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1.
Bull Cancer ; 107(2): 181-190, 2020 Feb.
Artigo em Francês | MEDLINE | ID: mdl-32005357

RESUMO

The Paul Strauss Center day-care accompaniment department ("SSAJ") is an oncologic supportive day-care, also an alternative to conventional hospitalization. In order to follow the SSAJ department's activity, in the "ambulatory turnover" context, we compared the 2008 and 2016 four first months activity. In 2016, there was an average of 4.96 patients per day versus 5.62 in 2008 (P<0.001); average day incoming of 653€ per stay in 2016 versus 775€ in 2008 (P<0.001). In 2016, there was an average 63.9 % of imagery done versus 27.7 % in 2008 (P<0.001). The 2016 average patient following period was of 84.7 days versus 67.6 days in 2008 (P=0.019). Average time between first day-care visit and death was 161.7 days in 2016 versus 133.5 days in 2008 (P=0.0033). Average day activity is lower in 2016 than 2008, nonetheless number of total stays and inpatients has increased on the four months period. The SSAJ intervenes more precociously in 2016 than 2008. Hospital technical platform is better used, but average per-stay incoming has statistically lowered. The SSAJ limits and prepares complete hospitalizations. Inpatient close reevaluation after a "shorter-willing" stay, home issues anticipation and identification with the home-care team, and worsening prevention gives this activity all its meaning.


Assuntos
Institutos de Câncer/estatística & dados numéricos , Hospital Dia/estatística & dados numéricos , Neoplasias/terapia , Idoso , Antineoplásicos/uso terapêutico , Hospital Dia/economia , Diagnóstico por Imagem/estatística & dados numéricos , França , Humanos , Pessoa de Meia-Idade , Neoplasias/diagnóstico por imagem , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos
3.
JAMA ; 322(9): 843-856, 2019 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-31479136

RESUMO

Importance: Medical imaging increased rapidly from 2000 to 2006, but trends in recent years have not been analyzed. Objective: To evaluate recent trends in medical imaging. Design, Setting, and Participants: Retrospective cohort study of patterns of medical imaging between 2000 and 2016 among 16 million to 21 million patients enrolled annually in 7 US integrated and mixed-model insurance health care systems and for individuals receiving care in Ontario, Canada. Exposures: Calendar year and country (United States vs Canada). Main Outcomes and Measures: Use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and nuclear medicine imaging. Annual and relative imaging rates by imaging modality, country, and age (children [<18 years], adults [18-64 years], and older adults [≥65 years]). Results: Overall, 135 774 532 imaging examinations were included; 5 439 874 (4%) in children, 89 635 312 (66%) in adults, and 40 699 346 (30%) in older adults. Among adults and older adults, imaging rates were significantly higher in 2016 vs 2000 for all imaging modalities other than nuclear medicine. For example, among older adults, CT imaging rates were 428 per 1000 person-years in 2016 vs 204 per 1000 in 2000 in US health care systems and 409 per 1000 vs 161 per 1000 in Ontario; for MRI, 139 per 1000 vs 62 per 1000 in the United States and 89 per 1000 vs 13 per 1000 in Ontario; and for ultrasound, 495 per 1000 vs 324 per 1000 in the United States and 580 per 1000 vs 332 per 1000 in Ontario. Annual growth in imaging rates among US adults and older adults slowed over time for CT (from an 11.6% annual percentage increase among adults and 9.5% among older adults in 2000-2006 to 3.7% among adults in 2013-2016 and 5.2% among older adults in 2014-2016) and for MRI (from 11.4% in 2000-2004 in adults and 11.3% in 2000-2005 in older adults to 1.3% in 2007-2016 in adults and 2.2% in 2005-2016 in older adults). Patterns in Ontario were similar. Among children, annual growth for CT stabilized or declined (United States: from 10.1% in 2000-2005 to 0.8% in 2013-2016; Ontario: from 3.3% in 2000-2006 to -5.3% in 2006-2016), but patterns for MRI were similar to adults. Changes in annual growth in ultrasound were smaller among adults and children in the United States and Ontario compared with CT and MRI. Nuclear medicine imaging declined in adults and children after 2006. Conclusions and Relevance: From 2000 to 2016 in 7 US integrated and mixed-model health care systems and in Ontario, rates of CT and MRI use continued to increase among adults, but at a slower pace in more recent years. In children, imaging rates continued to increase except for CT, which stabilized or declined in more recent periods. Whether the observed imaging utilization was appropriate or was associated with improved patient outcomes is unknown.


Assuntos
Diagnóstico por Imagem/tendências , Abdome/diagnóstico por imagem , Adolescente , Adulto , Idoso , Criança , Diagnóstico por Imagem/estatística & dados numéricos , Cabeça/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética/estatística & dados numéricos , Imagem por Ressonância Magnética/tendências , Pessoa de Meia-Idade , Ontário , Cintilografia/estatística & dados numéricos , Cintilografia/tendências , Coluna Vertebral/diagnóstico por imagem , Tórax/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Tomografia Computadorizada por Raios X/tendências , Ultrassonografia/estatística & dados numéricos , Ultrassonografia/tendências , Estados Unidos , Adulto Jovem
4.
Can Assoc Radiol J ; 70(4): 344-353, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31522841

RESUMO

PURPOSE: The required training sample size for a particular machine learning (ML) model applied to medical imaging data is often unknown. The purpose of this study was to provide a descriptive review of current sample-size determination methodologies in ML applied to medical imaging and to propose recommendations for future work in the field. METHODS: We conducted a systematic literature search of articles using Medline and Embase with keywords including "machine learning," "image," and "sample size." The search included articles published between 1946 and 2018. Data regarding the ML task, sample size, and train-test pipeline were collected. RESULTS: A total of 167 articles were identified, of which 22 were included for qualitative analysis. There were only 4 studies that discussed sample-size determination methodologies, and 18 that tested the effect of sample size on model performance as part of an exploratory analysis. The observed methods could be categorized as pre hoc model-based approaches, which relied on features of the algorithm, or post hoc curve-fitting approaches requiring empirical testing to model and extrapolate algorithm performance as a function of sample size. Between studies, we observed great variability in performance testing procedures used for curve-fitting, model assessment methods, and reporting of confidence in sample sizes. CONCLUSIONS: Our study highlights the scarcity of research in training set size determination methodologies applied to ML in medical imaging, emphasizes the need to standardize current reporting practices, and guides future work in development and streamlining of pre hoc and post hoc sample size approaches.


Assuntos
Pesquisa Biomédica , Diagnóstico por Imagem/estatística & dados numéricos , Aprendizado de Máquina , Humanos , Tamanho da Amostra
5.
Phys Ther ; 99(9): 1150-1166, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31505674

RESUMO

BACKGROUND: Over the past few decades, physical therapists have emerged as key health care providers in emergency departments (EDs), especially for patients with musculoskeletal disorders (MSKD). PURPOSE: The purpose of this review was to update the current evidence regarding physical therapist care for patients with MSKD in EDs and to update current recommendations for these models of care. DATA SOURCES: Systematic searches were conducted in 5 bibliographic databases. STUDY SELECTION: The studies selected presented quantitative data related to the care of patients with MSKD by physical therapists in an ED setting. DATA EXTRACTION: Raters reviewed studies and used the Effective Public Health Practice Project Quality Assessment Tool to assess their methodological quality. DATA SYNTHESIS: Fifteen studies were included. Two studies, 1 of weak and 1 of strong quality, demonstrated that physical therapist care in EDs was as effective as or more effective than usual medical care for pain reduction, and 6 studies of varying quality reported that physical therapist care in EDs was as effective as usual care in EDs in reducing disability. Eight studies of varying quality reported that physical therapist care could significantly reduce waiting time in EDs. Four studies of varying quality reported that physical therapists ordered no more, or even fewer, medical images than physicians. In terms of health care costs, 2 studies of moderate to high quality found no significant differences in costs between physical therapist care and usual care in EDs. Finally, 6 studies of varying quality reported that patients were as satisfied or more satisfied with physical therapist care as with usual medical care in EDs. LIMITATIONS: The roles of physical therapists in EDs vary depending on the setting, legislation, and training of providers. Only a limited number of high-quality studies were identified. CONCLUSIONS: Although the quality of the evidence is heterogeneous, physical therapist care for patients with MSKD in EDs may be beneficial.


Assuntos
Serviço Hospitalar de Emergência , Doenças Musculoesqueléticas/reabilitação , Modalidades de Fisioterapia , Diagnóstico por Imagem/estatística & dados numéricos , Custos de Cuidados de Saúde , Humanos , Doenças Musculoesqueléticas/psicologia , Satisfação do Paciente , Fisioterapeutas , Modalidades de Fisioterapia/economia , Modalidades de Fisioterapia/psicologia
6.
Crit Care Resusc ; 21(3): 212-219, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31462208

RESUMO

OBJECTIVE: Ionising radiation is a valuable tool in modern medicine including for patients in an intensive care unit (ICU). However, clinicians are faced with a trade-off between benefit of information received from procedure versus risks associated with radiation. As a first step to understanding the risk and benefits of radiation exposure to ICU patients, we aimed to assess the cumulative levels of ionising radiation patients receive during their ICU stay. DESIGN: Retrospective audit. SETTING: A single tertiary care ICU in South Australia. PARTICIPANTS: This audit included 526 patients admitted to the ICU at Flinders Medical Centre, Adelaide, SA, for longer than 120 hours (long stay) over a 12-month period from April 2015 to April 2016. MAIN OUTCOME MEASURES: Cumulative radiation exposure to ICU patients. RESULTS: The 526 patients audited underwent 4331 procedures totalling 5688.45 mSv of ionising radiation. The most frequent procedure was chest x-ray (82%), which contributed 1.2% to cumulative effective dose (CED). Although only 3.6% of the total procedures, abdominal and pelvic computed tomography (CT) contributed the most to CED (68%). Over 50% of patients received less than 1 mSv CED during their stay in the ICU. However, 6% received > 50 mSv and 1.3% received > 100 mSv CED. Trauma patients received significantly higher CED compared with other admission diagnoses, and CED increased with length of stay. CONCLUSION: Most ICU patients received low CED during their stay, with the majority receiving less than the recommended limit for members of the public (1 mSv). These results may educate clinicians regarding radiation exposures in ICU settings, highlighting the relatively low exposures and thus low risk to the patients.


Assuntos
Estado Terminal , Diagnóstico por Imagem/estatística & dados numéricos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Doses de Radiação , Exposição à Radiação , Radiação Ionizante , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Austrália , Feminino , Humanos , Masculino , Estudos Retrospectivos
7.
West J Emerg Med ; 20(4): 541-548, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31316691

RESUMO

Introduction: Advanced practice providers (APP), including physicians' assistants and nurse practitioners, have been increasingly incorporated into emergency department (ED) staffing over the past decade. There is scant literature examining resource utilization and the cost benefit of having APPs in the ED. The objectives of this study were to compare resource utilization in EDs that use APPs in their staffing model with those that do not and to estimate costs associated with the utilized resources. Methods: In this five-year retrospective secondary data analysis of the Emergency Department Benchmarking Alliance (EDBA), we compared resource utilization rates in EDs with and without APPs in non-academic EDs. Primary outcomes were hospital admission and use of computed tomography (CT), radiography, ultrasound, and magnetic resonance imaging (MRI). Costs were estimated using the 2014 physician fee schedule and inpatient payments from the Centers for Medicare and Medicaid Services. We measured outcomes as rates per 100 visits. Data were analyzed using a mixed linear model with repeated measures, adjusted for annual volume, patient acuity, and attending hours. We used the adjusted net difference to project utilization costs between the two groups per 1000 visits. Results: Of the 1054 EDs included in this study, 79% employed APPs. Relative to EDs without APPs, EDs staffing APPs had higher resource utilization rates (use per 100 visits): 3.0 more admissions (95% confidence interval [CI], 2.0-4.1), 1.7 more CTs (95% CI, 0.2-3.1), 4.5 more radiographs (95% CI, 2.2-6.9), and 1.0 more ultrasound (95% CI, 0.3-1.7) but comparable MRI use 0.1 (95% CI, -0.2-0.3). Projected costs of these differences varied among the resource utilized. Compared to EDs without APPs, EDs with APPs were estimated to have 30.4 more admissions per 1000 visits, which could accrue $414,717 in utilization costs. Conclusion: EDs staffing APPs were associated with modest increases in resource utilization as measured by admissions and imaging studies.


Assuntos
Serviço Hospitalar de Emergência/economia , Profissionais de Enfermagem , Assistentes Médicos , Diagnóstico por Imagem/economia , Diagnóstico por Imagem/estatística & dados numéricos , Humanos , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
8.
AJR Am J Roentgenol ; 213(4): W180-W184, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31237433

RESUMO

OBJECTIVE. The purpose of this study was to study trends in utilization of imaging in emergency departments (ED) in relation to trends in ED visits and the specialties of the interpreting physicians. MATERIALS AND METHODS. This study was conducted with Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004-2016 and Health Care Cost and Utilization Project (HCUP) data from 2006 to 2014. Yearly utilization was calculated per 1000 Medicare beneficiaries for different noninvasive imaging modalities performed during ED visits, and the specialties of the physicians making the interpretations were recorded. The number of ED visits by Medicare patients was obtained from the HCUP. RESULTS. The number of ED visits by Medicare fee-for-service patients increased 8.0% (from 20.0 million in 2006 to 21.6 million in 2014), and the total number of associated ED imaging examinations increased 38.4% (14.6 million to 20.2 million). The number of imaging examinations per ED visit was 0.73 in 2006, increasing to 0.94 by 2014. Utilization trends per 1000 Medicare fee-for-service enrollees in the ED for the major modalities were as follows: CT +153.0% (77.8 in 2004 to 196.7 in 2016), noncardiac ultrasound +134% (11.2 in 2004 to 26.2 in 2016), and radiography +30% (259 in 2004 to 336 in 2016). Utilization of MRI and nuclear medicine was very low. In 2016, radiologists interpreted 99.5% (CT), 99.2% (MRI), 98.0% (radiography), 87.6% (ultrasound), and 94.5% (nuclear medicine) of imaging examinations. CONCLUSION. Utilization of imaging in EDs is increasing not only in the Medicare population but also per ED visit. Radiologists strongly predominate in interpreting examinations in all modalities.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/tendências , Humanos , Estados Unidos , Revisão da Utilização de Recursos de Saúde
9.
Nurs Outlook ; 67(6): 713-724, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31248627

RESUMO

BACKGROUND: Little is known about the extent of ordering low-value services by. PURPOSE: To compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs). METHOD: We used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ̱regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR). FINDINGS: PCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates. DISCUSSION: PCNPs and PCMDs order low-value back images at an effectively similar rate.


Assuntos
Dor nas Costas/diagnóstico por imagem , Diagnóstico por Imagem/economia , Diagnóstico por Imagem/estatística & dados numéricos , Medicare/economia , Profissionais de Enfermagem/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/economia , Estudos de Coortes , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
10.
Ann Intern Med ; 170(12): 880-885, 2019 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-31181572

RESUMO

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.


Assuntos
Sistemas de Apoio a Decisões Clínicas/legislação & jurisprudência , Diagnóstico por Imagem , Medicaid/legislação & jurisprudência , Medicare/legislação & jurisprudência , Procedimentos Desnecessários , Diagnóstico por Imagem/estatística & dados numéricos , Documentação , Utilização de Instalações e Serviços , Fidelidade a Diretrizes , Humanos , Reembolso de Seguro de Saúde , Medição de Risco , Estados Unidos , Procedimentos Desnecessários/estatística & dados numéricos
11.
AJR Am J Roentgenol ; 213(3): 637-643, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31063428

RESUMO

OBJECTIVE. The purpose of this study is to investigate the magnitude of physician variation in the use of imaging and the factors associated with variation in an urban emergency department (ED) in the United States. MATERIALS AND METHODS. This retrospective cohort study was conducted from April 1, 2013, to March 31, 2014, in the ED of a level I adult trauma center in the northeastern United States. The study cohort included all patient visits to the ED during the study period. We built hierarchic and logistic regression models to determine per-physician utilization of low- and high-cost imaging, and we identified factors correlated with variation in use. Global (i.e., intraclass correlation coefficient) and individual variability metrics were used to profile physician variation after controlling for patient-, visit-, and physician-related covariates. RESULTS. A total of 56,793 patients presented to the ED during the study; of these patients, 49.5% (28,135) underwent imaging, with 38.2% (21,686) undergoing low-cost imaging and 21.9% (12,430) undergoing high-cost imaging. Statistically significant predictors of imaging orders were patient age and sex, number of secondary diagnoses, certain primary diagnoses, time of arrival in the ED, and ED crowding. Unadjusted and adjusted intraclass correlation coefficients were 0.0072 and 0.0066, respectively, for low-cost imaging, and 0.0097 and 0.0090, respectively, for high-cost imaging. The coefficient of variation for adjusted imaging odds ratios was 10.9% and 14.0% for low- and high-cost imaging, respectively, indicating a moderate degree of variation. CONCLUSION. Unexplained and moderate variation in imaging utilization exists among ED physicians, even after controlling for patient, visit, and physician characteristics. Improvement initiatives using well-defined ED imaging quality measures may help improve quality and reduce waste.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
12.
Hosp Top ; 97(3): 87-98, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31130107

RESUMO

Health care organizations worldwide are constantly under pressure to deliver quality services. Reducing the waiting time of patients is considered to be a significant issue in hospitals. In this study, a radio-diagnosis department in a healthcare organization is considered. The present study mainly focuses on the queuing system of a computed tomography scan section of a public hospital in South India. Simulation is used as an aid to study the behavior of the system. This article also contributes a Visual Basic with Applications based excel tool to tackle the need for a user-friendly tool for scheduling the patients.


Assuntos
Agendamento de Consultas , Tomografia Computadorizada por Raios X/métodos , Simulação por Computador/tendências , Diagnóstico por Imagem/métodos , Diagnóstico por Imagem/normas , Diagnóstico por Imagem/estatística & dados numéricos , Humanos , Índia , Satisfação do Paciente , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Tomografia Computadorizada por Raios X/normas , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Listas de Espera
13.
Arch Phys Med Rehabil ; 100(9): 1592-1598, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31002811

RESUMO

OBJECTIVE: Carpal tunnel syndrome (CTS) is frequently seen as a work-related disorder. Few studies have examined the treatment of CTS by insurance coverage, and none have used a large, population-based dataset. This study examined the extent to which the use of CTS tests and treatments varied for those on workers' compensation insurance (WCI) vs private insurance and Medicaid, controlling for patient and provider characteristics. DESIGN: Analysis of 10 years of data (2005-2014) from the National Ambulatory Medical Care Survey. SETTING: United States office-based physician practices. PARTICIPANTS: Adults 18-64 years who had a physician visit for CTS (N=23,236,449). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We examined use of 2 diagnostic tests, imaging and electromyography, and 7 treatments: casting, splinting, occupational therapy (OT), physical therapy (PT), carpal tunnel release surgery, steroid injections, and nonsteroidal anti-inflammatory drug (NSAID). RESULTS: Individuals who sought care for CTS were more likely to be covered by private insurance (56.9%) than WCI (9.8%) or Medicaid (6.5%). The most commonly prescribed treatment for all types of insurance coverage was splints, followed by NSAID prescription, and OT or PT therapies. Steroid injections (1.2%) and CTS surgery (4.5%) were used significantly less than other treatment types. Patients on WCI were less likely to receive diagnostic tests, and more likely to receive OT or PT than those on other types of insurance coverage. CONCLUSION: Patients with CTS who seek ambulatory care are most likely to be covered by private insurance. Insurance coverage appears to play a role in treatment and diagnostic choices for CTS.


Assuntos
Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/terapia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Indenização aos Trabalhadores/estatística & dados numéricos , Adolescente , Adulto , Anti-Inflamatórios não Esteroides/uso terapêutico , Síndrome do Túnel Carpal/cirurgia , Diagnóstico por Imagem/estatística & dados numéricos , Eletromiografia/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Ocupacional/estatística & dados numéricos , Modalidades de Fisioterapia/estatística & dados numéricos , Contenções/estatística & dados numéricos , Esteroides/uso terapêutico , Estados Unidos , Adulto Jovem
14.
Eur J Cancer Care (Engl) ; 28(4): e13043, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30993764

RESUMO

Population-based cancer registry data from three Spanish areas were used to assess the patterns of care and adherence to guidelines for cutaneous malignant melanoma. We included 934 cases diagnosed in 2009-2013. Completeness of the pathology reports, imaging for detecting distant metastasis and the use of sentinel lymph node biopsy (SLNB) were analysed. The proportion of pathology reports that mentioned the essential pathological features required for T staging was 93%, ranging across geographic areas from 81% to 98% (p < 0.001). The percentage of low-risk patients who underwent no imaging studies, as proposed by guidelines, or only chest imaging ranged among areas from 0.6% to 84% (p < 0.001). Of the patients with clinically node-negative melanoma >1 mm thick and no distant metastases, 68% underwent SLNB, varying by area from 61% to 78% (p = 0.017). This study revealed wide geographic variation in different aspects of melanoma care. The use of a standardised structured pathology report could strengthen the completeness of reporting. Improvement strategies should also include efforts to reduce overuse of imaging in low-risk patients and to increase the adherence to guidelines recommendations on the use of SLNB.


Assuntos
Disparidades em Assistência à Saúde , Melanoma/cirurgia , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Diagnóstico por Imagem/normas , Diagnóstico por Imagem/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes , Humanos , Excisão de Linfonodo/normas , Excisão de Linfonodo/estatística & dados numéricos , Metástase Linfática , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto/normas , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela/normas , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Neoplasias Cutâneas/patologia , Espanha
15.
PLoS One ; 14(4): e0214905, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30964899

RESUMO

BACKGROUND: Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients' need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter. METHODS: We used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient's ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models. RESULTS: Among the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models. CONCLUSIONS: Patient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Triagem/estatística & dados numéricos , Adolescente , Adulto , Idoso , Aglomeração , Feminino , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Processamento de Linguagem Natural , Estados Unidos , Adulto Jovem
16.
Occup Environ Med ; 76(5): 317-325, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30890565

RESUMO

OBJECTIVES: To assess radiation exposure-related work history and risk of cataract and cataract surgery among radiologic technologists assisting with fluoroscopically guided interventional procedures (FGIP). METHODS: This retrospective study included 35 751 radiologic technologists who reported being cataract-free at baseline (1994-1998) and completed a follow-up questionnaire (2013-2014). Frequencies of assisting with 21 types of FGIP and use of radiation protection equipment during five time periods (before 1970, 1970-1979, 1980-1989, 1990-1999, 2000-2009) were derived from an additional self-administered questionnaire in 2013-2014. Multivariable-adjusted relative risks (RRs) for self-reported cataract diagnosis and cataract surgery were estimated according to FGIP work history. RESULTS: During follow-up, 9372 technologists reported incident physician-diagnosed cataract; 4278 of incident cases reported undergoing cataract surgery. Technologists who ever assisted with FGIP had increased risk for cataract compared with those who never assisted with FGIP (RR: 1.18, 95% CI 1.11 to 1.25). Risk increased with increasing cumulative number of FGIP; the RR for technologists who assisted with >5000 FGIP compared with those who never assisted was 1.38 (95% CI 1.24 to 1.53; p trend <0.001). These associations were more pronounced for FGIP when technologists were located ≤3 feet (≤0.9 m) from the patient compared with >3 feet (>0.9 m) (RRs for >5000 at ≤3 feet vs never FGIP were 1.48, 95% CI 1.27 to 1.74 and 1.15, 95% CI 0.98 to 1.35, respectively; pdifference=0.04). Similar risks, although not statistically significant, were observed for cataract surgery. CONCLUSION: Technologists who reported assisting with FGIP, particularly high-volume FGIP within 3 feet of the patient, had increased risk of incident cataract. Additional investigation should evaluate estimated dose response and medically validated cataract type.


Assuntos
Catarata/diagnóstico , Diagnóstico por Imagem/efeitos adversos , Medição de Risco/normas , Adulto , Catarata/epidemiologia , Estudos de Coortes , Diagnóstico por Imagem/estatística & dados numéricos , Feminino , Fluoroscopia/efeitos adversos , Fluoroscopia/métodos , Fluoroscopia/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Inquéritos e Questionários
17.
PLoS One ; 14(3): e0213373, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30875381

RESUMO

There is widespread concern over the health risks and healthcare costs from potentially inappropriate high-cost imaging. As a result, the Centers for Medicare and Medicaid Services (CMS) will soon require high-cost imaging orders to be accompanied by Clinical Decision Support (CDS): software that provides appropriateness information at the time orders are placed via a best practice alert for targeted (i.e. likely inappropriate) imaging orders, although the impacts of CDS in this context are unclear. In this randomized trial of 3,511 healthcare providers at Aurora Health Care, we study the impacts of CDS on the ordering behavior of providers. We find that CDS reduced targeted imaging orders by a statistically significant 6%, however there was no statistically significant change in the total number of high-cost scans or of low-cost scans. The results suggest that the impending CMS mandate requiring healthcare systems to adopt CDS may modestly increase the appropriateness of high-cost imaging.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Diagnóstico por Imagem/economia , Benchmarking , Diagnóstico por Imagem/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Pessoal de Saúde , Humanos , Masculino , Medicaid/economia , Sistemas de Registro de Ordens Médicas , Medicare/economia , Estudos Prospectivos , Software , Estados Unidos , Wisconsin
19.
Emerg Radiol ; 26(4): 381-389, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30790114

RESUMO

PURPOSE: Diagnostic imaging has mirrored the steady growth of healthcare utilization in the USA. This has created greater opportunity for diagnostic errors, which can be costly in terms of morbidity and mortality as well as dollars and cents. The purposes of this study were to describe all return visits to a tertiary care urban pediatric emergency department (PED) resulting from diagnostic imaging discrepancies and to calculate the costs of these return visits. METHODS: From July 2014 to February 2015, all children who underwent a diagnostic imaging study during an ED visit were assembled. Analysis was performed on all children who were called back and returned to the ED following a discrepant read. Direct and indirect costs to the patient, family, hospital, and society for these return visits were calculated. RESULTS: During the study period, 8310 diagnostic imaging studies were performed, with 207 (2.5%) discrepant reads. Among the discrepant reads, 37 (0.4% of total, 17.9% of discrepant) patients had a return visit to the ED for further management. Including ED charges, time and travel costs to the family, and costs of radiation exposure, return visits for radiologic discrepancies over this 8-month period cost a total of $84,686.47, averaging $2288.82 per patient. CONCLUSIONS: Though the overall diagnostic imaging discrepancy rate among our study population was low, the clinically significant discrepancies requiring return ED visits were potentially high risk, and costly for the patient, family, and healthcare system.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Erros de Diagnóstico/estatística & dados numéricos , Diagnóstico por Imagem/estatística & dados numéricos , Serviço Hospitalar de Emergência , Adolescente , Criança , Pré-Escolar , Continuidade da Assistência ao Paciente/economia , Erros de Diagnóstico/economia , Diagnóstico por Imagem/economia , Feminino , Hospitais Pediátricos , Humanos , Lactente , Masculino
20.
Phys Ther ; 99(8): 1020-1026, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30715477

RESUMO

BACKGROUND: Significant progress has been made in implementing direct access. As more therapists transition into direct access roles, it seems prudent to consider how additional resources common to other first-contact providers might impact patient care. OBJECTIVES: Direct referral for diagnostic imaging by physical therapists is relatively rare in the civilian setting and little has been published on the subject. The primary objective of this study was to examine the appropriateness of diagnostic imaging studies referred by civilian physical therapists at an academic medical center. Secondary objectives were to track reimbursement data and overall use rates. DESIGN: This was a single-center, retrospective practice analysis of 10 physical therapists over a period of nearly 5 years. METHODS: The electronic medical record was reviewed for each patient who had an imaging referral placed by a physical therapist. Relevant clinical exam findings and patient history were provided to a radiologist who then applied the American College of Radiology Appropriateness Criteria to determine appropriateness. Reimbursement data and therapist use rates were also evaluated. RESULTS: Of the 108 total imaging studies, 91% were considered appropriate. Overall, use rates per direct access evaluation were 9% for plain film x-rays and 4% for advanced imaging. Reimbursement was 100%. LIMITATIONS: This study was limited to 10 physical therapists at 1 practice location. Appropriateness was evaluated by 1 radiologist. The educational background of referring therapists was not evaluated. CONCLUSIONS: Physical therapists demonstrated appropriate use of diagnostic imaging in the vast majority of cases (91%). They were judicious in their use of imaging, and there were no issues with reimbursement. These findings could be useful for physical therapists interested in acquiring diagnostic imaging referral privileges.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Privilégios do Corpo Clínico , Fisioterapeutas , Encaminhamento e Consulta/estatística & dados numéricos , Centros Médicos Acadêmicos , Diagnóstico por Imagem/economia , Feminino , Humanos , Doenças Musculoesqueléticas/diagnóstico , Fisioterapia , Serviço Hospitalar de Radiologia/estatística & dados numéricos , Estudos Retrospectivos
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