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1.
Am Surg ; 86(9): 1057-1061, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33049163

RESUMO

BACKGROUND: Timely access to emergency general surgery services, including trauma, is a critical aspect of patient care. This study looks to identify resource availability at small rural hospitals in order to improve the quality of surgical care. METHODS: Forty-five nonteaching hospitals in West Virginia were divided into large community hospitals with multiple specialties (LCHs), small community hospitals with fewer specialties (SCHs), and critical access hospitals (CAHs). A 58-question survey on optimal resources for surgery was completed by 1 representative surgeon at each hospital. There were 8 LCHs, 18 SCHs, and 19 CAHs with survey response rates of 100%, 83%, and 89%, respectively. RESULTS: One hundred percent of hospitals surveyed had respiratory therapy and ventilator support, computerized tomography (CT) scanner and ultrasound, certified operating rooms, lab support, packed red blood cells (PRBC), and FFP accessible 24/7. Availability of cryoprecipitate, platelets, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) decreased from LCHs to CAHs. The majority had board-certified general surgeons; however, only 86% LCHs, 53% SCHs, and 50% CAHs had advanced trauma life support (ATLS) certification. One hundred percent of LCHs had operating room (OR) crew on call within 30 minutes, emergency cardiovascular equipment, critical care nursing, on-site pathologist, and biologic/synthetic mesh, whereas fewer SCHs and CAHs had these resources. One hundred percent of LCHs and SCHs had anesthesia availability 24/7 compared to 78% of CAHs. DISCUSSION: Improving access to the aforementioned resources is of utmost importance to patient outcomes. This will enhance rural surgical care and decrease emergency surgical transfers. Further education and research are necessary to support and improve rural trauma systems.


Assuntos
Recursos em Saúde/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Hospitais Rurais/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Humanos , Inquéritos e Questionários , Estados Unidos , West Virginia
2.
Am J Cardiol ; 134: 41-47, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32900469

RESUMO

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Mortalidade Hospitalar , Artéria Torácica Interna/transplante , Complicações Pós-Operatórias/epidemiologia , Distribuição por Idade , Idoso , Feminino , Custos Hospitalares/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Mediastinite/epidemiologia , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Distribuição por Sexo , Acidente Vascular Cerebral/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia
3.
Surg Clin North Am ; 100(5): 835-847, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32882166

RESUMO

Nearly 60 million people live in a rural area across the United States. Since 2005, 162 rural hospitals have closed, and the rate of rural hospital closures seems to be accelerating. Major drivers of rural hospital closures are poor financial health, aging facilities, and low occupancy rates. Rural hospitals are particularly vulnerable to policy and market changes, and even small changes can have a disproportionate effect on rural hospital financial viability. Surgery can be safely performed in rural hospitals; however, hospital closures may be putting the rural population at increased risk of morbidity and mortality from surgical disease.


Assuntos
Fechamento de Instituições de Saúde/economia , Fechamento de Instituições de Saúde/estatística & dados numéricos , Hospitais Rurais/economia , Hospitais Rurais/estatística & dados numéricos , Serviços de Saúde Rural/economia , Serviços de Saúde Rural/normas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Previsões , Hospitais Rurais/tendências , Humanos , População Rural , Procedimentos Cirúrgicos Operatórios/tendências , Estados Unidos , Local de Trabalho
4.
Surg Clin North Am ; 100(5): 869-877, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32882169

RESUMO

Rural hospitals are closing at an increasing rate. From 2010 to 2014, 47 rural hospitals closed, affecting 1.5 million people. The presence of surgeons is critical to keeping these hospitals open; to provide initial trauma care, cancer screening, and care to populations that cannot easily travel; and to provide solid general surgery procedures to almost 60 million Americans. Actions to provide surgeons trained for rural practice include exposure of surgery to students in high school (and earlier), recruitment of rural students into medical school, rural rotations in medical school, rural tracts within surgical residencies, and programs to support and retain rural surgeons.


Assuntos
Cirurgia Geral/estatística & dados numéricos , Fechamento de Instituições de Saúde/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Serviços de Saúde Rural , Recursos Humanos , Currículo , Cirurgia Geral/educação , Estados Unidos
5.
Am J Public Health ; 110(9): 1315-1317, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32673119

RESUMO

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients.Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services.Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons < .001).Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care.Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Obstetrícia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitais Rurais/classificação , Humanos , Propriedade , Gravidez , Estados Unidos
6.
J Trauma Acute Care Surg ; 88(6): 734-741, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32453256

RESUMO

BACKGROUND: The emergency medical system (EMS) Field Triage Decision Scheme (FTDS) exists to direct certain injured patients to high-level care facilities. In rural states, this may require long transport durations, with uncertainty about the effects on clinical decline. We investigate adherence to the FTDS and the effect of transport duration on clinical decline in helicopter emergency medical system (HEMS) and ground emergency medical system (GEMS) transport in the Commonwealth of Kentucky. METHODS: This institutional review board-approved study retrospectively analyzed deidentified data from the 2017 National EMS Information System for Kentucky. Patients were classified using step 1 FTDS criteria (respiratory rate [RR], <10 or >29 breaths per minute; systolic blood pressure (SBP), <90 mm Hg; or Glasgow Coma Scale [GCS] score, <14 points), by mode of transport (HEMS or GEMS), and by arrival at an appropriate center (levels I-III trauma center). Clinical decline was defined in both groups as an in route decrease in GCS of 2 points or greater, a SBP decrease of 1 SD or greater into or within the low range, an RR increase of 1 SD or greater into or within the high range, or an RR decrease of 1 SD or greater into or within the low range. RESULTS: Almost half (46.3%) of step 1 patients were transported to an inappropriate center; the most common reason recorded was "closest facility" (57.8%). The percent of step 1 patients who declined in route increased with prehospital time in both HEMS and GEMS (p < 0.001). Overall, 12.2% of step 1 patients declined during transport, most commonly because of decreasing GCS (median change, -5 points; interquartile range, -3 to -9, in GCS declining patients). Helicopter EMS patients were more likely to meet step 1 criteria at the scene (29.9% vs. 5.8% GEMS, p < 0.001) and to decline (27.8% vs. 6.1% GEMS, p < 0.001). CONCLUSION: This study demonstrates that, in a rural state, injured patients meeting FTDS step 1 criteria reach levels I to III trauma centers only about half the time. The FTDS step 1 criteria identified patients at higher risk of further prehospital clinical decline. Rather than decline after 1 hour, these data show that an increasing proportion of patients experience clinical decline throughout prehospital transport. LEVEL OF EVIDENCE: Therapeutic, Level IV.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Ambulâncias/estatística & dados numéricos , Deterioração Clínica , Hospitais Rurais/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Resgate Aéreo/normas , Ambulâncias/normas , Tomada de Decisão Clínica , Escala de Coma de Glasgow , Fidelidade a Diretrizes , Humanos , Kentucky , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Triagem/normas , Triagem/estatística & dados numéricos , Incerteza , Ferimentos e Lesões/cirurgia
7.
J Psychosom Res ; 133: 109997, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32220648

RESUMO

OBJECTIVE: To assess the impact of integrating Psychiatric Assessment Officers (PAO) and telepsychiatry in rural hospitals on their all-cause emergency department (ED) revisit rates. As a pilot project, a full-time PAO was embedded in each of three rural hospitals in New York State and was augmented by telepsychiatry. METHOD: A retrospective data analysis using ED census data obtained from the hospitals. The intervention group, defined as those patients treated by PAOs, was compared via a difference-in-difference method against a contemporaneous comparison group defined as those who visited the same EDs and had PAO-qualifying behavioral health diagnoses but were not seen by PAOs. RESULTS: The intervention group was associated with an approximately 36% lower all-cause ED revisit rate during the first 90-day period (i.e. 1-90 days) following the initial PAO treatment (p = .003). A reduction of the similar magnitude (44%) persisted into the subsequent 90-day period (i.e., 91-180 days since the initial PAO treatment; p < .001). CONCLUSION: The PAO telepsychiatry pilot program suggests a potential way to provide relief for overburdened EDs in rural communities that lack resources to treat patients with severe behavioral health symptoms.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Psiquiatria , Telemedicina , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos
8.
J Laparoendosc Adv Surg Tech A ; 30(3): 322-327, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32045322

RESUMO

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is the gold standard for many conditions affecting the gallbladder; however, open cholecystectomy (OC) is offered as the initial approach in a surprisingly high percentage of cases. Materials and Methods: The Kids' Inpatient Database (1997-2012) was searched for International Classification of Disease, 9th revision, Clinical Modification procedure code (51.2x). LC and OC performed in patients <20 years old were identified. Propensity score-matched analyses using 39 variables were performed to isolate the effects of race, income group, location, gender, payer status, and hospital size on the percentage of LCs and OCs offered. Cases were weighted to provide national estimates. Results: A total of 78,578 cases were identified, comprising LC (88.1%) and OC (11.9%). Girls were 1.6 (CI: 1.4, 1.7) times more likely to undergo LC versus boys. Large facilities were 1.4 (1.3, 1.7) times more likely to perform LCs than small facilities. Children in lower income quartiles were 1.2 (1.1, 1.3) times more likely to undergo LC compared with those in higher income quartiles. Rates of LC were not affected by race, hospital location, or payer status. Conclusions: Risk-adjusted analysis of a large population-based data set demonstrated evidence that confirms, but also refutes, traditional disparities to minimally invasive surgery access. Despite laparoscopic gold standard, OC remains the initial approach in a surprisingly high percentage of pediatric cases independent of demographics or socioeconomic status. Additional research is required to identify factors affecting the distribution of LC and OC within the pediatric population.


Assuntos
Colecistectomia Laparoscópica/estatística & dados numéricos , Doenças da Vesícula Biliar/cirurgia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adolescente , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Americanos Asiáticos/estatística & dados numéricos , Criança , Pré-Escolar , Colecistectomia/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Tamanho das Instituições de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Lactente , Recém-Nascido , Tempo de Internação , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pontuação de Propensão , Estudos Retrospectivos , Fatores Sexuais , Resultado do Tratamento , Estados Unidos
9.
BMJ Open Qual ; 9(1)2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32098774

RESUMO

INTRODUCTION: A urinary catheter constitutes a one-point patient restraint, can induce deconditioning and may lead to patient mortality. An audit performed at Winchester District Memorial Hospital revealed that 20% of patients had a urinary catheter, of whom 31% did not meet the criteria for catheterisation. The main objective of this study was to use the Influencer Change Model and the Choosing Wisely Canada toolkit to create a bundle of interventions that would reduce the unnecessary use of urinary catheters in hospitalised patients. METHODS: In a rural teaching hospital, a time-series quasi-experiment was employed to decrease inappropriate use of urinary catheters. Both the Choosing Wisely Canada toolkit for appropriate use of urinary catheters and the Influencer change management approach were used to create effective interventions. RESULTS: This study revealed that there was no improvement in appropriate urinary catheter use during Plan-Do-Study-Act (PDSA) cycle 1. There was gradual improvement during PDSA cycle 2, with the percentage of inappropriate urinary catheter use dropping from an initial 31% before any interventions to less than 5% by the end of this study. DISCUSSION/CONCLUSION: This study aimed to reduce the inappropriate use of urinary catheters in a rural hospital with limited resources. The findings indicate that by using a change model, such as the Influencer Change Model, it is possible to promote better patient care through empowering healthcare staff to implement accepted protocols more stringently and thereby to decrease the inappropriate use of urinary catheters to 0%.


Assuntos
Hospitais Rurais/normas , Cateterismo Urinário/normas , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Hospitais Rurais/organização & administração , Hospitais Rurais/estatística & dados numéricos , Humanos , Sobremedicalização/prevenção & controle , Ontário/epidemiologia , Revisão por Pares , Qualidade da Assistência à Saúde , Cateterismo Urinário/métodos , Cateterismo Urinário/estatística & dados numéricos
10.
Medicine (Baltimore) ; 99(8): e19067, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32080080

RESUMO

Unplanned resection of soft-tissue sarcomas (STS) predispose the patients to recurrences and metastases, secondary wide resection is usually warranted.To investigate the outcomes of re-excision of STS after unplanned initial resection.The records of 39 patients undergoing re-excision of STS after unplanned initial resection from January 2006 through December 2015 were retrospectively investigated.There were 17 males and 22 females, the mean age was 45.7 years. Most initial unplanned resections were performed in rural hospitals by surgeons from general surgery department, dermatology department, plastic surgery department, and orthopedic department. Thirty-five patients underwent secondary wide resections in our department. Histopathological findings indicated positive margins after primary surgeries in 18 patients. Until the conclusion of 37.2-month follow-up, 7 patients developed metastasis, 3 had local recurrence, and 7 were dead. Positive margins were associated with increased metastases and lower survival rates (P < .05). There was no significant difference in recurrences between the 2 groups.Unplanned initial resection of STS often lead to unfavorable prognosis. Primary wide resections are warranted for this disease entity.


Assuntos
Reoperação/estatística & dados numéricos , Sarcoma/mortalidade , Sarcoma/cirurgia , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Hospitais Rurais/estatística & dados numéricos , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Metástase Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Prognóstico , Reoperação/mortalidade , Estudos Retrospectivos , Sarcoma/diagnóstico por imagem , Sarcoma/patologia , Taxa de Sobrevida , Adulto Jovem
11.
Health Serv Res ; 55(2): 288-300, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31989591

RESUMO

OBJECTIVE: To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene and arriving at destination); and total activation time (minutes between 9-1-1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes. DATA SOURCES/STUDY SETTING: We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010-2016). STUDY DESIGN: We examined the effects of rural hospital closures on EMS transport times for emergent 9-1-1 calls in rural areas using a pre-post, retrospective cohort study with the matched comparison group using difference-in-difference and quantile regression models. PRINCIPAL FINDINGS: Closures increased mean EMS transport times by 2.6 minutes (P = .09) and total activation time by 7.2 minutes (P = .02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects. CONCLUSIONS: Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Fechamento de Instituições de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/organização & administração , Hospitais Rurais/organização & administração , Hospitais Rurais/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Transporte de Pacientes/organização & administração , Idoso , Estudos de Coortes , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transporte de Pacientes/estatística & dados numéricos , Estados Unidos
12.
Ann Emerg Med ; 75(3): 392-399, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31474481

RESUMO

STUDY OBJECTIVE: Telemedicine has potential to add value to the delivery of emergency care in rural emergency departments (EDs); however, previous work suggests that it may be underused. We seek to understand barriers to telemedicine implementation in rural EDs, and to describe characteristics of rural EDs that do and do not use telemedicine. METHODS: We performed a secondary analysis of data from the 2016 National Emergency Department Inventory survey, identifying rural EDs that did and did not use telemedicine in 2016. All rural EDs that did not use telemedicine were administered a follow-up survey asking about ED staffing, transfer patterns, and perceived barriers to telemedicine use. We used a similar instrument to survey a sample of EDs that did use telemedicine, but we replaced the question about barriers with questions related to telemedicine use. Data are presented with descriptive statistics. RESULTS: We identified 977 rural EDs responding to the 2016 National Emergency Department Inventory-USA survey; 453 (46%; 95% confidence interval 43% to 50%) did not use telemedicine. Among rural nonusers, 374 EDs (83%; 95% confidence interval 79% to 86%) responded to our second survey. Of the 177 rural EDs using telemedicine that we surveyed, 153 responded (86%; 95% confidence interval 80% to 91%). Among rural EDs not using telemedicine, 235 (67%) reported that their ED, hospital, or health system leadership had considered it. Cost was the most commonly cited reason for lack of adoption (n=86; 37%). CONCLUSION: Among US rural EDs, cost is a commonly reported barrier that may be limiting the extent of telemedicine adoption.


Assuntos
Serviço Hospitalar de Emergência , Hospitais Rurais , Telemedicina , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Custos de Cuidados de Saúde , Hospitais Rurais/economia , Hospitais Rurais/organização & administração , Hospitais Rurais/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Inquéritos e Questionários , Telemedicina/economia , Telemedicina/organização & administração , Telemedicina/estatística & dados numéricos , Estados Unidos , Adulto Jovem
13.
J Surg Res ; 246: 395-402, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31629495

RESUMO

BACKGROUND: Laparoscopic appendectomy is a preferred approach in children with appendicitis. Patient characteristics associated with open appendectomy are poorly characterized, although such information can help optimize the care. MATERIAL AND METHODS: To characterize the factors associated with open appendectomy, we performed a retrospective analysis using the 2014 Nationwide Readmissions Database, capturing 49.3% of US hospitalizations. We identified surgically managed appendicitis using International Classification of Diseases, Ninth Revision, Clinical Modification among patients aged 18 or younger. Factors associated with open appendectomy, 30-d readmission rate, and hospitalization length were assessed using logistic regression, Cox proportional hazards regression, and Poisson regression, respectively. RESULTS: Of 46,147 children with surgically managed appendicitis, 85.2% had laparoscopic appendectomy. Low-volume hospitals (odds ratio, OR: 3.01 [95% confidence interval, CI: 1.81-5.01]), rural hospitals (OR: 2.36 [95%CI: 1.63-3.40]), public insurance (OR: 1.19 [95%CI: 1.03-1.36]), lower-income neighborhood residence (OR: 1.40 [95%CI: 1.06-1.86]), younger age (OR: 5.00 [95%CI: 3.64-6.86] in <5 year-old), and abscess complicating appendicitis (OR: 1.91 [95%CI: 1.58-2.31]) were associated with open appendectomy. Laparoscopic appendectomy was associated with shorter hospitalization (incidence rate ratio: 0.77 [95%CI: 0.69-0.87]) and less readmission with wound infection, but not with 30-d readmission, or readmission with intraabdominal abscess. CONCLUSIONS: Along with clinical factors, non-clinical factors including appendicitis volume and rural/teaching status of the treating hospitals play a role in the choice of surgical approach. Awareness of the patient- and hospital-level factors associated with open appendectomy may allow for future resource distribution or improvement in access to care, resulting in population-level impact.


Assuntos
Abscesso Abdominal/epidemiologia , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Infecção da Ferida Cirúrgica/epidemiologia , Abscesso Abdominal/etiologia , Abscesso Abdominal/cirurgia , Adolescente , Fatores Etários , Apendicectomia/métodos , Apendicite/complicações , Criança , Pré-Escolar , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia
14.
Pediatr Emerg Care ; 36(3): e160-e162, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29016517

RESUMO

OBJECTIVE: This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents. METHODS: This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed. RESULTS: From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison. CONCLUSIONS: Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Envenenamento/epidemiologia , Pré-Escolar , Humanos , Lactente , Estudos Retrospectivos , População Rural/estatística & dados numéricos , Uganda
15.
J Surg Res ; 245: 629-635, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31522036

RESUMO

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Assuntos
Tratamento de Emergência/efeitos adversos , Disparidades em Assistência à Saúde/economia , Renda/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , População Rural/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , População Urbana/estatística & dados numéricos , Adulto Jovem
16.
BMC Geriatr ; 19(1): 348, 2019 12 11.
Artigo em Inglês | MEDLINE | ID: mdl-31829166

RESUMO

BACKGROUND: Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals. METHODS: Seventeen hospitals reported 353 falls over 2 years. We categorized falls by type (assisted vs. unassisted) and outcome (injurious vs. non-injurious). We used multivariate logistic regression to determine factors that predicted fall type and outcome. RESULTS: With all other factors being equal, the odds of falling unassisted were 2.55 times greater for a patient aged ≥65 than < 65 (95% confidence interval [CI] = 1.30-5.03), 3.70 times greater for a patient with cognitive impairment than without (95% CI = 2.06-6.63), and 6.97 times greater if a gait belt was not identified as an intervention for a patient than if it was identified (95% CI = 3.75-12.94). With all other factors being equal, the odds of an injurious fall were 2.55 times greater for a patient aged ≥65 than < 65 (95% CI = 1.32-4.94), 2.48 times greater if a fall occurred in the bathroom vs. other locations (95% CI = 1.41-4.36), and 3.65 times greater if the fall occurred when hands-on assistance was provided without a gait belt, compared to hands-on assistance with a gait belt (95% CI = 1.34-9.97). CONCLUSIONS: Many factors associated with unassisted or injurious falls in rural hospitals were consistent with research conducted in larger facilities. A novel finding is that identifying a gait belt as an intervention decreased the odds of patients falling unassisted. Additionally, using a gait belt during an assisted fall decreased the odds of injury. We expanded upon other research that found an association between assistance during falls and injury by discovering that the manner in which a fall is assisted is an important consideration for risk mitigation.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Avaliação Geriátrica/métodos , Hospitais Rurais/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Fatores de Risco
17.
Health Aff (Millwood) ; 38(12): 2086-2094, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31794309

RESUMO

Rates of rural hospital closures have been increasing over the past decade. Closures will almost certainly restrict rural residents' access to important inpatient services, and they could also be related in important ways to the supply of physicians in the local health care system. We used data from the Area Health Resources Files for the period 1997-2016 to examine the relationship between rural hospital closures and the supply of physicians across different specialties in the years leading up to and after a closure. We observed significant annual reductions of up to 8.3 percent in the supply of general surgeons in the years leading up to a closure. We also found that rural hospital closures were associated with immediate and persistent decreases in the supply of surgical specialists and long-term decreases in the supply of physicians across multiple specialties-including an average annual 8.2 percent decrease in the supply of primary care physicians in the six years after a closure and beyond. This dynamic relationship could lead to reduced access to care for rural residents. Future policy efforts must focus on supporting and maintaining health care delivery models that do not depend on hospitals.


Assuntos
Fechamento de Instituições de Saúde/tendências , Mão de Obra em Saúde , Hospitais Rurais , Médicos de Atenção Primária/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Hospitais Rurais/estatística & dados numéricos , Humanos , Médicos de Atenção Primária/provisão & distribução , Serviços de Saúde Rural/estatística & dados numéricos , Cirurgiões/provisão & distribução , Estados Unidos
18.
Obstet Gynecol ; 134(6): 1260-1268, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31764737

RESUMO

OBJECTIVE: To evaluate perioperative outcomes for women with uterine cancer undergoing hysterectomy at rural and public hospitals in New York State. METHODS: The New York Statewide Planning And Research Cooperative System database was used to identify women with uterine cancer who underwent hysterectomy from 2000 to 2015. Perioperative complications, inpatient mortality, and resource utilization were compared at rural, public and private hospitals. Multilevel mixed effect log-linear models were developed to evaluate the association between hospital type and outcomes of interest. Patient characteristics, hospital and surgeon clustering were accounted for within the model. RESULTS: Over the years studied, there were 193 hospitals that cared for 46,298 women with uterine cancer. Of these, 9.8% were public, 15.0% were rural, and 75.1% were private metropolitan. They cared for 11.0%, 2.2% and 86.8% of patients, respectively. The proportion of patients cared for at rural hospitals decreased significantly from 5.2% in 2000 to 0.6% in 2014 (P<.001). There was no change in the volume of patients cared for at public hospitals (11.3 to 10.3%, P>.05). In a multivariable model adjusting for patient risk, there were no significant differences in perioperative morbidity, transfusion and length of stay across the three hospital types (P>.05). Compared with private hospitals, treatment at a rural hospital was associated with increased inpatient mortality (adjusted risk ratio 4.03, 95% CI 1.02-15.97). CONCLUSION: In New York State, operative uterine cancer care is shifting away from rural hospitals. Public hospitals have similar risk-adjusted outcomes compared with private metropolitan facilities.


Assuntos
Hospitais Públicos/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Histerectomia/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Regionalização , Neoplasias Uterinas/cirurgia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Pessoa de Meia-Idade , New York , Serviços de Saúde da Mulher
19.
BMC Med Educ ; 19(1): 380, 2019 Oct 18.
Artigo em Inglês | MEDLINE | ID: mdl-31627749

RESUMO

BACKGROUND: There is an ongoing debate about the impact of studying medicine in rural vs. metropolitan campuses on student assessment outcomes. The UNSW Medicine Rural Clinical School has five main campuses; Albury-Wodonga, Coffs Harbour, Griffith, Port Macquarie and Wagga Wagga. Historical data of student assessment outcomes at these campuses raised concerns regarding potential biases in assessment undertaken, as well as the availability and quality of learning resources. The current study aims to identify the extent to which the location of examination (rural versus metropolitan) has an impact on student marks in OSCEs. METHODS: Assessment data was employed for this study from 275 medical students who sat their final examinations in Years 3 and 6 of the undergraduate Medicine program at UNSW in 2018. The data consists of matched student assessment results from the Year 3 (Y3) MCQ examination and OSCE, and from the Year 6 (Y6) MCQ, OSCE and management viva examinations. The analysis used Univariate Analysis of Variance and linear regression models to identify the impact of site of learning and site of examination on assessment outcomes. RESULTS: The results demonstrate that neither site of learning nor site of examination had any significant impact on OSCE or Management Viva assessment outcomes while potential confounders are controlled. CONCLUSION: It is suggested that some of the supposed disadvantages inherent at rural campuses are effectively mitigated by perceived advantages; more intensive interaction with patients, the general and medical communities at those sites, as well as effective e-learning resources and moderation of assessment grades.


Assuntos
Competência Clínica/estatística & dados numéricos , Educação de Graduação em Medicina/normas , Avaliação Educacional , Hospitais Rurais , Estudantes de Medicina , Feminino , Hospitais Rurais/estatística & dados numéricos , Humanos , Masculino , Adulto Jovem
20.
BMJ Open ; 9(10): e030272, 2019 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619423

RESUMO

OBJECTIVES: To examine the role of hospitals and office-based physicians in empirical networks that deliver care to the same population with regard to the timely provision of appropriate care after hospital discharge. DESIGN: Secondary data analysis of a nationwide cohort using cross-classified multilevel models. SETTING: Transition from hospital to ambulatory care. PARTICIPANTS: All patients discharged for acute myocardial infarction (AMI) from Germany's largest statutory health insurance fund group in 2011. MAIN OUTCOME MEASURE: Patients' odds of receiving a statin prescription within 30 days after hospital discharge. RESULTS: We found significant variation in 30-day statin prescribing between hospitals (median OR (MOR) 1.40; 95% credible interval (CrI) 1.36 to 1.45), hospital-physician pairs caring for the same patients (MOR 1.32; 95% CrI 1.26 to 1.38) and to a lesser extent between physicians (MOR 1.14; 95% CrI 1.11 to 1.19). About 67% of the variance between hospital-physician pairs and about 45% of the variance between hospitals was explained by hospital characteristics including a rural location, teaching status and the number of beds, the number of patients shared between a hospital and an office-based physician as well as 16 patient characteristics, including multimorbidity and dementia. We found no impact of physician characteristics. CONCLUSIONS: Timely prescription of appropriate secondary prevention pharmacotherapy after AMI is subject to considerable practice variation which is not consistent with clinical guidelines. Hospitals contribute more to the observed variation than physicians, and most of the variation lies at the patient level. To ensure care continuity for patients, it is important to strengthen hospital capacity for discharge management and coordination between hospitals and office-based physicians.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/prevenção & controle , Médicos/estatística & dados numéricos , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Alemanha , Fidelidade a Diretrizes/estatística & dados numéricos , Tamanho das Instituições de Saúde , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Alta do Paciente , Transferência da Responsabilidade pelo Paciente , Médicos/organização & administração , Guias de Prática Clínica como Assunto , Prevenção Secundária , Fatores de Tempo , Cuidado Transicional
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