuse in Malawi.


Assuntos
Abuso Sexual na Infância/terapia , Centros Comunitários de Saúde/organização & administração , Adolescente , Criança , Abuso Sexual na Infância/diagnóstico , Bem-Estar da Criança , Centros Comunitários de Saúde/normas , Aconselhamento , Feminino , Humanos , Aplicação da Lei , Malaui , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Desenvolvimento de Programas , Qualidade da Assistência à Saúde , Maus-Tratos Conjugais/terapia , População Urbana , Adulto Jovem
9.
BMC Cancer ; 18(1): 567, 2018 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-29769057

RESUMO

BACKGROUND: Management of squamous cell carcinoma of the anus (SCCA) is becoming more relevant, as its incidence increases. The purpose of this study was to investigate possible differences in patient population and care delivery for SCCA between academic and community cancer programs in the United States. METHODS: A review of available data from the American College of Surgeons Committee on Cancer National Cancer DataBase focused on gender, age, race, type of health insurance, comorbidity score, distance traveled for care, stage at diagnosis, and therapy utilization (surgery, chemotherapy, and radiation therapy) as first course of treatment (FCT). The analysis included 38,766 patients treated for SCCA. Of them, 14,422 patients received treatment at Academic Cancer Programs (ACPs), while 24,344 were treated at Community Cancer Programs (CCPs) between the years 2003 and 2013. RESULTS: Over the 11-year study period, ACPs had significantly more male patients, of younger age, a greater non-white race population, with more Medicaid or no insurance coverage, who traveled farther for cancer center care (p < 0.001). There was no difference between ACPs and CCPs with respect to Charlson co-morbidity score and stage of SCCA at diagnosis. For stage 0 patients, use of chemotherapy was 8% for ACPs, 9% for CCPs, and use of radiotherapy was 10% for ACPs and 14% for CCPs. The incidence of stage unknown was identical at both ACPs and CCPs (11.5%). CCPs had a greater overall utilization of radiation therapy as FCT for stage 0, I, II and IV patients (p < 0.001). CONCLUSIONS: Our study indicates that gender, demographic and socio-economic differences exist in the patient population with SCCA accessing different cancer programs in the US. The high incidence of stage unknown patients reflects ongoing challenges in the pre-treatment phase. A significant percentage of stage 0 patients received systemic chemotherapy and/or radiotherapy, rather than surgery alone. Despite comparable stage at diagnosis and comorbidity scores between ACPs and CCPs, there appear to be variations in treatment choices, especially with the use of radiotherapy, with associated cost and toxicity risks. Further analysis and monitoring of SCCA management in the US may lead to improved compliance with NCCN guidelines.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Neoplasias do Ânus/terapia , Institutos de Câncer/organização & administração , Carcinoma de Células Escamosas/terapia , Centros Comunitários de Saúde/organização & administração , Padrões de Prática Médica/estatística & dados numéricos , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/estatística & dados numéricos , Fatores Etários , Neoplasias do Ânus/diagnóstico , Neoplasias do Ânus/patologia , Institutos de Câncer/normas , Institutos de Câncer/estatística & dados numéricos , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patologia , Terapia Combinada/economia , Terapia Combinada/métodos , Terapia Combinada/estatística & dados numéricos , Centros Comunitários de Saúde/normas , Centros Comunitários de Saúde/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos
10.
Qual Health Res ; 28(9): 1395-1405, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29577844

RESUMO

Low rates of documentation of sexual histories have been reported and research on sexual history taking (SHT) has focused on the content of, barriers to collecting, and interventions to improve documentation of sexual histories. Absent from this literature is an understanding of the contextual factors affecting SHT. To address this gap, a focused ethnography of one health center was conducted. Data were collected through observations of health care encounters and interviews with health care providers (HCPs). No SHT was observed and this was likely influenced by patients' characteristics, communication between patients and HCPs, the prioritization of patients' basic needs, and time constraints imposed upon encounters. Given that the health center studied serves patients experiencing homelessness, behavioral health concerns, and opioid use disorder, findings illuminate areas for future inquiry into a patient population affected by social as well as physiologic determinants of health and potentially at high risk for adverse sexual health outcomes.


Assuntos
Centros Comunitários de Saúde/organização & administração , Pessoas em Situação de Rua , Anamnese/normas , Comportamento Sexual , Antropologia Cultural , Atitude do Pessoal de Saúde , Comunicação , Centros Comunitários de Saúde/normas , Competência Cultural , Feminino , Comportamentos de Risco à Saúde , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Relações Profissional-Paciente
11.
J Gen Intern Med ; 33(6): 906-913, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29453528

RESUMO

BACKGROUND: To monitor progress towards eliminating health disparities, community health centers have reported on hypertension control, diabetes control, and birthweight by race and ethnicity since 2008. OBJECTIVE: To evaluate racial/ethnic time trends in quality outcomes in health centers and to assess both within- and between-center disparities in outcomes. DESIGN AND SAMPLE: Using 2009-2014 data from all US health centers (n = 1047 centers, serving 19.6 million patients/year), we evaluated racial/ethnic time trends in quality outcomes for health centers and assessed within- and between-center disparities. MAIN MEASURES: Percentage of patients achieving control of blood pressure < 140/90 mmHg among hypertensive persons, control of glycosylated hemoglobin ≤ 9.0% among diabetic persons, and birthweight ≥ 2500 g. All outcomes were reported by race/ethnicity. KEY RESULTS: There was no evidence of improved outcomes among racial/ethnic subgroups from 2009 to 2014, though electronic health record adoption, medical recognition, and insurance coverage rates increased substantially. Two exceptions were increased rates of normal birthweight for black patients (87.0% to 88.8%, or 0.3 percentage points/year, p = 0.02) and decreased rates of diabetes control for white patients (74.2% to 69.5%, or -1.0 percentage points/year, p < 0.01). Within centers, the largest racial/ethnic disparities in 2009 were white/black disparities in hypertension control (8.7 percentage points, 95% CI 7.4-10.1), white/black disparities in diabetes control (3.4 percentage points, 95% CI 2.0-4.7), and white/Hispanic disparities in diabetes control (4.4 percentage points, 95% CI 2.8-6.0). All disparities remained statistically unchanged from 2009 to 2014. White patients were more likely to be seen at a health center in the top performance quintile compared with black and Hispanic patients (p < 0.001). CONCLUSIONS: Though quality outcomes in health centers continued to compare favorably to other care settings, we found no evidence of improved quality or reduced disparities in diabetes control, hypertension control, or birthweight from 2009 to 2014. Within- and between-center racial/ethnic disparities in quality were evident, and both should be targeted in future interventions.


Assuntos
Centros Comunitários de Saúde/normas , Grupos de Populações Continentais/etnologia , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/normas , Qualidade da Assistência à Saúde/normas , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Centros Comunitários de Saúde/tendências , Grupos Étnicos , Feminino , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/tendências , Resultado do Tratamento , Adulto Jovem
12.
J Autism Dev Disord ; 48(1): 28-35, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28866856

RESUMO

This study determined the accuracy of Modified Checklist for Autism in Toddlers (M-CHAT) in detecting toddlers with autism spectrum disorder (ASD) and other developmental disorders (DD) in community mother and child health clinics. We analysed 19,297 eligible toddlers (15-36 months) who had M-CHAT performed in 2006-2011. Overall sensitivities for detecting ASD and all DD were poor but better in the 21 to <27 months and 27-36-month age cohorts (54.5-64.3%). Although positive predictive value (PPV) was poor for ASD, especially the younger cohort, positive M-CHAT helped in detecting all DD (PPV = 81.6%). This suggested M-CHAT for screening ASD was accurate for older cohorts (>21 months) and a useful screening tool for all DD.


Assuntos
Transtorno do Espectro Autista/diagnóstico , Lista de Checagem/normas , Centros Comunitários de Saúde/normas , Deficiências do Desenvolvimento/diagnóstico , Programas de Rastreamento/normas , Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/psicologia , Lista de Checagem/métodos , Pré-Escolar , Estudos de Coortes , Deficiências do Desenvolvimento/epidemiologia , Deficiências do Desenvolvimento/psicologia , Feminino , Humanos , Lactente , Malásia/epidemiologia , Masculino , Programas de Rastreamento/métodos , Estudos Retrospectivos
13.
J Cyst Fibros ; 17(3): 360-367, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29074367

RESUMO

BACKGROUND: The Epidemiologic Study of Cystic Fibrosis using 1995-1996 and 2003-2005 data found that CF centres with lowest FEV1 tended to use fewer intravenous antibiotics. We repeated the analyses using 2013-2014 UK CF registry data to determine if this was still the case. METHODS: Analysing data for 2013 and 2014 separately, 28 adult CF centres were ranked according to median % age-adjusted FEV1. The top 7 centres were placed in the 'upper quarter' (best FEV1), the bottom 7 centres in 'lower quarter' (lowest FEV1), and the rest in 'middle half'. IV use was stratified according to %FEV1, then compared between the three groups. RESULTS: Centres in the 'upper quarter' and 'middle half' used significantly more IV antibiotics compared to centres in the 'lower quarter' (van Elteren test P-value<0.001). Regression analyses showed that people with CF attending centres in the 'upper quarter' or 'middle half' are 30-50% more likely to receive at least one IV course per year compared to people attending centres in the 'lower quarter'. CONCLUSIONS: CF centres with lowest FEV1 are still distinguished by lower use of intravenous antibiotics.


Assuntos
Antibacterianos/administração & dosagem , Centros Comunitários de Saúde , Fibrose Cística , Volume Expiratório Forçado , Infecções por Pseudomonas , Administração Intravenosa , Adulto , Centros Comunitários de Saúde/normas , Centros Comunitários de Saúde/estatística & dados numéricos , Estudos Transversais , Fibrose Cística/epidemiologia , Fibrose Cística/microbiologia , Fibrose Cística/fisiopatologia , Progressão da Doença , Feminino , Humanos , Masculino , Infecções por Pseudomonas/diagnóstico , Infecções por Pseudomonas/tratamento farmacológico , Melhoria de Qualidade , Testes de Função Respiratória/métodos , Testes de Função Respiratória/estatística & dados numéricos , Resultado do Tratamento , Reino Unido/epidemiologia
14.
J Gen Intern Med ; 33(3): 258-267, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29086341

RESUMO

BACKGROUND: Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely. OBJECTIVE: This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications. DESIGN: Qualitative, interview-based study. PARTICIPANTS: Twenty-four providers from five VA PC clinics. APPROACH: Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review. KEY RESULTS: Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have. CONCLUSIONS: We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.


Assuntos
Alcoolismo/tratamento farmacológico , Atitude do Pessoal de Saúde , Pessoal de Saúde/normas , Atenção Primária à Saúde/normas , Pesquisa Qualitativa , United States Department of Veterans Affairs/normas , Alcoolismo/epidemiologia , Instituições de Assistência Ambulatorial/normas , Centros Comunitários de Saúde/normas , Feminino , Humanos , Masculino , Ambulatório Hospitalar/normas , Atenção Primária à Saúde/métodos , Inquéritos e Questionários , Estados Unidos/epidemiologia
15.
Am J Health Promot ; 32(6): 1425-1430, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29129109

RESUMO

PURPOSE: To determine whether increasing the proportion of healthier options in vending machines decreases the amount of calories, fat, sugar, and sodium vended, while maintaining total sales revenue. DESIGN: This study evaluated the impact of altering nutritious options to vending machines throughout the Banner Health organization by comparing vended items' sales and nutrition information over 6 months compared to the same 6 months of the previous year. SETTING: Twenty-three locations including corporate and patient-care centers. INTERVENTION: Changing vending machine composition toward more nutritious options. MEASURES: Comparisons of monthly aggregates of sales, units vended, calories, fat, sodium, and sugar vended by site. ANALYSIS: A pre-post analysis using paired t tests comparing 6 months before implementation to the equivalent 6 months postimplementation. RESULTS: Significant average monthly decreases were seen for calories (16.7%, P = .002), fat (27.4%, P ≤ .0001), sodium (25.9%, P ≤ .0001), and sugar (11.8%, P = .045) vended from 2014 to 2015. Changes in revenue and units vended did not change from 2014 to 2015 ( P = .58 and P = .45, respectively). CONCLUSION: Increasing the proportion of healthier options in vending machines from 20% to 80% significantly lowered the amount of calories, sodium, fat, and sugar vended, while not reducing units vended or having a negative financial impact.


Assuntos
Bebidas/normas , Centros Comunitários de Saúde/normas , Centros Comunitários de Saúde/tendências , Dieta Saudável/normas , Distribuidores Automáticos de Alimentos/normas , Promoção da Saúde/métodos , Lanches/psicologia , Arizona , Bebidas/estatística & dados numéricos , Centros Comunitários de Saúde/estatística & dados numéricos , Dieta Saudável/estatística & dados numéricos , Distribuidores Automáticos de Alimentos/estatística & dados numéricos , Previsões , Promoção da Saúde/estatística & dados numéricos , Humanos
16.
Acad Med ; 93(3): 406-413, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28930763

RESUMO

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.


Assuntos
Centros Comunitários de Saúde/normas , Educação em Saúde/organização & administração , Medicaid/economia , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/provisão & distribução , Centros Comunitários de Saúde/provisão & distribução , Controle de Custos/métodos , Reforma dos Serviços de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Humanos , Medicina , Prática Associada/economia , Patient Protection and Affordable Care Act/legislação & jurisprudência , Pobreza/economia , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Estados Unidos/epidemiologia , Recursos Humanos
17.
BMC Fam Pract ; 18(1): 114, 2017 12 29.
Artigo em Inglês | MEDLINE | ID: mdl-29284408

RESUMO

BACKGROUND: Monitoring and evaluating changes of quality of primary care for older adult hypertensive patients is part of effective delivery of primary care. This study aimed to investigate changes of older adult hypertensive patients' perceived quality of primary care over time in Shanghai. METHODS: Two rounds of cross-sectional questionnaire surveys were conducted in Shanghai in November 2011 and June 2013. A total of 437 patients participated in the first Round survey and 443 in the second. Primary care attributes were collected from Community Health Center users through on-site face-to-face interview surveys using the validated Primary Care Assessment Tool. Multiple linear regressions were used to determine whether there was any difference in primary quality of care scores between 2011 and 2013 surveys. RESULTS: Compared with those in the first Round, participants in the second Round reported higher scores in total primary care quality (28.73 vs. 27.75, P < 0.001), as well as primary care attributes including first-contact utilization (2.81 vs. 2.60, P < 0.001) and accessibility (2.48 vs. 2.44, P < 0.05), continuity of care (3.38 vs. 3.27, P < 0.001), coordination of information (3.82 vs. 3.67, P < 0.001), comprehensiveness of service availability (3.51 vs. 3.39, P < 0.001) and provision (2.69 vs. 2.43, P < 0.001), and cultural competence (2.67 vs. 2.49, P < 0.05), but a lower score in coordination of services (2.45 vs. 2.55, P < 0.05). CONCLUSION: Older adult hypertensive patients perceived better primary care quality from 2011 to 2013 in Shanghai. This may be associated with the general practitioner team service in Shanghai where hypertensive patients were targeted.


Assuntos
Centros Comunitários de Saúde/normas , Hipertensão/tratamento farmacológico , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Idoso , Idoso de 80 Anos ou mais , Administração de Caso , China , Centros Comunitários de Saúde/estatística & dados numéricos , Continuidade da Assistência ao Paciente , Estudos Transversais , Competência Cultural , Feminino , Pesquisas sobre Serviços de Saúde , Gestão da Informação em Saúde , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Percepção , Atenção Primária à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos
19.
PLoS One ; 12(7): e0182249, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28759575

RESUMO

OBJECTIVES: This study aimed to identify the barriers female sex workers (FSWs) in Bangladesh face with regard to accessing sexual and reproductive health (SRH) care, and assess the satisfaction with the healthcare received. METHODS: Data were collected from coverage areas of four community-based drop-in-centers (DICs) in Dhaka where sexually transmitted infection (STI) and human immunovirus (HIV) prevention interventions have been implemented for FSWs. A total of 731 FSWs aged 15-49 years were surveyed. In addition, in-depth interviews (IDIs) were conducted with 14 FSWs and 9 service providers. Respondent satisfaction was measured based on recorded scores on dignity, privacy, autonomy, confidentiality, prompt attention, access to social support networks during care, basic amenities, and choice of institution/care provider. RESULTS: Of 731 FSWs, 353 (51%) reported facing barriers when seeking sexual and reproductive healthcare. Financial problems (72%), shame about receiving care (52.3%), unwillingness of service providers to provide care (39.9%), unfriendly behavior of the provider (24.4%), and distance to care (16.9%) were mentioned as barriers. Only one-third of the respondents reported an overall satisfaction score of more than fifty percent (a score of between 9 and16) with formal healthcare. Inadequacy or lack of SRH services and referral problems (e.g., financial charge at referral centers, unsustainable referral provision, or unknown location of referral) were reported by the qualitative FSWs as the major barriers to accessing and utilizing SRH care. CONCLUSIONS: These findings are useful for program implementers and policy makers to take the necessary steps to reduce or remove the barriers in the health system that are preventing FSWs from accessing SRH care, and ultimately meet the unmet healthcare needs of FSWs.


Assuntos
Disparidades em Assistência à Saúde , Serviços Preventivos de Saúde/normas , Serviços de Saúde Reprodutiva/normas , Profissionais do Sexo , Adolescente , Adulto , Bangladesh , Cidades , Centros Comunitários de Saúde/normas , Centros Comunitários de Saúde/estatística & dados numéricos , Feminino , Pessoal de Saúde , Acesso aos Serviços de Saúde , Humanos , Pessoa de Meia-Idade , Serviços Preventivos de Saúde/estatística & dados numéricos , Serviços de Saúde Reprodutiva/estatística & dados numéricos
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