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2.
J Stroke Cerebrovasc Dis ; 29(11): 105200, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066919

RESUMO

BACKGROUND: Because "time is brain," acute stroke trials are migrating to the prehospital setting. The impact upon enrollment in post-arrival trials of earlier recruitment in a prehospital trial requires delineation. METHODS: We analyzed all patients recruited into acute and prevention stroke trials during an 8-year period when an academic medical center (AMC) was participating in a prehospital treatment trial - the NIH Field Administration of Stroke Treatment - Magnesium (FAST-MAG) study. RESULTS: During the study period, in addition to FAST-MAG, the AMC participated in 33 post-arrival stroke trials: 27 for acute cerebral ischemia, one for intracerebral hemorrhage, and 5 secondary prevention trials. Throughout the study period, the AMC was recruiting for at least 3 concurrent post-arrival acute trials. Among 199 patients enrolled in acute stroke trials, 98 (49%) were in FAST-MAG and 101 (51%) in concurrent, post-arrival acute trials. Among FAST-MAG patients, 67% were not eligible for any concurrent acute, post-arrival trial. Of 134 patients eligible for post-arrival acute trials, 101 (76%) were enrolled in post-arrival trials and 32 (24%) in FAST-MAG. Leading reasons FAST-MAG patients were ineligible for post-arrival acute trials were: NIHSS too low (23.4%), intracranial hemorrhage (17.9%), IV tPA used in standard management (9.0%), NIHSS too high (7.1%), and age too high (5.2%). CONCLUSIONS: A prehospital hyperacute stroke trial with wide entry criteria reduced only modestly, by one-fourth, enrollment into concurrently active, post-arrival stroke trials. Simultaneous performance of prehospital and post-arrival acute and secondary prevention stroke trials in research networks is feasible.


Assuntos
Ensaios Clínicos Fase III como Assunto , Serviços Médicos de Emergência , Estudos Multicêntricos como Assunto , Admissão do Paciente , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/terapia , Centros Médicos Acadêmicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Definição da Elegibilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho da Amostra , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo
3.
Am J Respir Crit Care Med ; 202(7): e95-e112, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33000953

RESUMO

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.


Assuntos
Tomada de Decisão Compartilhada , Detecção Precoce de Câncer/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Neoplasias Pulmonares/diagnóstico , Fumar/etnologia , Definição da Elegibilidade , Grupos Étnicos/estatística & dados numéricos , Custos de Cuidados de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Ciência da Implementação , Cobertura do Seguro , Marketing de Serviços de Saúde/métodos , Medicaid , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Grupos Minoritários/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Encaminhamento e Consulta/estatística & dados numéricos , Fatores Sexuais , Fumar/epidemiologia , Fumar/terapia , Abandono do Hábito de Fumar/estatística & dados numéricos , Classe Social , Estados Unidos
5.
BMJ Open ; 10(10): e044566, 2020 10 05.
Artigo em Inglês | MEDLINE | ID: mdl-33020111

RESUMO

OBJECTIVES: To analyse enrolment to interventional trials during the first wave of the COVID-19 pandemic in England and describe the barriers to successful recruitment in the circumstance of a further wave or future pandemics. DESIGN: We analysed registered interventional COVID-19 trial data and concurrently did a prospective observational study of hospitalised patients with COVID-19 who were being assessed for eligibility to one of the RECOVERY, C19-ACS or SIMPLE trials. SETTING: Interventional COVID-19 trial data were analysed from the clinicaltrials.gov and International Standard Randomized Controlled Trial Number databases on 12 July 2020. The patient cohort was taken from five centres in a respiratory National Institute for Health Research network. Population and modelling data were taken from published reports from the UK government and Medical Research Council Biostatistics Unit. PARTICIPANTS: 2082 consecutive admitted patients with laboratory-confirmed SARS-CoV-2 infection from 27 March 2020 were included. MAIN OUTCOME MEASURES: Proportions enrolled, and reasons for exclusion from the aforementioned trials. Comparisons of trial recruitment targets with estimated feasible recruitment numbers. RESULTS: Analysis of trial registration data for COVID-19 treatment studies enrolling in England showed that by 12 July 2020, 29 142 participants were needed. In the observational study, 430 (20.7%) proceeded to randomisation. 82 (3.9%) declined participation, 699 (33.6%) were excluded on clinical grounds, 363 (17.4%) were medically fit for discharge and 153 (7.3%) were receiving palliative care. With 111 037 people hospitalised with COVID-19 in England by 12 July 2020, we determine that 22 985 people were potentially suitable for trial enrolment. We estimate a UK hospitalisation rate of 2.38%, and that another 1.25 million infections would be required to meet recruitment targets of ongoing trials. CONCLUSIONS: Feasible recruitment rates, study design and proliferation of trials can limit the number, and size, that will successfully complete recruitment. We consider that fewer, more appropriately designed trials, prioritising cooperation between centres would maximise productivity in a further wave.


Assuntos
Pesquisa Biomédica , Infecções por Coronavirus , Pandemias , Seleção de Pacientes , Pneumonia Viral , Ensaios Clínicos Controlados Aleatórios como Assunto , Betacoronavirus/isolamento & purificação , Pesquisa Biomédica/organização & administração , Pesquisa Biomédica/estatística & dados numéricos , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Definição da Elegibilidade , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Reino Unido
6.
Am J Cardiol ; 134: 62-68, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32933754

RESUMO

The reduction of cardiovascular events with icosapent ethyl-intervention (REDUCE-IT) trial showed in persons with prior cardiovascular disease (CVD) or diabetes mellitus (DM) that icosapent ethyl (IPE) reduced CVD events by 25%. We projected the preventable initial and total CVD events if REDUCE-IT trial eligibility criteria were applied to US adults. We identified US adults with available REDUCE-IT inclusion criteria from NHANES Surveys 1999-2016 and estimated primary (CVD death, nonfatal myocardial infarction, stroke, revascularization, or unstable angina) and secondary composite (CVD death, nonfatal MI or stroke) events using REDUCE-IT published event rates in the IPE and placebo groups, the difference being the number of preventable events. From 11,445 adults aged ≥45 years (representing 111.1 million [M]), a total of 319 persons (3.0 M) fit key REDUCE-IT eligibility criteria: triglycerides of 135 to 499 mg/dL, HbA1c <10%, blood pressure <200/100 mm Hg, and on a statin with LDL-C of 40 to 99 mg/dL. 63% had prior CVD and 37% had DM + ≥1 risk factor (primary prevention cohort). If these persons are given IPE for the REDUCE-IT median trial period of 4.9 years, we estimated preventing a total 349,817 (71,391/year) primary CVD outcomes of which 146,011 (29,798/year) were initial events. Most (24,151) preventable events were from the secondary prevention cohort. Using FDA eligibility criteria, an estimated 4.6 million persons would be eligible for IPE, with 60,544 preventable primary CVD outcomes annually from REDUCE-IT USA event rates. In conclusion, many CVD events in US adults with known CVD or DM and well-controlled LDL-C on statin therapy can be prevented with IPE.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus/tratamento farmacológico , Ácido Eicosapentaenoico/análogos & derivados , Definição da Elegibilidade , Reguladores do Metabolismo de Lipídeos/uso terapêutico , Revascularização Miocárdica/estatística & dados numéricos , Idoso , Angina Instável/prevenção & controle , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/mortalidade , Ácido Eicosapentaenoico/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Inquéritos Nutricionais , Prevenção Primária , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle
7.
J Stroke Cerebrovasc Dis ; 29(10): 105179, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912564

RESUMO

BACKGROUND: Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey. METHODS: A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. RESULTS: Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P = 0.047, 95% CI: 1.004-1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P = 0.052, 95% CI: 0.988-10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P = 0.023, 95% CI: 1.110-4.132). CONCLUSION: Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.


Assuntos
Atitude do Pessoal de Saúde , Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Conhecimentos, Atitudes e Prática em Saúde , Controle de Infecções/tendências , Pneumonia Viral/terapia , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/terapia , Betacoronavirus/patogenicidade , Tomada de Decisão Clínica , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Estudos Transversais , Definição da Elegibilidade/tendências , Pesquisas sobre Serviços de Saúde , Interações Hospedeiro-Patógeno , Humanos , Exposição Ocupacional/prevenção & controle , Pandemias , Admissão do Paciente/tendências , Transferência de Pacientes/tendências , Equipamento de Proteção Individual/tendências , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Formulação de Políticas , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/virologia , Telemedicina/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
8.
Medicine (Baltimore) ; 99(38): e22245, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957371

RESUMO

BACKGROUND: CMS recently decided to produce private "healthcare disparities reports" that include dual eligibility (DE) as the sole stratifying variable used to assess pneumonia readmission disparities. RESEARCH DESIGN: We measure the relationship between DE status and readmissions, both with and without conceptually relevant social risk factors, including air pollution, severe housing problems, and food insecurity, using data from county- and hospital-level readmission rates, DE status, and social risk factors. RESULTS: At the county level, the relationship between DE status and readmissions is partially confounded by at least three social risk factors. DE populations vary widely across hospitals, creating unequal between-hospital comparisons. CONCLUSIONS: Because of differences in the DE population, between-hospital comparisons could be misleading using a methodology that stratifies by DE only. We suggest viable alternatives to sole-factor stratification to properly account for social risk factors and better isolate quality differences that might yield readmission rate inequities. IMPLICATIONS: CMS's healthcare disparities reports provided to hospitals are limited by relying exclusively on DE proportion as the measure of social risk, undercutting the power of quality measurement and its related incentives to close or minimize healthcare inequities.


Assuntos
Definição da Elegibilidade , Disparidades em Assistência à Saúde , Medicaid/organização & administração , Medicare/organização & administração , Determinantes Sociais da Saúde , Poluição do Ar/efeitos adversos , Abastecimento de Alimentos , Habitação , Humanos , Readmissão do Paciente , Pneumonia/terapia , Fatores de Risco , Estados Unidos
9.
Oncology (Williston Park) ; 34(8): 317-319, 2020 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-32785928

RESUMO

A 78-year-old man had a medical history of hypertension, atrial fibrillation, chronic kidney disease, and metastatic castration-resistant prostate cancer (CRPC). He had progressed to first-line therapy for CRPC with abiraterone plus androgen-deprivation therapy (ADT) and as second-line therapy he was being treated with docetaxel, with biochemical progression in his last prostate specific antigen measurement. He was admitted to the hospital on April 2020, in the middle of the coronavirus disease 2019 (COVID-19) pandemic, because of painful bone lesions and deterioration of renal function.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias Ósseas/tratamento farmacológico , Infecções por Coronavirus/terapia , Cuidados Paliativos , Pneumonia Viral/terapia , Neoplasias de Próstata Resistentes à Castração/tratamento farmacológico , Insuficiência Respiratória/terapia , Idoso , Antagonistas de Androgênios/uso terapêutico , Androstenos/uso terapêutico , Antineoplásicos/uso terapêutico , Betacoronavirus , Conservadores da Densidade Óssea/uso terapêutico , Neoplasias Ósseas/complicações , Neoplasias Ósseas/secundário , Dor do Câncer/complicações , Dor do Câncer/terapia , Infecções por Coronavirus/complicações , Progressão da Doença , Docetaxel/uso terapêutico , Combinação de Medicamentos , Definição da Elegibilidade , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Unidades de Terapia Intensiva/provisão & distribução , Lopinavir/uso terapêutico , Masculino , Oxigenoterapia , Pandemias , Pneumonia Viral/complicações , Neoplasias de Próstata Resistentes à Castração/complicações , Neoplasias de Próstata Resistentes à Castração/patologia , Insuficiência Renal , Insuficiência Respiratória/etiologia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Ritonavir/uso terapêutico , Índice de Gravidade de Doença , Ácido Zoledrônico/uso terapêutico
10.
Health Aff (Millwood) ; 39(10): 1822-1831, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32757955

RESUMO

The recent coronavirus disease 2019 (COVID-19) global pandemic has resulted in unprecedented job losses in the United States, disrupting health insurance coverage for millions of people. Several models have predicted large increases in Medicaid enrollment among those who have lost jobs, yet the number of Americans who have gained coverage since the pandemic began is unknown. We compiled Medicaid enrollment reports covering the period from March 1 through June 1, 2020, for twenty-six states. We found that in these twenty-six states, Medicaid covered more than 1.7 million additional Americans in roughly a three-month period. Relative changes in Medicaid enrollment differed significantly across states, although enrollment growth was not systemically related to job losses. Our results point to the important effects of state policy differences in the response to COVID-19.


Assuntos
Infecções por Coronavirus/epidemiologia , Definição da Elegibilidade/estatística & dados numéricos , Emprego/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Estudos de Coortes , Infecções por Coronavirus/prevenção & controle , Bases de Dados Factuais , Definição da Elegibilidade/métodos , Emprego/economia , Feminino , Humanos , Incidência , Seguro Saúde/organização & administração , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Estados Unidos
11.
Diab Vasc Dis Res ; 17(4): 1479164120945674, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32722930

RESUMO

AIM: We examined eligibility and preventable cardiovascular disease events in US adults with diabetes mellitus from the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME). METHODS: We identified adults with diabetes mellitus eligible for EMPA-REG OUTCOME based on trial eligibility criteria available from the National Health and Nutrition Examination Surveys, 2007-2016. We estimated composite cardiovascular disease endpoints, as well as all-cause deaths, death from cardiovascular disease and hospitalizations for heart failure from trial treatment and placebo event rates, the difference indicating the preventable events. RESULTS: Among 29,629 US adults aged ⩾18 years (representing 231.9 million), 4672 (27.3 million) had diabetes mellitus, with 342 (1.86 million) meeting eligibility criteria of EMPA-REG OUTCOME. We estimated from trial primary endpoint event rates of 10.5% and 12.1% in the empagliflozin and placebo groups, respectively, that based on the 'treatment' of our 1.86 million estimated EMPA-REG OUTCOME eligible subjects, 12,066 (95% confidence interval: 10,352-13,780) cardiovascular disease events could be prevented annually. Estimated annual preventable deaths from any cause, cardiovascular causes and hospitalizations from heart failure were 17,078 (95% confidence interval: 14,652-19,504), 14,479 (95% confidence interval: 12,422-16,536) and 9467 (95% confidence interval: 8122-10,812), respectively. CONCLUSION: Empagliflozin, if provided to EMPA-REG OUTCOME eligible US adults, may prevent many cardiovascular disease events, cardiovascular and total deaths, as well as heart failure hospitalizations.


Assuntos
Compostos Benzidrílicos/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Tomada de Decisão Clínica , Diabetes Mellitus Tipo 2/tratamento farmacológico , Definição da Elegibilidade , Glucosídeos/uso terapêutico , Seleção de Pacientes , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Ensaios Clínicos como Assunto , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/mortalidade , Progressão da Doença , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/prevenção & controle , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Fatores de Proteção , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
12.
BMC Public Health ; 20(1): 1088, 2020 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-32653037

RESUMO

BACKGROUND: Disparities in access to care persist for Latino youth born in the United States (US). The association of maternal characteristics, such as maternal citizenship status and insurance coverage, on youth health insurance coverage is unclear and is important to examine given the recent sociopolitical shifts occurring in the US. METHODS: We analyzed pooled cross-sectional data from the 2010-2018 National Health Interview Survey to examine the association of Latina maternal citizenship status on maternal insurance coverage status and youth uninsurance among US-born Latino youth. Our study sample consisted of 15,912 US-born Latino youth (ages < 18) with linked mothers. Our outcome measures were maternal insurance coverage type and youth uninsurance and primary predictor was maternal citizenship status. Generalized structural equation modeling was used to examine the relationships between maternal characteristics (maternal citizenship, maternal insurance coverage status) and youth uninsurance. RESULTS: Overall, 7% of US-born Latino youth were uninsured. Just 6% of youth with US-born mothers were uninsured compared to almost 10% of those with noncitizen mothers. Over 18% of youth with uninsured mothers were uninsured compared to 2.2% among youth with mothers who had private insurance coverage. Compared to both US-born and naturalized citizen Latina mothers, noncitizen Latina mothers had 4.75 times the odds of reporting being uninsured. Once adjusted for predisposing, enabling, and need factors, maternal uninsurance was strongly associated with youth uninsurance and maternal citizenship was weakly associated with youth uninsurance among US-born Latino youth. CONCLUSION: Maternal citizenship was associated with both maternal uninsurance and youth uninsurance among US-born Latino youth. Federal- and state-level health policymaking should apply a two-generational approach to ensure that mothers of children are offered affordable health insurance coverage, regardless of their citizenship status, thus reducing uninsurance among US-born Latino youth.


Assuntos
Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Adolescente , Adulto , Estudos Transversais , Definição da Elegibilidade , Feminino , Nível de Saúde , Humanos , Seguro Saúde/estatística & dados numéricos , Análise de Classes Latentes , Masculino , Pessoa de Meia-Idade , Mães/estatística & dados numéricos , Estados Unidos
13.
Stroke ; 51(8): 2593-2596, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32716828

RESUMO

During the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organization recommended measures to mitigate the outbreak such as social distancing and confinement. Since these measures have been put in place, anecdotal reports describe a decrease in the number of endovascular therapy (EVT) treatments for acute ischemic stroke due to large vessel occlusion. The purpose of our study was to determine the effect on EVT for patients with acute ischemic stroke during the COVID-19 confinement. In this retrospective, observational study, data were collected from November 1, 2019, to April 15, 2020, at 17 stroke centers in countries where confinement measures have been in place since March 2020 for the COVID-19 pandemic (Switzerland, Italy, France, Spain, Portugal, Germany, Canada, and United States). This study included 1600 patients treated by EVT for acute ischemic stroke. Date of EVT and symptom onset-to-groin puncture time were collected. Mean number of EVTs performed per hospital per 2-week interval and mean stroke onset-to-groin puncture time were calculated before confinement measures and after confinement measures. Distributions (non-normal) between the 2 groups (before COVID-19 confinement versus after COVID-19 confinement) were compared using 2-sample Wilcoxon rank-sum test. The results show a significant decrease in mean number of EVTs performed per hospital per 2-week interval between before COVID-19 confinement (9.0 [95% CI, 7.8-10.1]) and after COVID-19 confinement (6.1 [95% CI, 4.5-7.7]), (P<0.001). In addition, there is a significant increase in mean stroke onset-to-groin puncture time (P<0.001), between before COVID-19 confinement (300.3 minutes [95% CI, 285.3-315.4]) and after COVID-19 confinement (354.5 minutes [95% CI, 316.2-392.7]). Our preliminary analysis indicates a 32% reduction in EVT procedures and an estimated 54-minute increase in symptom onset-to-groin puncture time after confinement measures for COVID-19 pandemic were put into place.


Assuntos
Infecções por Coronavirus , Gerenciamento Clínico , Procedimentos Endovasculares/estatística & dados numéricos , Pandemias , Pneumonia Viral , Quarentena , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/terapia , Definição da Elegibilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Espanha , Tempo para o Tratamento , Resultado do Tratamento
14.
Med Care ; 58(8): 717-721, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692137

RESUMO

OBJECTIVE: Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment. DATA SOURCES: Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014. STUDY DESIGN: A retrospective analysis of administrative data for a national sample of cancer decedents. DATA EXTRACTION METHODS: Comorbidities were evaluated using Elixhauser and Charlson coding algorithms. PRINCIPAL FINDINGS: Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P<0.001). CONCLUSION: There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.


Assuntos
Comorbidade , Definição da Elegibilidade/normas , Medicare/estatística & dados numéricos , Risco Ajustado/métodos , United States Department of Veterans Affairs/estatística & dados numéricos , Idoso , Definição da Elegibilidade/métodos , Definição da Elegibilidade/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Privatização/estatística & dados numéricos , Estudos Retrospectivos , Risco Ajustado/estatística & dados numéricos , Estados Unidos
15.
Med Care ; 58(8): 727-733, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692139

RESUMO

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.


Assuntos
Medicina Hospitalar/economia , Medicaid/economia , Patient Protection and Affordable Care Act/estatística & dados numéricos , California , Definição da Elegibilidade/métodos , Definição da Elegibilidade/estatística & dados numéricos , Humanos , Medicaid/estatística & dados numéricos , Estados Unidos
16.
S Afr Med J ; 110(4): 302-307, 2020 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-32657742

RESUMO

BACKGROUND: The recent amendment to the Health Professions Council of South Africa (HPCSA) Form 57 MED allows specialist registration on publication of the compulsory MMed research assignment in an accredited journal. No data exist on the conversion rate of MMed dissertations to publication. OBJECTIVES: To establish conversion rates of MMed dissertations to accredited publications. Associated variables arising from the publishing exercise were also investigated. METHODS: A total of 309 MMed dissertations, submitted between 1996 and 2017, were downloaded from the public domain. Each dissertation was recorded as to format, submission year, awarding university and clinical discipline. Electronic searches determined publication outcomes. Journal title, accreditation status, year of publication, registrar position on author ranking and publication type were extracted for each output. Descriptive analysis was undertaken and, where appropriate, Fisher's exact test at p>0.05 was used to establish statistical significance. RESULTS: A total of 116 dissertations were published at an overall conversion rate of 37.5%, culminating in 136 outputs. Publication-ready dissertations had a significantly higher conversion rate (60.3%) than monographs (30.5%) (p>0.0001). All but 6 of the 80 publishing journals were accredited. SAMJ was the journal of choice for 13% of papers. The registrar was the first author in the majority of publications. In the case of monographs, 66% were published after dissertation submission compared with 50% of publication-ready formats. CONCLUSIONS: Conversion of the South African MMed dissertation into a journal-accredited scientific article was achieved in 60.3% of publication-ready-format submissions, suggesting that the HPCSA amendment facilitating specialist registration is attainable. Retrospective reviews of dissertations provide valuable insights to improve understanding of the contentious issue of the registrar research requirement that permits specialist registration.


Assuntos
Dissertações Acadêmicas como Assunto , Educação Médica , Política de Saúde , Editoração/estatística & dados numéricos , Especialização , Acreditação , Definição da Elegibilidade , Humanos , Publicações Periódicas como Assunto , Estudos Retrospectivos , África do Sul
17.
J Stroke Cerebrovasc Dis ; 29(8): 104902, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689587

RESUMO

BACKGROUND: The endovascular treatment (ET) for acute ischemic stroke (AIS) is increasing among eligible patients. To help address care quality, administrative data sets are utilized but do not usually include formal outcome scales. We explore the predictive ability of discharge destination from acute hospitalizations for long-term disability among AIS patients eligible for ET within a clinical trial. METHODS: We analyzed publicly available data from the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial. We evaluated patients who survived beyond the time of discharge from their acute hospitalizations. We calculated positive and negative predictive values and accompanying likelihood ratios for patients discharged to home, inpatient rehabilitation facility (IRF), or subacute nursing facility (SNF) for unfavorable outcome as defined by modified Rankin Scale (mRS) scores ≥3 at 90-days. RESULTS: Our final analysis included 127 patients (median age 67 [23-89] years, 51.2% men). There were 23.6% patients discharged home, 53.5% to IRF, and 22.8% to SNF. Approximately 61% of patients had 90-day post-stroke mRS scores ≥3. Patients discharged to SNF had the highest positive predictive value (93.1%) and positive likelihood ratio (8.77 [CI 95% 2.18-35.25]) for unfavorable outcome. Discharge to home had the highest negative likelihood ratio (2.09 [CI 95% 1.54-2.83]) for unfavorable outcome. CONCLUSIONS: Among AIS patients eligible for ET within the DEFUSE 3 trial, discharge destination can provide high predictive value of 90-day functional outcomes. A discharge to SNF is highly predictive of long-term unfavorable outcomes.


Assuntos
Isquemia Encefálica/terapia , Definição da Elegibilidade , Procedimentos Endovasculares , Alta do Paciente , Instituições de Cuidados Especializados de Enfermagem , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Cardiovasc Diabetol ; 19(1): 87, 2020 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-32534590

RESUMO

BACKGROUND: Cardiovascular outcome trials of sodium-glucose co-transporter-2 inhibitors (SGLT2i CVOTs) found the agents to be associated with clinical benefits in terms of cardiovascular and renal outcomes. We performed a meta-analysis to assess and compare the overall prevalence of eligibility for the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV among unselected patients with type 2 diabetes. METHODS: This meta-analysis was registered in PROSPERO (CRD42020172032). PubMed, CENTRAL, Scopus and Web of Science were researched in March 2020. Studies evaluating the prevalence of eligibility for each SGLT2i CVOT were selected. Endpoints were estimated using a random-effects model. RESULTS: Five studies, evaluating 1,703,519 patients with type 2 diabetes, were included. Overall, the prevalence of eligible patients according to the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV was 36.4%, 49.5%, 17.0% and 19.0%, respectively. In head-to-head comparisons, DECLARE-TIMI 58 was associated with the highest odds of eligibility (1.74 versus CANVAS, 5.15 versus EMPA-REG OUTCOME and 4.81 versus VERTIS-CV), followed by CANVAS and EMPA-REG OUTCOME/VERTIS-CV. A high heterogeneity was found for all the outcomes. CONCLUSIONS: The present review showed that a considerable number of patients counseled in clinical practice could have been eligible for SGLT2i CVOTs. Particularly, dapagliflozin was shown to be the SGLT2i with the largest generalizability of findings from its CVOT according to the odds ratio of eligibility for the enrollment criteria among unselected patients with type 2 diabetes. Further country- or region-specific studies are needed to confirm the applicability of our results.


Assuntos
Glicemia/efeitos dos fármacos , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Biomarcadores/sangue , Glicemia/metabolismo , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidade , Definição da Elegibilidade , Medicina Baseada em Evidências , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
20.
Eur J Epidemiol ; 35(10): 899-912, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32594286

RESUMO

As randomized trials in the USA and Europe have convincingly demonstrated efficacy of lung cancer screening by computed tomography (CT), European countries are discussing the introduction of screening programs. To maintain acceptable cost-benefit and clinical benefit-to-harm ratios, screening should be offered to individuals at sufficiently elevated risk of having lung cancer. Using federal-wide survey and lung cancer incidence data (2008-2013), we examined the performance of four well-established risk models from the USA (PLCOM2012, LCRAT, Bach) and the UK (LLP2008) in the German population, comparing with standard eligibility criteria based on age limits, minimal pack years of smoking (or combination of total duration with average intensity) and maximum years since smoking cessation. The eligibility criterion recommended by the United States Preventive Services Taskforce (USPSTF) would select about 3.2 million individuals, a group equal in size to the upper fifth of ever smokers age 50-79 at highest risk, and to 11% of all adults aged 50-79. According to PLCOM2012, the model showing best concordance between numbers of lung cancer cases predicted and reported in registries, persons with 5-year risk ≥ 1.7% included about half of all lung cancer incidence in the full German population. Compared to eligibility criteria (e.g. USPSTF), risk models elected individuals in higher age groups, including ex-smokers with longer average quitting times. Further studies should address how in Germany these shifts may affect expected benefits of CT screening in terms of life-years gained versus the potential harm of age-specific increasing risk of over-diagnosis.


Assuntos
Detecção Precoce de Câncer/métodos , Definição da Elegibilidade , Neoplasias Pulmonares/diagnóstico , Programas de Rastreamento/métodos , Adulto , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Neoplasias Pulmonares/epidemiologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Inquéritos e Questionários , Tomografia Computadorizada por Raios X
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