Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 233
Filtrar
2.
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
3.
Am J Perinatol ; 37(8): 792-799, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32428965

RESUMO

OBJECTIVE: Pregnant women have been historically excluded from clinical trials for nonobstetric conditions, even during prior epidemics. The objective of this review is to describe the current state of research for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: We conducted a search of international trial registries for trials relating to the novel coronavirus. The eligibility criteria for each trial were reviewed for inclusion/exclusion of pregnant women. Relevant data were extracted and descriptive statistics were calculated for individual and combined data. The total number of trials from each registry were compared, as well as the proportions of pregnancy-related trials within each. RESULTS: Among 621,370 trials in the World Health Organization International Clinical Trials Registry, 927 (0.15%) were COVID-19 related. Of those, the majority (52%) explicitly excluded pregnancy or failed to address pregnancy at all (46%) and only 16 (1.7%) were pregnancy specific. When categorized by region, 688 (74.2%) of COVID-19 trials were in Asia, followed by 128 (13.8%) in Europe, and 66 (7.2%) in North America. Of the COVID-19 trials which included pregnant women, only three were randomized-controlled drug trials. CONCLUSION: Approximately 1.7% of current COVID-19 research is pregnancy related and the majority of trials either explicitly exclude or fail to address pregnancy. Only three interventional trials worldwide involved pregnant women. The knowledge gap concerning the safety and efficacy of interventions for COVID-19 created by the exclusion of pregnant women may ultimately harm them. While "ethical" concerns about fetal exposure are often cited, it is in fact unethical to habitually exclude pregnant women from research. KEY POINTS: · Pregnancy was excluded from past pandemic research.. · Pregnancy is being excluded from COVID-19 research.. · Exclusion of pregnant women is potentially harmful..


Assuntos
Ensaios Clínicos como Assunto , Infecções por Coronavirus , Definição da Elegibilidade/normas , Pandemias , Seleção de Pacientes/ética , Pneumonia Viral , Complicações Infecciosas na Gravidez , Sistema de Registros/estatística & dados numéricos , Betacoronavirus/isolamento & purificação , Ensaios Clínicos como Assunto/ética , Ensaios Clínicos como Assunto/organização & administração , Ensaios Clínicos como Assunto/normas , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Feminino , Saúde Global , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/terapia
4.
Am J Clin Oncol ; 43(8): 559-566, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32398404

RESUMO

OBJECTIVES: Treatments for metastatic renal cell carcinoma (mRCC) are often compared across trials, but trial eligibility criteria and endpoints differ. In an effort to better align trials, the Definition for the Assessment of Time to event Endpoints in CANcer trials (DATECAN) project published recommendations in 2015 to be used in mRCC clinical trial design. We analyzed mRCC trial criteria to determine if DATECAN's recommendations were followed. MATERIALS AND METHODS: We compared eligibility criteria across 29 phase 3 mRCC trials conducted between 2003 and 2019. We then evaluated endpoints used in 10 phase 3 trials activated between 2015 and 2019 to determine their compliance with DATECAN's recommendations. RESULTS: Among the 29 trials, performance status, renal function, and disease characteristics differed in terms of requirements and measures used. In terms of endpoints, the 10 trials did not entirely follow DATECAN's recommendations. In total, 7/10 trials' primary endpoint was progression-free survival (PFS) as recommended; 4/9 trials used PFS as an endpoint but did not publish their definition of PFS, and the 5 that did, included "death from any cause" instead of DATECAN's recommendation of "death from kidney cancer." CONCLUSIONS: Key eligibility criteria were somewhat inconsistent across the phase 3 mRCC trials studied. Endpoints in the newer trials did not align with DATECAN's recommendations. Not only is greater standardization needed to facilitate meta-analyses and cross-trial comparisons, but as evident from lack of adherence to DATECAN's recommendations, greater promotion and adoption of recommendations are needed to better harmonize trial design.


Assuntos
Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/terapia , Definição da Elegibilidade/normas , Neoplasias Renais/patologia , Neoplasias Renais/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Humanos
5.
Can J Cardiol ; 36(3): 335-356, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32145863

RESUMO

Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.


Assuntos
Assistência ao Convalescente/normas , Definição da Elegibilidade , Transplante de Coração/normas , Seleção de Pacientes , Árvores de Decisões , Definição da Elegibilidade/normas , Humanos
6.
Transplantation ; 104(7): 1437-1444, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31568216

RESUMO

BACKGROUND: Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation. METHODS: We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation. RESULTS: During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset. CONCLUSIONS: Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.


Assuntos
Definição da Elegibilidade/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Definição da Elegibilidade/normas , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Seguimentos , Acesso aos Serviços de Saúde/normas , Hispano-Americanos/estatística & dados numéricos , Humanos , Falência Renal Crônica/epidemiologia , Transplante de Rim/normas , Masculino , Pessoa de Meia-Idade , Prevalência , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
7.
Transplantation ; 104(7): 1396-1402, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31651793

RESUMO

BACKGROUND: Model for End-Stage Liver Disease (MELD) score-based liver transplant allocation was implemented as a fair and objective measure to prioritize patients based upon disease severity. Accuracy and reproducibility of MELD is an essential assumption to ensure fairness in organ access. We hypothesized that variability in laboratory methodology between centers could impact allocation scores for individuals on the transplant waiting list. METHODS: Aliquots of 30 patient serum samples were analyzed for creatinine, bilirubin, and sodium in all transplant centers within United Network for Organ Sharing (UNOS) region 9. Descriptive statistics, intraclass correlation coefficients (ICCs), and linear mixed-effects regression were used to determine the relationship between center, bilirubin, and calculated MELD-sodium (MELD-Na) score. RESULTS: The mean MELD-Na score per sample ranged from 14 to 38. The mean range in MELD-Na per sample was 3 points, but 30% of samples had a range of 4-6 points. Correlation plots and intraclass correlation coefficient analysis confirmed bilirubin interfered with creatinine, with worsening agreement in creatinine at high bilirubin levels. Center and bilirubin were independently associated with creatinine reported in mixed-effects models. Unbiased hierarchical clustering suggested that samples from specific centers have consistently higher creatinine and MELD-Na values. CONCLUSIONS: Despite implementation of creatinine standardization, centers within a single UNOS region report clinically significant differences in MELD-Na on an identical sample, with differences of up to 6 points in high MELD-Na patients. The bias in MELD-Na scores based upon center choice within a region should be addressed in the current efforts to eliminate disparities in liver transplant access.


Assuntos
Doença Hepática Terminal/diagnóstico , Transplante de Fígado/normas , Alocação de Recursos/normas , Índice de Gravidade de Doença , Centros de Atenção Terciária/normas , Aloenxertos/provisão & distribução , Bilirrubina/sangue , Serviços de Laboratório Clínico/normas , Creatinina/sangue , Definição da Elegibilidade/normas , Doença Hepática Terminal/sangue , Humanos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Padrões de Referência , Reprodutibilidade dos Testes , Sódio/sangue , Estados Unidos , Listas de Espera
8.
Ann Otol Rhinol Laryngol ; 129(4): 347-354, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31735055

RESUMO

OBJECTIVE: To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery. METHODS: Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center. RESULTS: A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4). CONCLUSION: Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.


Assuntos
Implante Coclear , Demografia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Perda Auditiva Neurossensorial , Fatores Etários , Implante Coclear/métodos , Implante Coclear/normas , Definição da Elegibilidade/métodos , Definição da Elegibilidade/normas , Estudos de Avaliação como Assunto , Feminino , Perda Auditiva Neurossensorial/epidemiologia , Perda Auditiva Neurossensorial/cirurgia , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Encaminhamento e Consulta/estatística & dados numéricos , Estados Unidos/epidemiologia
9.
Health Serv Res ; 54(6): 1233-1245, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576563

RESUMO

OBJECTIVE: To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE: 2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN: Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS: Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS: Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.


Assuntos
Elegibilidade Dupla ao MEDICAID e MEDICARE , Definição da Elegibilidade/normas , Medicaid/estatística & dados numéricos , Medicaid/normas , Medicare/estatística & dados numéricos , Medicare/normas , Risco Ajustado/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Governo Estadual , Estados Unidos
11.
Trop Med Int Health ; 24(9): 1042-1053, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31283066

RESUMO

OBJECTIVES: Many low- and middle-income countries (LMICs) provide subsidised access to health services for the poor. Proxy means tests (PMTs) for income are typically employed to identify eligible beneficiaries for subsidised services but often result in significant mistargeting of benefits. We assessed the PMT approach used in Myanmar's hospital equity fund (HEF). METHODS: We analysed inclusion/exclusion errors by comparing household eligibility under the PMT used for HEF with household consumption (the gold standard proxy for income in LMICs). We assessed receipt of benefits post-hospitalisation against HEF eligibility rules and household income. Focus groups/interviews were conducted to understand administrative factors that influence targeting. We modelled (linear regression) predictors of household consumption to improve PMT accuracy. RESULTS: We found large targeting errors (86% of households in the bottom consumption quartile would be excluded and 15% of households in the top consumption quartile deemed eligible). HEF scores for PMT held little explanatory power for household income: 93% of individuals meeting the HEF eligibility criteria did not receive benefits post-hospitalisation, while 23% of ineligible individuals received programme support. Re-weighting PMT indicators on electricity access, land ownership and livestock ownership, and assigning weights to home-ownership, households with elderly/disabled members and household head education levels could significantly improve targeting accuracy. Poor programme awareness and uneven adherence to official eligibility determination procedures among staff likely affected targeting. CONCLUSIONS: Re-weighting PMT indicators and increasing training and communication about qualification procedures could improve allocation of limited funds, though accurate targeting may continue to be challenging in contexts of low state capacity.


Assuntos
Definição da Elegibilidade/organização & administração , Hospitalização/estatística & dados numéricos , Assistência Médica/organização & administração , Pobreza , Definição da Elegibilidade/normas , Feminino , Acesso aos Serviços de Saúde/economia , Humanos , Renda , Masculino , Assistência Médica/normas , Mianmar , Características de Residência , Fatores Socioeconômicos
13.
Eur J Cardiovasc Nurs ; 18(7): 593-600, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31113221

RESUMO

BACKGROUND: Transcatheter aortic valve implantation may be indicated for patients with aortic stenosis and high risk of postoperative mortality. The assessment of suitability for transcatheter aortic valve implantation requires consensus agreement of a team of cardiologists and cardiac surgeons. The burden of comorbidities, frailty and cognitive impairment are factors included when risks for transcatheter aortic valve implantation are balanced against the expected benefits. Although transcatheter aortic valve implantation is a possibility for many, there are still ineligible patients. Knowledge of their experiences of being deemed ineligible are lacking. AIM: The aim of this study was to explore patients' experiences of being considered for transcatheter aortic valve implantation but judged ineligible. METHODS: Individual in-depth interviews were performed with eight persons, and qualitative content analysis was used for the analysis. RESULTS: Being ineligible for transcatheter aortic valve implantation may induce both hope and despair. Hope was linked to experiences of acceptance, relief of symptoms, support and control; despair was associated with feelings of being missed and abandoned, and of grief and insecurity. Some expressed great anxiety, since their incurable heart disease meant an imminent death. Others were more concerned over practical problems that affected everyday life. CONCLUSION: Being ineligible for transcatheter aortic valve implantation does not necessarily lead to despair. Hope is built through relationships, continuity and support. A combination of person-centred care and palliative care during the end-of-life phase should be offered to patients in order to help clients re-conceptualise hope during this stage of their illness. Cardiovascular nurses in the transcatheter aortic valve implantation team are suitable to facilitate continued care based on the patient's needs, desires and local conditions.


Assuntos
Estenose da Valva Aórtica/cirurgia , Definição da Elegibilidade/normas , Esperança , Seleção de Pacientes , Pacientes/psicologia , Substituição da Valva Aórtica Transcateter/psicologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Fatores de Risco , Índice de Gravidade de Doença
15.
BMC Cardiovasc Disord ; 19(1): 61, 2019 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-30876390

RESUMO

BACKGROUND: With development of cholesterol management guidelines by the American College of Cardiology/American Heart Association (ACC/AHA), more individuals at risk of cardiovascular disease may be eligible for statin therapy. It is not known how this affects statin eligibility in the Africa and Middle East Region. METHODS: Data were used from the Africa Middle East Cardiovascular Epidemiological (ACE) study. The percentage of subjects eligible for statins per the ACC/AHA 2013 cholesterol guidelines and the 2002 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III) recommendations were compared. Analyses were carried out according to age, gender, community (urban/rural), and country income categories based on World Bank definitions. RESULTS: According to the ACC/AHA recommendations, 1695 out of 4378 subjects (39%; 95% confidence interval [CI], 37-40%) satisfied statin eligibility criteria vs. 1043/4378 (24%; 95% CI, 23-25%) per NCEP-ATP recommendations, representing a 63% increase in statin eligibility. Consistent increases in eligibility for statin therapy were seen according to the ACC/AHA vs. NCEP-ATP guidelines across sub-groups of age, gender, community, and country income. Notable increases for statin eligibility according to ACC/AHA vs. NCEP-ATP were seen, respectively, in subjects aged ≥65 years (86% vs. 39%), in males (46% vs. 25%), in low-income countries (28% vs. 14%), and rural communities (37% vs. 19%). CONCLUSION: An increase in statin eligibility was seen applying ACC/AHA cholesterol guidelines compared with previous NCEP-ATP recommendations in the Africa Middle East region. The economic consequences of these guideline recommendations will need further research. TRIAL REGISTRATION: The ACE trial is registered under NCT01243138 .


Assuntos
Doenças Cardiovasculares/prevenção & controle , Colesterol/sangue , Dislipidemias/tratamento farmacológico , Definição da Elegibilidade/normas , Fidelidade a Diretrizes/normas , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Adolescente , Adulto , África/epidemiologia , Fatores Etários , Idoso , Biomarcadores/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Estudos Transversais , Dislipidemias/sangue , Dislipidemias/diagnóstico , Dislipidemias/epidemiologia , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Renda , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Medição de Risco , Fatores de Risco , Saúde da População Rural/normas , Fatores Sexuais , Resultado do Tratamento , Saúde da População Urbana/normas , Adulto Jovem
16.
Can J Cardiol ; 35(1): 1-11, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30595170

RESUMO

Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community." Although rare, SCD in the young is devastating to families and communities, underpinning our society's desire to avoid any circumstances predisposing to the loss of human life during exertion. The Canadian Cardiovascular Society Position Statement on the cardiovascular screening of athletes provides evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine electrocardiogram (ECG) screening in preventing SCD. We recommend that the cardiac screening and care of athletes within the Canadian health care model comprise a sequential (tiered) approach to the identification of cardiac risk, emphasizing the limitations of screening, the importance of shared decision-making when cardiac conditions are diagnosed, and the creation of policies and procedures for the management of emergencies in sport settings. Thus, we recommend against the routine (first-line or blanket mass performance of ECG) performance of a 12-lead ECG for the initial cardiovascular screening of competitive athletes. Organization/athlete-centred cardiovascular screening and care of athletes program is recommended. Such screening should occur in the context of a consistent, systematic approach to cardiovascular screening and care that provides: assessment, appropriate investigations, interpretation, management, counselling, and follow-up. The recommendations presented comprise a tiered framework that allows institutions some choice as to program creation.


Assuntos
Atletas , Cardiologia , Doenças Cardiovasculares/diagnóstico , Definição da Elegibilidade/normas , Guias de Prática Clínica como Assunto , Sociedades Médicas , Medicina Esportiva/normas , Morte Súbita Cardíaca/prevenção & controle , Humanos , Programas de Rastreamento/métodos
17.
BMC Infect Dis ; 19(1): 94, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30691407

RESUMO

BACKGROUND: India has the world's highest tuberculosis burden, and Mumbai is particularly affected by multidrug resistant tuberculosis (MDR-TB). WHO recommends short, intensive treatment ("Short Course") for previously untreated pulmonary MDR-TB patients but does not require universal drug susceptibility testing (DST) before Short Course. DST would likely screen out many MDR-TB patients in places like Mumbai with significant drug resistance. METHODS: MDR-TB patients at a private clinic were recruited for a prospective observational cohort. Short Course eligibility was evaluated by clinical criteria and DST results. Eligibility by DST was classified as rifampin monoresistance (as tested by Xpert MTB/RIF), rifampin, fluoroquinolones, and 2nd-line injectable drugs resistance (as tested by line probe assays) and resistance to other drugs. RESULTS: Of 559 participants with MDR-TB, 33% met clinical eligibility for Short Course. DST for rifampin, fluoroquinolones, and 2nd-line injectable drugs excluded 74.7% of participants. Complete phenotypic DST excluded 96.6% of participants. Prior treatment with either 1st or 2nd-line drugs did not significantly affect eligibility. CONCLUSIONS: In a global MDR-TB hotspot, < 5% of participants with MDR-TB were appropriate for Short Course by clinical characteristics and DST results. Rapid molecular testing would not sufficiently identify drug resistance in this population. Eligibility rates were not significantly reduced by prior TB treatment.


Assuntos
Antituberculosos/administração & dosagem , Definição da Elegibilidade , Seleção de Pacientes , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adulto , Instituições de Assistência Ambulatorial , Estudos de Coortes , Esquema de Medicação , Definição da Elegibilidade/normas , Definição da Elegibilidade/estatística & dados numéricos , Feminino , Fluoroquinolonas/administração & dosagem , Fidelidade a Diretrizes/estatística & dados numéricos , Hospitais Privados , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Rifampina/administração & dosagem , Adulto Jovem
18.
J Am Geriatr Soc ; 67(3): 581-587, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30674080

RESUMO

BACKGROUND/OBJECTIVES: Previous research indicates that eligibility criteria for medication therapy management (MTM) services in Medicare prescription drug (Part D) plans, defined under the Medicare Modernization Act (MMA), are associated with racial/ethnic disparities and ineffective in identifying individuals with medication utilization issues. Our study's objective was to determine the comparative effectiveness of MTM eligibility criteria under MMA and in the Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial/ethnic groups. DESIGN: ACA and MMA MTM eligibility criteria were compared on proportions of eligible individuals among patients with medication utilization issues. Multinomial logistic regression was conducted to control for patient/community characteristics. Need-based and demand-based analyses were used to determine disparities due to need and demand for healthcare. Main/sensitivity analyses were conducted for the range of eligibility thresholds. SETTING: Medicare data (2012-2013) linked to Area Health Resources Files. PARTICIPANTS: A total of 964 610 patients 65 years or older. MEASUREMENTS: Medication safety/adherence measures, developed primarily by the Pharmacy Quality Alliance, were used to determine medication utilization issues. RESULTS: Higher proportions of patients were eligible based on ACA than MMA MTM eligibility criteria. For example, in 2013, proportions based on ACA and MMA MTM eligibility criteria would be 99.7% and 26.2%, respectively, in the main analysis (p < .001); in the demand-based main analysis, ACA criteria were associated with 13.6% and 9.8%, respectively, higher effectiveness than MMA criteria among non-Hispanic blacks and Hispanics than non-Hispanic whites. CONCLUSION: ACA MTM eligibility criteria are more effective than MMA criteria in identifying older patients needing MTM, particularly among minorities. J Am Geriatr Soc 67:581-587, 2019.


Assuntos
Definição da Elegibilidade , Disparidades em Assistência à Saúde , Conduta do Tratamento Medicamentoso , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Revisão de Uso de Medicamentos/estatística & dados numéricos , Definição da Elegibilidade/métodos , Definição da Elegibilidade/normas , Grupos Étnicos , Feminino , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare Part D/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/normas , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Saúde das Minorias/normas , Saúde das Minorias/estatística & dados numéricos , Seleção de Pacientes , Assistência Farmacêutica/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
19.
Catheter Cardiovasc Interv ; 93(4): 620-625, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30280475

RESUMO

OBJECTIVES: To compare coronary revascularization appropriateness for non-acute coronary syndrome cases under the 2017 update vs the 2012 appropriate use criteria (AUC). BACKGROUND: In 2017, the 2012 AUC for coronary revascularization were updated. We examined how applying these new 2017 updates to our previous inappropriate cases would change their appropriateness. METHODS: We identified 50 cases of patients who underwent coronary revascularization for stable ischemic heart disease who were deemed inappropriate under the 2012 AUC. Two separate physicians reviewed the cases and applied a new AUC based on the 2017 AUC. Next, if there was a change, the reason was identified. RESULTS: Average age was 64, majority being male (29; 58%). Forty-two (84%) were asymptomatic upon presentation. Most cases (27, 54%) dealt with percutaneous coronary intervention (PCI) of the right coronary artery. After applying the 2017 AUC, 34 of the 50 inappropriate failures (68%) would be changed from "inappropriate" to "may be appropriate care." Of the 34 cases, 25 (73.5%) were changed due to the new AUC no longer expecting the patient to be on ≥2 anti-angina medications prior to PCI. Of the 34 cases, eight (23.5%) were changed due to the new AUC expanding the use of non-invasive modalities. CONCLUSIONS: Applying the 2017 AUC led to a statistically higher number of cases being deemed "may be appropriate." The most common cause for the change included the change in requirement for anti-angina regimen and the expanded role of non-invasive modalities.


Assuntos
Tomada de Decisão Clínica , Definição da Elegibilidade/normas , Fidelidade a Diretrizes/normas , Isquemia Miocárdica/terapia , Seleção de Pacientes , Intervenção Coronária Percutânea/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Idoso , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico por imagem , Intervenção Coronária Percutânea/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
20.
Am J Med Qual ; 34(2): 176-181, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29973059

RESUMO

Maintenance of Certification (MOC) is one way physicians demonstrate to the public that they are competent to deliver safe, high-quality medical care. The authors conducted a qualitative content analysis of information from 24 Member Boards of the American Board of Medical Specialties. A constant comparative approach was used to categorize themes of quality and safety and related concepts. All Boards (24/24) had public websites with formal documents and 23/24 had at least 1 representative respond to a survey. Sixty-three percent (15/24) of Boards had a patient safety requirement, and 96% (23/24) of Boards had a quality improvement requirement. Nearly all Boards incorporate quality improvement and most incorporate patient safety, but their assessment methods and level of inclusion on the topic vary. Sharing methods of incorporating quality and safety among certifying Boards will allow Member Boards to cater to the evolution of the MOC landscape and benefit from other Boards' experiences.


Assuntos
Certificação/normas , Medicina/normas , Segurança do Paciente/normas , Qualidade da Assistência à Saúde/normas , Certificação/organização & administração , Estudos Transversais , Definição da Elegibilidade/normas , Humanos , Medicina/organização & administração , Melhoria de Qualidade , Estados Unidos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...