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2.
Pediatrics ; 144(2)2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31358664

RESUMO

CONTEXT: Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. OBJECTIVE: To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. DATA SOURCES: Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care." STUDY SELECTION: English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. DATA EXTRACTION: Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. RESULTS: Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. LIMITATIONS: Quantitative meta-analysis was not possible because of study heterogeneity. CONCLUSIONS: Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.


Assuntos
Grupos de Populações Continentais/etnologia , Grupos Étnicos , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/normas , Unidades de Terapia Intensiva Neonatal/normas , Terapia Intensiva Neonatal/normas , Humanos , Recém-Nascido , Terapia Intensiva Neonatal/métodos , Qualidade da Assistência à Saúde/normas
3.
Arch Cardiovasc Dis ; 112(6-7): 374-380, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31160206

RESUMO

BACKGROUND: In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible. AIM: To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway. METHODS: RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included. RESULTS: Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65). CONCLUSIONS: The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.


Assuntos
Procedimentos Clínicos/normas , Serviços Médicos de Emergência/normas , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Operador de Emergência Médica , Feminino , França , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores Sexuais , Fatores de Tempo , Transporte de Pacientes/normas , Resultado do Tratamento
4.
PLoS One ; 14(5): e0217197, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31120921

RESUMO

Health disparities research in low- and middle-income countries (LMICs) is hampered by the difficulty of measuring economic status in low-resource settings. We previously developed the EconomicClusters k-medoids clustering-based algorithm for defining population-specific economic models based on few Demographic and Health Surveys (DHS) assets. The algorithm previously defined a twenty-group economic model for Cameroon. The aims of this study are to optimize the functionality of our EconomicClusters algorithm and app based on collaborator feedback from early use of this twenty-group economic model, to test the validity of the model as a metric of economic status, and to assess the utility of the model in another LMIC context. We condense the twenty Cameroonian economic groups into fewer, ordinally-ranked, groups using agglomerative hierarchical clustering based on mean cluster child height-for-age Z-score (HAZ), women's literacy score, and proportion of children who are deceased. We develop an EconomicClusters model for Ghana consisting of five economic groups and rank these groups based on the same three variables. The proportion of variance in women's literacy score accounted for by the EconomicClusters model was 5-12% less than the proportion of variance accounted for by the DHS Wealth Index model. The proportion of the variance in child HAZ and proportion of children who are deceased accounted for by the EconomicClusters model was similar to (0.4-2.5% less than) the proportion of variance accounted for by the DHS Wealth Index model. The EconomicClusters model requires asking only five questions, as opposed to greater than twenty Wealth Index questions. The EconomicClusters algorithm and app could facilitate health disparities research in any country with DHS data by generating ordinally-ranked, population-specific economic models that perform nearly as well as the Wealth Index in evaluating variability in health and social outcomes based on wealth status but that are more feasible to assess in time-constrained settings.


Assuntos
Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/normas , Modelos Econômicos , Camarões , Criança , Estudos Transversais , Demografia , Desenvolvimento Econômico , Gana , Saúde Global , Humanos , Pobreza , Fatores Socioeconômicos
5.
J Stroke Cerebrovasc Dis ; 28(5): 1302-1310, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30824298

RESUMO

BACKGROUND: The quality of care and outcomes for people who experience stroke whilst in hospital for another condition has not been previously studied in Australia. AIMS: To explore differences in long-term outcomes among patients with in-hospital events treated in stroke units (SUs) compared to those managed in other hospital wards. METHODS: Forty-five hospitals participating in the Australian Stroke Clinical Registry between January 2010 and December 2014 contributed data. Survival of all patients with in-hospital stroke to 180 days after stroke and health-related quality of life, using EQ-5D-3L among 73% eligible, were compared using multilevel, multivariable regression models. Models were adjusted for age, sex, index of relative socioeconomic disadvantage, ability to walk, stroke type, transfer from another hospital, and history of stroke. RESULTS: Among 20,786 stroke events, 1182 (5.1%) occurred in-hospital (median age 77 years, 49% male). Patients with in-hospital stroke treated in SUs died less often within 30 days (Hazard Ratio 0.56; 95% CI 0.39-0.81) than those not admitted to SUs. Survivors reported similar health-related quality of life between 90 and 180 days compared to those treated in other wards (coefficient = 0.01, 95% CI -0.06-0.09, P = .78). Patients managed in SUs more often received recommended management (e.g. swallowing screening). CONCLUSION: The benefits of SU care may extend to patients experiencing in-hospital stroke. Validation, including accounting for potential residual confounding factors, is required.


Assuntos
Disparidades em Assistência à Saúde/normas , Unidades Hospitalares/normas , Hospitalização , Pacientes Internados , Indicadores de Qualidade em Assistência à Saúde/normas , Reabilitação do Acidente Vascular Cerebral/normas , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Humanos , Masculino , Qualidade de Vida , Recuperação de Função Fisiológica , Sistema de Registros , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
7.
Pediatr Blood Cancer ; 66(6): e27663, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30786168

RESUMO

BACKGROUND: In 2014, a task force of the International Society of Paediatric Oncology (SIOP) Paediatric Oncology in Developing Countries Nursing Workgroup published six baseline standards to provide a framework for pediatric oncology nursing care in low- and lower-middle income countries (L/LMIC). We conducted an international survey in 2016-2017 to examine the association between country income level and nurses' resporting of conformity to the standards at their respective institutions. PROCEDURE: Data from a cross-sectional web-based survey completed by nurses representing 54 countries were analyzed (N = 101). Responses were clustered by relevance to each standard and compared according to the 2017 World Bank-defined country income classification (CIC) of hospitals. RESULTS: CIC and nurse-to-patient ratios in inpatient wards were strongly associated (P < 0.0001). Nurses in L/LMIC prepared chemotherapy more often (P < 0.0001) yet were less likely to have access to personal protective equipment such as nitrile gloves (P = 0.0007) and fluid-resistant gowns (P = 0.011) than nurses in high-resource settings. Nurses in L/LMIC were excluded more often from physician/caregiver meetings to discuss treatment options (P = 0.04) and at the time of diagnosis (P = 0.002). Key educational topics were missing from nursing orientation programs across all CICs. An association between CIC and the availability of written policies (P = 0.009) was found. CONCLUSIONS: CIC and the ability to conform to pediatric oncology baseline nursing standards were significantly associated in numerous elements of the baseline standards, a likely contributor to suboptimal patient outcomes in L/LMIC. To achieve the goal of high-quality cancer care for children worldwide, nursing disparities must be addressed.


Assuntos
Disparidades em Assistência à Saúde/normas , Renda/estatística & dados numéricos , Neoplasias/enfermagem , Enfermagem Oncológica/normas , Enfermagem Pediátrica/normas , Qualidade da Assistência à Saúde/normas , Padrão de Cuidado , Estudos Transversais , Países em Desenvolvimento , Humanos , Agências Internacionais , Prognóstico , Inquéritos e Questionários
9.
J Ren Care ; 45(1): 4-8, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30784230

RESUMO

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here we highlight the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is a World Health Organization Sustainable Development Goal. While universal health coverage may not include all elements of kidney care in all countries, understanding what is locally feasible and important with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.


Assuntos
Efeitos Psicossociais da Doença , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Nefropatias/complicações , Política de Saúde , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Terapia de Substituição Renal
10.
Fam Community Health ; 42(2): 117-122, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30768476

RESUMO

The purpose of this study was to examine relationships between food security, parental health behaviors, and overweight/obesity among 2- to 5-year-old children in West Tennessee (N = 264). Results from logistic regression models indicate that the association between parental characteristics and child weight status varies by child sex and household food security. These findings highlight the need for more nuanced analysis that can produce results that inform and shape the development of precise health promotion and intervention strategies designed for diverse low-resource populations.


Assuntos
Abastecimento de Alimentos/métodos , Disparidades em Assistência à Saúde/normas , Obesidade/etiologia , Sobrepeso/etiologia , Instituições de Assistência Ambulatorial , Pré-Escolar , Feminino , Humanos , Masculino
11.
Rev Epidemiol Sante Publique ; 67 Suppl 1: S33-S40, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30639052

RESUMO

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.


Assuntos
Implementação de Plano de Saúde , Política de Saúde , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Populações Vulneráveis , Tomada de Decisões , Emergências , França/epidemiologia , Implementação de Plano de Saúde/legislação & jurisprudência , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/normas , Política de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/legislação & jurisprudência , Disparidades em Assistência à Saúde/organização & administração , Disparidades em Assistência à Saúde/normas , Humanos , Programas Nacionais de Saúde/legislação & jurisprudência , Programas Nacionais de Saúde/organização & administração , Programas Nacionais de Saúde/tendências , Direitos do Paciente/legislação & jurisprudência , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/legislação & jurisprudência , Atenção Primária à Saúde/organização & administração , Fatores Socioeconômicos , Populações Vulneráveis/estatística & dados numéricos
12.
Nurs Adm Q ; 43(1): 19-25, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30516703

RESUMO

Guam, an unincorporated territory of the United States, is one of the ten (10) US Affiliated Pacific Islands. The geographic location in the western Pacific Ocean, as well as the ties to the US position Guam as a strategic hub between the continental US, Asia, and the Pacific region. Health disparities in Guam and the Micronesian region are significant, and the non-communicable disease crisis is worsening, threatening the existing poor health infrastructure on the islands. Migration of islanders from the Micronesian region, whose countries also suffer health disparities, adds to the burden of the weak health care system on Guam. A critical nursing workforce shortage plagues the health care community, and strong nursing leadership is needed to address the problems. Nurse leaders, through many organizations, are working to implement strategies to address the issues facing the islands. Increased collaboration with partners on the island, on the US mainland, and globally, are necessary to effectively address Guam's health care concerns.


Assuntos
Disparidades em Assistência à Saúde/normas , Liderança , Enfermeiras e Enfermeiros/provisão & distribução , Guam , Ocupações em Saúde/tendências , Humanos , Enfermeiras e Enfermeiros/tendências
13.
Pediatr Dermatol ; 36(1): 169-171, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30318854

RESUMO

As the transgender community has become increasingly visible in public life, a greater awareness of this group's unique health needs and obstacles to optimal medical care has developed. Unfortunately, transgender youth face multiple barriers within the health care system, including access to equitable and gender-affirming care. As dermatologists who care for children and adolescents, we must be aware of the challenges facing transgender youth and work to correct the disparities that exist for this vulnerable group. An initial step in supporting our transgender patients is to advocate for changes to the iPLEDGE system for prescribing isotretinoin (and other Risk Evaluation and Mitigation Strategy systems), specifically requesting a change to its gender-binary categorization model that compromises an individual's right to self-identify. By promoting a gender-neutral patient categorization that is based instead upon reproductive potential, a simple change to the iPLEDGE program allows us to safely treat all of our patients requiring isotretinoin, while preserving our transgender patients' rights to self-determination and self-identification.


Assuntos
Acne Vulgar/tratamento farmacológico , Fármacos Dermatológicos/uso terapêutico , Isotretinoína/uso terapêutico , Padrões de Prática Médica , Pessoas Transgênero , Adolescente , Criança , Assistência à Saúde , Feminino , Identidade de Gênero , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Pediatras , Melhoria de Qualidade
14.
Nurs Res ; 68(2): 99-109, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30540700

RESUMO

BACKGROUND: An emphasis on precision health (PH) has stimulated precision medicine studies to focus on the interplay of biological, behavioral, and environmental factors with disease risks, treatments, prognoses, and outcomes affecting health disparities. It is imperative, as well, that improving health equity among underserved populations remains central to the efforts and aims of PH. OBJECTIVES: The aim if this study was to apply the transdisciplinary ConNECT Framework: A Model for Advancing Behavioral Medicine Science and Practice to Foster Health Equity to PH by integrating a population health agenda for reducing health disparities. METHODS: There are five ConNECT principles: (a) integrating context; (b) fostering a norm of inclusion; (c) ensuring equitable diffusion of innovations; (d) harnessing communication technology; and (e) prioritizing specialized training as an organizing framework to PH, including examples of how to integrate behavioral and socioecological determinants to better understand the contexts of individuals, systems, and place to design targeted treatments and interventions. RESULTS: We describe proactive, actionable strategies for the systematic application of ConNECT Framework principles to address health equity via the PH initiative. Context and implications for nursing research and practice are also described. DISCUSSION: The ConNECT Framework emphasizes that diversity inclusion is imperative for true population health benefit from PH, broadly in public health, behavioral medicine, medicine, and nursing, to equip health researchers and practitioners to account for contextual socioecologic data that can be aligned with biologic data for more population responsive and individually tailored interventions to prevent, diagnose, and treat diseases.


Assuntos
Equidade em Saúde/normas , Disparidades em Assistência à Saúde/normas , Pesquisa em Enfermagem/normas , Medicina de Precisão/enfermagem , Atenção Primária à Saúde/normas , Humanos , Comunicação Interdisciplinar
15.
Arch Dis Child ; 104(4): 372-380, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30087151

RESUMO

Our primary objective was to assess if sustained participation in continuous quality improvement (CQI) activities could improve delivery of 'basic developmental care' to disadvantaged children in primary care settings. Secondary objectives were to assess if delivery of developmental care differed by age and geographic location.Data were analysed using multivariable logistic regression and generalised estimating equations. 109 indigenous primary care centres across Australia from 2012 to 2014 and2466 client files from indigenous children aged 3-59 months were included. Outcome measures were delivery of basic developmental care.We found that the proportion of children who received basic developmental care ranged from 55% (advice about physical and mental stimulation of child) (1279, 55.1%) to 74% (assessment of developmental milestones) (1510, 73.7%). Ninety-three per cent (92.6%, 88) of children received follow-up care. Centres with sustained CQI participation (completed three or more consecutive audit cycles) (508, 53.9%) were twofold more likely to deliver basic developmental care compared with centres without sustained CQI (completed less than three consecutive audit cycles) (118, 31.0%) (adjusted OR (aOR) 2.37, 95% CI 1.33 to 4.23). Children aged 3-11 months (229, 54.9%) were more likely to receive basic developmental care than children aged 24-59 months (151, 38.5%) (aOR 2.42, 95% CI 1.67 to 3.51). Geographic location had little effect (aOR 0.68, 95% CI 0.30 to 1.53). Overall our study found that sustained CQI can improve basic developmental care in primary care settings. However, many disadvantaged children are not receiving services. Improved resourcing of developmental care and CQI in primary care centres is needed.


Assuntos
Serviços de Saúde da Criança/normas , Assistência à Saúde/normas , Deficiências do Desenvolvimento/terapia , Disparidades em Assistência à Saúde/normas , Atenção Primária à Saúde/normas , Melhoria de Qualidade , Austrália , Estudos Transversais , Feminino , Humanos , Lactente , Masculino , Grupo com Ancestrais Oceânicos , Saúde da População Rural , Saúde da População Urbana , Populações Vulneráveis/estatística & dados numéricos
16.
J Appl Res Intellect Disabil ; 32(2): 300-312, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30175427

RESUMO

BACKGROUND: People with intellectual disabilities are a high risk population for developing osteoporosis and fragility fractures, yet they experience barriers to accessing dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) screening and fracture assessment. Reasonable adjustments are a statutory requirement in the UK, but there is a paucity of evidence-based examples to assist their identification, implementation and evaluation. METHOD: Thirty adults with intellectual disabilities underwent DXA BMD screening and fracture risk assessment. Reasonable adjustments were identified and implemented. RESULTS: The presence of osteopenia or osteoporosis was detected in 23 out of 29 (79%) participants. Osteoporosis professionals report that 17 of 18 reasonable adjustments identified and implemented are both important and easy to implement. CONCLUSION: Adults across all levels of intellectual disabilities can complete DXA BMD screening with reasonable adjustments. Widely implementing these reasonable adjustments would contribute to reducing inequalities in health care for adults with intellectual disabilities.


Assuntos
Absorciometria de Fóton/normas , Densidade Óssea , Fraturas Ósseas/diagnóstico por imagem , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Deficiência Intelectual , Osteoporose/diagnóstico por imagem , Medição de Risco/normas , Adulto , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
17.
Gastroenterology ; 156(1): 119-129.e3, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30243620

RESUMO

BACKGROUND & AIMS: We have few population-level data on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. We investigated the numbers of unplanned hospital encounters (UHEs), patient and facility factors associated with UHEs, and variation in quality and outcomes in the performance of ERCP in 3 large American states. METHODS: We collected data on 68,642 ERCPs, performed at 635 facilities in California, Florida, and New York from 2009 through 2014. The primary endpoint was number of UHEs with an ERCP-related event within 7 days of ERCP; secondary endpoints included number of UHEs within 30 days and mortality within 30 days. Each facility was assigned a risk-standardized cohort, and variations in number of UHEs were analyzed with multivariable analysis. RESULTS: Among all ERCPs, 5.8% resulted in a UHE within 7 days and 10.2% within 30 days. Performance of sphincterotomy was significantly associated with a higher risk of UHE at 7 and 30 days (P < .001). Younger age, female sex, and more advanced comorbidity were associated with UHE. There was substantial heterogeneity in rates of UHE among facilities: 4.2% at facilities in the 5th percentile and 25.2% at facilities in the 95th percentile. Increasing facility volume and ability to perform endoscopic ultrasonography were associated inversely with risk. The median number of ERCPs performed each year was 68.7, but 69% of facilities performed 100 or fewer ERCPs per year. Risk for UHE after sphincterotomy decreased with increasing facility volume until an inflection point of 157 ERCPs per year was reached. CONCLUSIONS: In an analysis of outcomes of 68,642 ERCPs performed in 3 states, we found a higher-than-expected number of UHEs. There is substantial unexplained variation in risk for adverse events after ERCPs among facilities, and volume is the strongest predictor of risk. Annual facility volumes above approximately 150 ERCPs per year may protect against UHE.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Serviço Hospitalar de Emergência , Disparidades em Assistência à Saúde , Admissão do Paciente , Idoso , California , Colangiopancreatografia Retrógrada Endoscópica/normas , Serviço Hospitalar de Emergência/normas , Feminino , Florida , Disparidades em Assistência à Saúde/normas , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , New York , Admissão do Paciente/normas , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
18.
J Med Internet Res ; 20(12): e11034, 2018 12 05.
Artigo em Inglês | MEDLINE | ID: mdl-30518513

RESUMO

BACKGROUND: eHealth provides individuals with new means of accessing health information and communicating with providers through online channels. Prior evidence suggests that patients use eHealth to find information online when they receive care that is low in patient centeredness. However, it is unclear how other problems with the healthcare-delivery system motivate the use of eHealth, how these problems relate to different kinds of eHealth activities, and which populations are most likely to use eHealth when they receive low-quality care. OBJECTIVE: We aimed to determine how two types of negative care experiences-low patient centeredness and care coordination problems-motivate the use of different eHealth activities, and whether more highly educated individuals, who may find these tools easier to use, are more likely to use eHealth following negative experiences than less highly educated individuals. METHODS: Using nationally representative data from the 2017 Health Information National Trends Survey, we used factor analysis to group 25 different eHealth activities into categories based on the correlation between respondents' reports of their usage. Subsequently, we used multivariate negative binomial generalized linear model regressions to determine whether negative healthcare experiences predicted greater use of these resulting categories. Finally, we stratified our sample based on education level to determine whether the associations between healthcare experiences and eHealth use differed across groups. RESULTS: The study included 2612 individuals. Factor analysis classified the eHealth activities into two categories: provider-facing (eg, facilitating communication with providers) and independent (eg, patient-driven information seeking and communication with non-providers). Negative care experiences were not associated with provider-facing eHealth activity in the overall population (care coordination: P=.16; patient centeredness: P=.57) or among more highly educated respondents (care coordination: P=.73; patient centeredness: P=.32), but respondents with lower education levels who experienced problems with care coordination used provider-facing eHealth more often (IRR=1.40, P=.07). Individuals engaged in more independent eHealth activities if they experienced problems with either care coordination (IRR=1.15 P=.01) or patient-centered communication (IRR=1.16, P=.01). Although care coordination problems predicted independent eHealth activity across education levels (higher education: IRR=1.13 P=.01; lower education: IRR=1.19, P=.07), the relationship between low perceived patient centeredness and independent activity was limited to individuals with lower education levels (IRR=1.25, P=.02). CONCLUSIONS: Individuals use a greater number of eHealth activities, especially activities that are independent of healthcare providers, when they experience problems with their healthcare. People with lower levels of education seem particularly inclined to use eHealth when they have negative healthcare experiences. To maximize the potential for eHealth to meet the needs of all patients, especially those who are traditionally underserved by the healthcare system, additional work should be performed to ensure that eHealth resources are accessible and usable to all members of the population.


Assuntos
Disparidades em Assistência à Saúde/normas , Assistência Centrada no Paciente/métodos , Qualidade da Assistência à Saúde/normas , Telemedicina/métodos , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Inquéritos e Questionários
19.
Am J Manag Care ; 24(11): 506-509, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30452207

RESUMO

OBJECTIVES: To provide recommendations that will improve approaches to measuring the value of new medical technologies to patients. STUDY DESIGN: Informed discussion by experts after literature review. METHODS: A working group was formed, and participants discussed how value frameworks should incorporate key features important to patients in evaluating new medical technologies, particularly for chronic diseases. RESULTS: The working group suggests that new value frameworks should integrate real-world evidence to complement randomized controlled trials, incorporate the ways in which real-world behavior mediates outcomes, and explicitly discuss how therapies affect real-world equity and disparities in care. CONCLUSIONS: Collective stakeholders that include key decision makers within our healthcare system need to recognize the importance of implementing real-world evidence and devote resources to further research into the chronic disease areas in which the impact of human behavior is amplified by the duration of disease and treatment.


Assuntos
Assistência à Saúde/organização & administração , Projetos de Pesquisa , Análise Custo-Benefício , Assistência à Saúde/economia , Assistência à Saúde/normas , Conhecimentos, Atitudes e Prática em Saúde , Disparidades em Assistência à Saúde/organização & administração , Disparidades em Assistência à Saúde/normas , Humanos , Adesão à Medicação , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos
20.
PLoS One ; 13(11): e0207432, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30452460

RESUMO

Gentrification has been argued to contribute to urban inequalities, including those of health disparities. Extant research has yet to conduct a systematic study of gentrification's relation with neighborhood health outcomes nationally. This gap is addressed in the current study through the utilization of census-tract data from the Center for Disease Control's 500 Cities project, the 2000 Census and the 2010-2014 American Community Survey to examine how gentrification relates to local self-rated physical health in select cities across the United States. We examine gentrification's association with neighborhood rates of poor self-rated physical health. We contextualize this relationship by evaluating gentrification's relation with city-level self-rated health inequalities. We find gentrification was significantly and positively related with self-rated physical neighborhood health outcomes. However, the presence and magnitude of gentrification within a city was not associated with health outcomes for cities overall. Based on these findings, we argue that gentrification's health benefits for cities are limited at best, though gentrification does not appear to be associated with deepening city-level health inequalities, either.


Assuntos
Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Saúde da População Urbana/tendências , Feminino , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Estados Unidos , Saúde da População Urbana/normas
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