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1.
PLoS One ; 15(10): e0241331, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33095834

RESUMO

BACKGROUND: In the early phase of the Covid-19 pandemic, mainly data related to the burden of care required by infected patients were reported. The aim of this study was to illustrate the timeline of actions taken and to measure and analyze their impact on surgical patients. METHOD: This is a retrospective review of actions to limit Covid-19 spread and their impact on surgical activity in a Swiss tertiary referral center. Data on patient care, human resources and hospital logistics were collected. Impact on surgical activity was measured by comparing 6-week periods before and after the first measures were taken. RESULTS: After the first Swiss Covid-19 case appeared on February 25, progressively restrictive measures were taken over a period of 23 days. Covid-19 positive inpatients increased from 5 to 131, and ICU patients from 2 to 31, between days 10 and 30, respectively, without ever overloading resources. A 43% decrease of elective visceral surgical procedures was observed after Covid-19 (295 vs 165, p<0.01), while the urgent operations (all specialties) decreased by 39% (1476 vs 897, p<0.01). Fifty-two and 38 major oncological surgeries were performed, respectively, representing a 27% decrease (p = 0.316). Outpatient consultations dropped by 59%, from 728 to 296 (p<0.01). CONCLUSION: While allowing for maximal care of Covid-19 patients during the pandemic, the shift of resources limited the access to elective surgical care, with less impact on cancer care.


Assuntos
Betacoronavirus/genética , Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/tendências , Neoplasias/cirurgia , Pneumonia Viral/epidemiologia , Oncologia Cirúrgica/tendências , Assistência Ambulatorial/tendências , Infecções por Coronavirus/virologia , Alocação de Recursos para a Atenção à Saúde , Mão de Obra em Saúde/tendências , Hospitalização/tendências , Humanos , Unidades de Terapia Intensiva , Pandemias , Pneumonia Viral/virologia , Reação em Cadeia da Polimerase , Encaminhamento e Consulta/tendências , Estudos Retrospectivos , Suíça/epidemiologia , Centros de Atenção Terciária
2.
J Stroke Cerebrovasc Dis ; 29(11): 105175, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066900

RESUMO

BACKGROUND: The COVID-19 pandemic caused public lockdowns around the world. We analyzed if the public lockdown altered the referral pattern of Code Stroke patients by Emergency Medical Services (EMS) to our Comprehensive Stroke Center. METHODS: Retrospective single-center study at a Bavarian Comprehensive Stroke Center. Patients who were directly referred to our stroke unit by EMS between the 1st of January 2020 and the 19th of April 2020 were identified and number of referrals, clinical characteristics and treatment strategies were analyzed during the public lockdown and before. The public lockdown started on 21st of March and ended on 19th April 2020. RESULTS: In total 241 patients were referred to our center during the study period, i.e. 171 before and 70 during the lockdown. The absolute daily number of Code Stroke referrals and the portion of patients with stroke mimics remained stable. The portion of female stroke patients decreased (55% to 33%; p = 0.03), and stroke severity as measured by the National Institutes of Health Stroke Scale (median 3 (IQR 0-7) versus 6 (IQR 1-15.5) points; p = 0.04) increased during the lockdown. There was no difference of daily numbers of patients receiving thrombolysis and thrombectomy. CONCLUSIONS: Referral of Code Stroke patients by EMS could be maintained sufficiently despite the COVID-19 pandemic lockdown. However, patients' health care utilization of the EMS may have changed within the public lockdown. EMS remains a useful tool for Code Stroke patient referral during lockdowns, but public education about stroke is required prior to further lockdowns.


Assuntos
Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Serviços Médicos de Emergência/tendências , Pneumonia Viral/terapia , Quarentena , Encaminhamento e Consulta/tendências , Acidente Vascular Cerebral/terapia , Trombectomia/tendências , Terapia Trombolítica/tendências , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Aceitação pelo Paciente de Cuidados de Saúde , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo
4.
Pract Neurol ; 20(5): 396-403, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32862137

RESUMO

Tele-neurology is a neurological consultation at a distance, or not in person, using various technologies to achieve connectivity, including the telephone and the internet. The telephone is ubiquitous and is a standard part of how we manage patients. Video consulting has been used for a long time in some centres, particularly in those where the geography means that patients have to travel long distances. Various technologies can be used, and with the development of various internet-based video-calling platforms, real-time video consulting has become much more accessible. We have provided a tele-neurology service in the North East of Scotland since 2006 using video conferencing with far-end camera control. More recently, we have complemented this using an internet-based platform (NHS Near Me). Here we outline the practicalities of video consulting in 'ordinary' times and comment on its use in the 'extraordinary' times of the coronavirus pandemic.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Exame Neurológico/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Encaminhamento e Consulta/tendências , Telemedicina/tendências , Comunicação por Videoconferência/tendências , Infecções por Coronavirus/epidemiologia , Humanos , Exame Neurológico/métodos , Exame Neurológico/normas , Neurologia/métodos , Neurologia/normas , Neurologia/tendências , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/normas , Escócia/epidemiologia , Telemedicina/métodos , Telemedicina/normas , Comunicação por Videoconferência/normas
5.
J Stroke Cerebrovasc Dis ; 29(11): 105229, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32828638

RESUMO

BACKGROUND AND AIMS: Concerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors. METHODS: Weekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges. RESULTS: The median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5th March) and the implementation of the Act-FAST campaign (6th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here. CONCLUSION: Despite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes.


Assuntos
Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Meio Ambiente , Ataque Isquêmico Transitório/terapia , Aceitação pelo Paciente de Cuidados de Saúde , Pneumonia Viral/terapia , Acidente Vascular Cerebral/terapia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Inglaterra/epidemiologia , Humanos , Análise de Séries Temporais Interrompida , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Pandemias , Admissão do Paciente/tendências , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/tendências , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo
6.
S Afr Med J ; 110(2): 132-134, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657684

RESUMO

BACKGROUND: South Africa (SA) has one of the lowest deceased organ donor rates in the world (1.4 donors per million population), with thousands of patients awaiting solid-organ transplantation. In order to improve access to transplantation we have to clearly define the reasons for the low deceased donation rate, specific to the population we serve. OBJECTIVES: Review of actual donor statistics highlights our successes, yet is not able to contextualise the factors responsible for the unsuccessful conversion of referred organ donors to actual organ donors. In an attempt to identify key factors preventing referred donors from becoming actual donors, we analysed the donor referral patterns at our institution over a 10-year period. METHODS: This was a retrospective descriptive study of consecutive deceased donor referrals at Groote Schuur Hospital, Cape Town, SA (from January 2007 to December 2016), utilising a regional donor referral registry. Qualitative and quantitative data were collected and presented as descriptive statistics and temporal trends. RESULTS: Over the 10-year study period, 861 possible organ donors were referred, with a steady increase in the number of referrals over time. Of the referrals, 514 (59.7%) were eligible for donation of at least one solid organ. Of the 508 families that were approached for consent to donation, 342 declined consent for a variety of reasons, resulting in a consent rate of 32.7%. Ultimately, at least one solid organ was obtained from 159 of the 166 consented donors. Despite the increasing number of possible and eligible donors, a statistically significant decline in consent rate was observed over time (ptrend=0.023). Furthermore, increasing trends in medical (as opposed to trauma) (ptrend<0.001) and extended criteria (as opposed to standard criteria) donor referrals (ptrend<0.001) were observed over the 10-year study period. CONCLUSIONS: Donor referral patterns have changed over time, with a notable increase in medical and extended criteria donors. Despite the increase in possible and eligible donors, the consent rate has declined. Further qualitative and quantitative research studies are required to understand and address this trend.


Assuntos
Transplante de Órgãos/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Adulto , Feminino , Hospitais Públicos , Humanos , Masculino , Encaminhamento e Consulta/tendências , Sistema de Registros , Estudos Retrospectivos , África do Sul , Centros de Atenção Terciária , Obtenção de Tecidos e Órgãos/tendências , Adulto Jovem
10.
World Neurosurg ; 142: e183-e194, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32599201

RESUMO

OBJECTIVE: In the present study, we quantified the effect of the coronavirus disease 2019 (COVID-19) on the volume of adult and pediatric neurosurgical procedures, inpatient consultations, and clinic visits at an academic medical center. METHODS: Neurosurgical procedures, inpatient consultations, and outpatient appointments at Vanderbilt University Medical Center were identified from March 23, 2020 through May 8, 2020 (during COVID-19) and March 25, 2019 through May 10, 2019 (before COVID-19). The neurosurgical volume was compared between the 2 periods. RESULTS: A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median before, 75; interquartile range [IQR], 72-80; median during, 45; IQR, 43-47; P < 0.001). A 42% reduction occurred in weekly adult procedures (median before, 62; IQR, 54-70; median during, 36; IQR, 34-39; P < 0.001), and a 31% reduction occurred in weekly pediatric procedures (median before, 13; IQR, 12-14; median during, 9; IQR, 8-10; P = 0.004). Among adult procedures, the most significant decreases were seen for spine (P < 0.001) and endovascular (P < 0.001) procedures and cranioplasty (P < 0.001). A significant change was not found in the adult open vascular (P = 0.291), functional (P = 0.263), cranial tumor (P = 0.143), or hydrocephalus (P = 0.173) procedural volume. Weekly inpatient consultations to neurosurgery decreased by 24% (median before, 99; IQR, 94-114; median during, 75; IQR, 68-84; P = 0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (median before, 329; IQR, 326-374; median during, 29; IQR, 26-39; P < 0.001). In contrast, weekly telehealth encounters increased from a median of 0 (IQR, 0-0) before to a median of 151 (IQR, 126-156) during COVID-19 (P < 0.001). CONCLUSIONS: Significant reductions occurred in neurosurgical operations, clinic visits, and inpatient consultations during COVID-19. Telehealth was increasingly used for assessments. The long-term effects of the reduced neurosurgical volume and increased telehealth usage on patient outcomes should be explored.


Assuntos
Assistência Ambulatorial/tendências , Infecções por Coronavirus , Neurocirurgia , Procedimentos Neurocirúrgicos/tendências , Pandemias , Pneumonia Viral , Encaminhamento e Consulta/tendências , Telemedicina/tendências , Centros Médicos Acadêmicos , Adolescente , Idoso , Betacoronavirus , Neoplasias Encefálicas/cirurgia , Criança , Pré-Escolar , Craniotomia/tendências , Remoção de Dispositivo , Procedimentos Endovasculares/tendências , Epilepsia/cirurgia , Feminino , Humanos , Hidrocefalia/cirurgia , Lactente , Masculino , Pessoa de Meia-Idade , Implantação de Prótese , Procedimentos Cirúrgicos Reconstrutivos/tendências , Doenças da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/cirurgia , Tennessee , Procedimentos Cirúrgicos Vasculares/tendências
11.
Diabetes Metab Syndr ; 14(5): 797-799, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32534432

RESUMO

BACKGROUND AND AIMS: With restrictions on face to face clinical consultations in the COVID-19 pandemic, Telemedicine has become an essential tool in providing continuity of care to patients. We explore the common pitfalls in remote consultations and strategies that can be adopted to avoid them. METHODS: We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020 including 'COVID-19', 'telemedicine' and 'remote consultations'. RESULTS: Telemedicine has become an integral part to support patient's clinical care in the current COVID-19 pandemic now and will be in the future for both primary and secondary care. Common pitfalls can be identified and steps can be taken to prevent them. CONCLUSION: Telemedicine it is going to play a key role in future of health medicine, however, telemedicine technology should be applied in appropriate settings and situations. Suitable training, enhanced documentations, communication and observing information governance guidelines will go a long way in avoiding pitfalls associated with remote consultations.


Assuntos
Infecções por Coronavirus/epidemiologia , Necessidades e Demandas de Serviços de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/organização & administração , Telemedicina/organização & administração , Betacoronavirus/fisiologia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/normas , Humanos , Pandemias , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Quarentena/organização & administração , Quarentena/normas , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/tendências , Telemedicina/métodos , Telemedicina/normas , Telemedicina/tendências
13.
Arch Cardiovasc Dis ; 113(6-7): 401-419, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32473996

RESUMO

BACKGROUND: Guidelines have been published concerning patient management after hospitalization for heart failure. The French national healthcare database (Systèmenationaldesdonnéesdesanté; SNDS) can be used to compare these guidelines with real-life practice. AIMS: To study healthcare utilization 30 days before and after hospitalization for heart failure, and the variations induced by the exclusion of institutionalized patients, who are less exposed to outpatient healthcare utilization. METHODS: We identified the first hospitalization for heart failure in 2015 of adult beneficiaries of the health insurance schemes covering 88% of the French population, who were alive 30 days after hospitalization. Outpatient healthcare utilization rates during the 30 days after hospitalization and the median times to outpatient care, together with their interquartile ranges, were described for all patients, and for a subgroup excluding institutionalized patients. RESULTS: Among the 104,984 patients included (mean age 79 years; 52% women), 74% were non-institutionalized (mean age 78 years; 47% women). The frequencies of at least one consultation after hospitalization and the median times to consultation were 69% (total sample) vs. 78% (subgroup excluding institutionalized patients) and 8 days (interquartile range 3; 16) vs. 7 days (3; 15) for general practitioners, 20% vs. 21% and 14 days (7; 23) vs. 16 days (9; 24) for cardiologists and 58% vs. 69% and 3 days (1; 9) vs. 2 days (1; 7) for nurses, with reimbursement of diuretics in 77% vs. 86%, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in 48% vs. 55% and beta-blockers in 55% vs. 63%. Departmental variations, excluding institutionalized patients, were large: general practice consultations (interquartile range 74%; 83%), cardiology consultations (11%; 23%) and nursing care (68%; 77%). CONCLUSIONS: Low outpatient healthcare utilization rates, long intervals to first healthcare utilization and departmental variations indicate a mismatch between guidelines and real-life practice, which is accentuated when including institutionalized patients.


Assuntos
Assistência Ambulatorial/tendências , Recursos em Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Insuficiência Cardíaca/terapia , Programas Nacionais de Saúde , Admissão do Paciente , Alta do Paciente , Padrões de Prática Médica/tendências , Idoso , Idoso de 80 Anos ou mais , Cardiologistas/tendências , Bases de Dados Factuais , Uso de Medicamentos/tendências , Feminino , França , Medicina Geral/tendências , Fidelidade a Diretrizes/tendências , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Serviços de Enfermagem/tendências , Guias de Prática Clínica como Assunto , Encaminhamento e Consulta/tendências , Fatores de Tempo
14.
Can J Neurol Sci ; 47(5): 693-696, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32450927

RESUMO

We assessed the impact of the coronavirus disease 19 (COVID-19) pandemic on code stroke activations in the emergency department, stroke unit admissions, and referrals to the stroke prevention clinic at London's regional stroke center, serving a population of 1.8 million in Ontario, Canada. We found a 20% drop in the number of code strokes in 2020 compared to 2019, immediately after the first cases of COVID-19 were officially confirmed. There were no changes in the number of stroke admissions and there was a 22% decrease in the number of clinic referrals, only after the provincial lockdown. Our findings suggest that the decrease in code strokes was mainly driven by patient-related factors such as fear to be exposed to the SARS-CoV-2, while the reduction in clinic referrals was largely explained by hospital policies and the Government lockdown.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/tendências , Admissão do Paciente/tendências , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/tendências , Acidente Vascular Cerebral/epidemiologia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Humanos , Ontário/epidemiologia , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia
16.
Aust J Gen Pract ; 49(4): 182-186, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32233343

RESUMO

BACKGROUND: Exercise prescription, while not traditionally part of the medical school curriculum or many advanced post-graduate training programs, is rapidly becoming an essential skill in primary care. Its importance relates to exercise being an effective evidence-based intervention for osteoarthritis, back pain, tendinopathy, some cancers, depression, diabetes and cardiovascular diseases. OBJECTIVE: The aim of this article is to describe the basic principles of exercise prescription in the context of a primary care medical consultation, assisting general practitioners to manage cases without the need for referral. Understanding the basic principles is important, but it should not be presumed that exercise prescription is always straightforward. DISCUSSION: A good mantra for exercise prescription is 'move, monitor, modify'. Failure of basic exercise prescription does not necessarily mean that procedural or medication treatment is required, but instead second-line exercise prescription may be indicated. Although referral to an exercise-based practitioner is a useful option, exercise prescription should become embedded as part of primary care medical practice because of its reported effectiveness and minimal side effects when appropriately implemented.


Assuntos
Terapia por Exercício/métodos , Atenção Primária à Saúde/métodos , Encaminhamento e Consulta/normas , Terapia por Exercício/efeitos adversos , Terapia por Exercício/instrumentação , Feminino , Humanos , Pessoa de Meia-Idade , Atenção Primária à Saúde/tendências , Encaminhamento e Consulta/tendências , Dispositivos Eletrônicos Vestíveis/tendências
17.
Clin Orthop Surg ; 12(1): 55-59, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32117539

RESUMO

Background: Previous studies have reported what patients value while choosing their surgeon, but there are no studies exploring the patterns of referral to spine surgeons among primary care physicians (PCPs). This study aims to identify any trends in PCPs' referral to orthopedic surgery versus neurosurgery for spinal pathology. Methods: In total, 450 internal medicine, family medicine, emergency medicine, neurology, and pain management physicians who practice at one of three locations (suburban community hospital, urban academic university hospital, and urban private practice) were asked to participate in the study. Consenting physicians completed our 24-question survey addressing their beliefs according to pathologies, locations of pathologies, and surgical interventions. Results: Overall, 108 physicians (24%) completed our survey. Fifty-seven physicians (52.8%) felt that neurosurgeons would provide better long-term comprehensive spinal care. Overall, 66.7% of physicians would refer to neurosurgery for cervical spine radiculopathy; 52.8%, to neurosurgery for thoracic spine radiculopathy; and 56.5%, to orthopedics for lumbar spine radiculopathy. Most physicians would refer all spine fractures to orthopedics for treatment except cervical spine fractures (56.5% to neurosurgeons). Most physicians would refer to neurosurgery for extradural tumors (91.7%) and intradural tumors (96.3%). Most would refer to orthopedic surgeons for chronic pain. Finally, physicians would refer to orthopedics for spine fusion (61.1%) and discectomy (58.3%) and to neurosurgery for minimally invasive surgery (59.3%). Conclusions: Even though both orthopedic surgeons and neurosurgeons are intensively trained to treat a similar breath of spinal pathology, physicians vary in their referring patterns according to spinal pathology, location of pathology, and intended surgery. Education on the role of spine surgeons among PCPs is essential in ensuring unbiased referral patterns.


Assuntos
Neurocirurgia , Procedimentos Ortopédicos , Médicos de Atenção Primária/tendências , Padrões de Prática Médica , Encaminhamento e Consulta/tendências , Humanos , Inquéritos e Questionários
18.
Pediatrics ; 145(4)2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32169895

RESUMO

BACKGROUND: For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis. METHODS: We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes. RESULTS: Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings. CONCLUSIONS: Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.


Assuntos
Asma/terapia , Crupe/terapia , Tratamento de Emergência/tendências , Gastroenterite/terapia , Encaminhamento e Consulta/tendências , Adolescente , Criança , Pré-Escolar , Intervalos de Confiança , Estudos Transversais , Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Tratamento de Emergência/estatística & dados numéricos , Humanos , Modelos Logísticos , Transferência de Pacientes/estatística & dados numéricos , Transferência de Pacientes/tendências , Encaminhamento e Consulta/estatística & dados numéricos , Estados Unidos , United States Agency for Healthcare Research and Quality/estatística & dados numéricos
19.
BMC Palliat Care ; 19(1): 31, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164672

RESUMO

BACKGROUND: Palliative care (PC) referral is recommended early in the course of advanced cancer. This study aims to describe, in an integrated onco-palliative care program (IOPC), patient's profile when first referred to this program, timing of this referral and its impact on the trajectory of care at end-of-life. METHODS: The IOPC combined the weekly onco-palliative meeting (OPM) dedicated to patients with incurable cancer, and/or the clinical evaluation by the PC team. Oncologists can refer to the multidisciplinary board of the OPM the patients for whom goals and organization of care need to be discussed. We analyzed all patients first referred at OPM in 2011-2013. We defined the index of precocity (IP), as the ratio of the time from first referral to death by the time from diagnosis of incurability to death, ranging from 0 (late referral) to 1 (early referral). RESULTS: Of the 416 patients included, 57% presented with lung, urothelial cancers, or sarcoma. At first referral to IOPC, 76% were receiving antitumoral treatment, 63% were outpatients, 56% had a performance status ≤2 and 46% had a serum albumin level > 35 g/l. The median [1st-3rd quartile] IP was 0.39 [0.16-0.72], ranging between 0.53 [0.20-0.79] (earliest referral, i.e. close to diagnosis of incurability, for lung cancer) to 0.16 [0.07-0.56] (latest referral, i.e. close to death relatively to length of metastatic disease, for prostate cancer). Among 367 decedents, 42 (13%) received antitumoral treatment within 14 days before death, and 157 (43%) died in PC units. CONCLUSIONS: The IOPC is an effective organization to enable early integration of PC and decrease aggressiveness of care near the end-of life. The IP is a useful tool to model the timing of referral to IOPC, while taking into account each cancer types and therapeutic advances.


Assuntos
Tomada de Decisão Compartilhada , Serviço Hospitalar de Oncologia/normas , Encaminhamento e Consulta/normas , Fatores de Tempo , Idoso , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/normas , Prestação Integrada de Cuidados de Saúde/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/classificação , Neoplasias/terapia , Serviço Hospitalar de Oncologia/organização & administração , Serviço Hospitalar de Oncologia/tendências , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Cuidados Paliativos/tendências , Encaminhamento e Consulta/tendências , Estudos Retrospectivos , Assistência Terminal/organização & administração , Assistência Terminal/normas , Assistência Terminal/tendências
20.
Matern Child Health J ; 24(4): 412-418, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32026324

RESUMO

OBJECTIVES: Universal screening for substance use during pregnancy, brief intervention, and referral to treatment (SBIRT) is recommended by ACOG and the USPSTF. Here we present the implementation of SBIRT into the electronic health record (EHR) to inform clinical intervention and collect data on the prevalence of substance use during pregnancy at three prenatal clinics. METHODS: A literature-based SBIRT instrument was developed. The tool was integrated into the EHR of a resident Ob/Gyn clinic, an MFM practice, and an Ob/Gyn generalist practice at our institution, an academic, tertiary care medical center in an urban area, and automated reports of aggregate retrospective EHR data were used to monitor patient responses to SBIRT over time. Data reports included patient responses to screening for substance use, brief intervention, and referral to treatment from January to December 2018 RESULTS: An interprofessional team of health care providers and systems analysts guided the SBIRT implementation process. As of December 2018, overall SBIRT performance during prenatal care encounters was 1797/2619 (69%), 432/1350 (32%), and 1290/1518 (85%) in the resident clinic, MFM practice, and generalist practice, respectively. Eighty (5.1%) women in the resident clinic, 2 (0.5%) in the MFM practice and 14 (1%) in the generalist practice reported past or present substance use. CONCLUSIONS FOR PRACTICE: Integrating universal SBIRT into prenatal care using the EHR requires a multi-disciplinary approach. The SBIRT tool facilitates reportable substance use screening, brief intervention, and referral to treatment during prenatal care. Future reports will further characterize substance use in our prenatal practices and inform intervention strategies in this population.


Assuntos
Programas de Rastreamento/métodos , Cuidado Pré-Natal/métodos , Encaminhamento e Consulta/tendências , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adulto , Feminino , Humanos , Programas de Rastreamento/tendências , Gravidez , Cuidado Pré-Natal/tendências , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia
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