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1.
JAMA Netw Open ; 4(1): e2034266, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33464319

RESUMO

Importance: Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. Objective: To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. Design, Setting, and Participants: This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Exposures: Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient's hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient's stay divided by the maximum number of patients with COVID-19 in the ICU. Main Outcomes and Measures: All-cause mortality was recorded through 30 days after discharge from the hospital. Results: Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). Conclusions and Relevance: This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.


Assuntos
/mortalidade , Estado Terminal/mortalidade , Hospitais de Veteranos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Veteranos/estatística & dados numéricos , Estudos de Coortes , Humanos , Estados Unidos , United States Department of Veterans Affairs
2.
Sr Care Pharm ; 36(1): 63, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33384036

RESUMO

The author discusses benefits available to US Veterans starting with the Department of Veterans Affairs and going into state funding and long-term care benefits.


Assuntos
Veteranos , Hospitais de Veteranos , Humanos , Amor , Estados Unidos , United States Department of Veterans Affairs
3.
Arch Pathol Lab Med ; 145(1): 75-81, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33367659

RESUMO

CONTEXT.­: A novel electronic consult (e-consult) system for a pathology and laboratory medicine service (PLMS) was implemented in 2015 at a high-complexity Veterans Administration health care facility. Consults were previously made through direct provider communication without documentation in the medical record. OBJECTIVE.­: To evaluate the utilization trends of the laboratory e-consult system at the Department of Veterans Affairs Connecticut facility during the first 2 years since inception. DESIGN.­: E-consultation involves pathology and laboratory medicine resident review followed by attending pathologist review and cosignature. E-consults to the pathology and laboratory medicine service from 2015 to 2017 were reviewed to record type of consult, requesting department, patient location, and turnaround time. RESULTS.­: The pathology and laboratory medicine service received 351 e-consults from 2015 to 2017. The volume varied by subsection: hematology and coagulation (215 of 351; 61%), chemistry (109 of 351; 31%), blood bank (19 of 351; 6%), and microbiology/virology (8 of 351; 2%). Hematology and coagulation consults were entirely for peripheral blood smear review (215 of 215; 100%). Chemistry consults were placed for toxicology/drugs of abuse (81 of 109; 74%), test utilization (17 of 109; 16%), or nontoxicology (11 of 109; 10%). Three services placed the majority of consults: primary care (279 of 351; 80%), hematology/oncology (39 of 351; 11%), and psychiatry (27 of 351; 8%). The median turnaround time for completion of e-consults was 1.2 days. Since e-consult implementation, the mean number of consults increased from 8.6/mo in 2015 to 18.1/mo in 2017, peaking in the last quarter of analysis in 2017 with a mean of 25.3 consults/mo. CONCLUSIONS.­: This novel e-consult system improved accessibility to and documentation of answers to laboratory questions and increased the visibility of the pathology and laboratory medicine service. Future goals include development of outcomes-based measures to better assess the clinical impact of e-consults.


Assuntos
Patologia/métodos , Patologia/organização & administração , Consulta Remota/métodos , Consulta Remota/organização & administração , Hospitais de Veteranos/organização & administração , Humanos , Laboratórios/organização & administração
4.
JMIR Public Health Surveill ; 7(1): e24502, 2021 01 22.
Artigo em Inglês | MEDLINE | ID: mdl-33338028

RESUMO

BACKGROUND: COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the United States. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, are needed. OBJECTIVE: We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among US veterans by using a multisite surveillance network. METHODS: We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers located in Atlanta, Bronx, Houston, Palo Alto, and Los Angeles, collectively serving more than 396,000 patients annually. From February 27 to July 17, 2020, we actively identified inpatient cases with COVID-19 by screening admitted patients and reviewing their laboratory test results. We then manually abstracted the patients' medical charts for demographics, underlying medical conditions, and clinical outcomes. Furthermore, we calculated hospitalization incidence and incidence rate ratios, as well as relative risk for invasive mechanical ventilation, intensive care unit admission, and case fatality rate after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS: We identified 621 laboratory-confirmed, hospitalized COVID-19 cases. The median age of the patients was 70 years, with 65.7% (408/621) aged ≥65 years and 94% (584/621) male. Most COVID-19 diagnoses were among non-Hispanic Black (325/621, 52.3%) veterans, followed by non-Hispanic White (153/621, 24.6%) and Hispanic or Latino (112/621, 18%) veterans. Hospitalization rates were the highest among veterans who were ≥85 years old, Hispanic or Latino, and non-Hispanic Black (430, 317, and 298 per 100,000, respectively). Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with those aged 18-29 years (95% CI: 5.7-34.6), whereas Hispanic or Latino and Black veterans had a 4.6- and 4.2-fold increased rate of hospitalization, respectively, compared with non-Hispanic White veterans (95% CI: 3.6-5.9). Overall, 11.6% (72/621) of the patients required invasive mechanical ventilation, 26.6% (165/621) were admitted to the intensive care unit, and 16.9% (105/621) died in the hospital. The adjusted relative risk for invasive mechanical ventilation and admission to the intensive care unit did not differ by age group or race and ethnicity, but veterans aged ≥65 years had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS: COVID-19 surveillance at the 5 Veterans Affairs Medical Centers across the United States demonstrated higher hospitalization rates and severe outcomes among older veterans, as well as higher hospitalization rates among Hispanic or Latino and non-Hispanic Black veterans than among non-Hispanic White veterans. These findings highlight the need for targeted prevention and timely treatment for veterans, with special attention to older aged, Hispanic or Latino, and non-Hispanic Black veterans.


Assuntos
/terapia , Hospitalização/estatística & dados numéricos , Hospitais de Veteranos , Vigilância da População/métodos , Veteranos/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , /mortalidade , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Disparidades nos Níveis de Saúde , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Resultado do Tratamento , Estados Unidos/epidemiologia
5.
Addict Behav ; 113: 106692, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33099250

RESUMO

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.


Assuntos
/mortalidade , Doenças do Sistema Endócrino/epidemiologia , Síndromes de Imunodeficiência/epidemiologia , Pneumopatias/epidemiologia , Fumar/epidemiologia , Veteranos/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Idoso , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Uso de Tabaco/epidemiologia , Estados Unidos/epidemiologia
6.
PLoS One ; 15(12): e0242007, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33370307

RESUMO

PURPOSE: Progressive Tinnitus Management (PTM) is an evidence-based interdisciplinary stepped-care approach to improving quality of life for patients with tinnitus. PTM was endorsed by Department of Veterans Affairs (VA) Audiology leadership in 2009. Factors affecting implementation of PTM are unknown. We conducted a study to: 1) estimate levels of PTM program implementation in VA Audiology and Mental Health clinics across the country; and 2) identify barriers and facilitators to PTM implementation based on the experiences of VA audiologists and mental health providers. METHOD: We conducted an anonymous, web-based survey targeting Audiology and Mental Health leaders at 144 major VA facilities. Quantitative analyses summarized respondents' facility characteristics and levels of program implementation (full PTM, partial PTM, or no PTM). Qualitative analyses identified themes in factors influencing the implementation of PTM across VA sites. RESULTS: Surveys from 87 audiologists and 66 mental health clinicians revealed that few facilities offered full PTM; the majority offered partial or no PTM. Inductive analysis of the open-ended survey responses identified seven factors influencing implementation of PTM: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans' preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice. CONCLUSION: Results suggest wide variation in services provided, a need for greater engagement of mental health providers in tinnitus care, and an interest among both audiologists and mental health providers in receiving tinnitus-related training. Future research should address barriers to PTM implementation, including methods to: 1) improve understanding among mental health providers of their potential role in tinnitus management; 2) enhance coordination of tinnitus-related care between health care disciplines; and 3) collect empirical data on Veterans' need for and interest in PTM, including delivery by telehealth modalities.


Assuntos
Medicina Baseada em Evidências/organização & administração , Implementação de Plano de Saúde/organização & administração , Hospitais de Veteranos/organização & administração , Zumbido/terapia , Audiologia/organização & administração , Progressão da Doença , Medicina Baseada em Evidências/estatística & dados numéricos , Implementação de Plano de Saúde/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Serviços de Saúde Mental/organização & administração , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Médicos/estatística & dados numéricos , Pesquisa Qualitativa , Qualidade de Vida , Inquéritos e Questionários/estatística & dados numéricos , Telemedicina/organização & administração , Telemedicina/estatística & dados numéricos , Zumbido/psicologia , Estados Unidos , United States Department of Veterans Affairs/organização & administração , Veteranos/psicologia
7.
Anesth Analg ; 131(5): e209-e212, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33094965

RESUMO

Using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-12), we measured the prevalence of disability in all eligible patients during a 4-month period who were presenting for preoperative evaluation at a US Veterans Affairs hospital. Overall disability was at least moderate in more than half of these patients (total n = 472 at Durham, NC). Two of the 6 WHODAS domains, "Getting Around" and "Participation in Society," contributed most to the overall scores-25% and 20%, respectively. Further studies are needed to determine the impact of domain-specific disabilities on postoperative outcomes and to identify potential interventions to address these vulnerabilities.


Assuntos
Avaliação da Deficiência , Período Pré-Operatório , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Pessoas com Deficiência , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Prevalência , Comportamento Social , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs
9.
J Am Med Inform Assoc ; 27(11): 1716-1720, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-33067628

RESUMO

OBJECTIVE: Reducing risk of coronavirus disease 2019 (COVID-19) infection among healthcare personnel requires a robust occupational health response involving multiple disciplines. We describe a flexible informatics solution to enable such coordination, and we make it available as open-source software. MATERIALS AND METHODS: We developed a stand-alone application that integrates data from several sources, including electronic health record data and data captured outside the electronic health record. RESULTS: The application facilitates workflows from different hospital departments, including Occupational Health and Infection Control, and has been used extensively. As of June 2020, 4629 employees and 7768 patients and have been added for tracking by the application, and the application has been accessed over 46 000 times. DISCUSSION: Data captured by the application provides both a historical and real-time view into the operational impact of COVID-19 within the hospital, enabling aggregate and patient-level reporting to support identification of new cases, contact tracing, outbreak investigations, and employee workforce management. CONCLUSIONS: We have developed an open-source application that facilitates communication and workflow across multiple disciplines to manage hospital employees impacted by the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/transmissão , Gerenciamento de Dados , Pessoal de Saúde , Saúde do Trabalhador , Sistemas de Identificação de Pacientes/métodos , Pneumonia Viral/transmissão , Software , Fluxo de Trabalho , Boston , Surtos de Doenças , Hospitais de Veteranos , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias , Integração de Sistemas , Estados Unidos
10.
Womens Health Issues ; 30(5): 320-329, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32830008

RESUMO

PURPOSE: One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS: Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS: At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS: We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.


Assuntos
Comportamento de Ajuda , Assédio Sexual/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Estados Unidos , Saúde dos Veteranos
11.
PLoS One ; 15(7): e0236554, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32716922

RESUMO

The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.


Assuntos
Infecções por Coronavirus/terapia , Registros Eletrônicos de Saúde , Pneumonia Viral/terapia , Medição de Risco/métodos , Rotas de Resultados Adversos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Tomada de Decisões , Feminino , Hospitais de Veteranos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
12.
Am J Cardiol ; 131: 7-11, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32718555

RESUMO

Complete revascularization (CR) at the time of coronary artery bypass graft (CABG) surgery improves long-term cardiac outcomes. No studies have previously reported angiographically confirmed CR rates post-CABG. This study's aim was to assess the impact upon long-term outcomes of CR versus incomplete revascularization (IR), confirmed by coronary angiography 1 year after CABG. Randomized On/Off Bypass Study patients who returned for protocol-specified 1-year post-CABG coronary angiograms were included. Patients with a widely patent graft supplying the major diseased artery within each diseased coronary territory were considered to have CR. Outcomes were all-cause mortality and major adverse cardiovascular events (MACE; all-cause mortality, nonfatal myocardial infarction, repeat revascularization) over the 4 years after angiography. Of the 1,276 patients, 756 (59%) had CR and 520 (41%) had IR. MACE was 13% CR versus 26% IR, p <0.001. This difference was driven by fewer repeat revascularizations (5% CR vs 18% IR; p <0.001). There were no differences in mortality (7.1% CR vs 8.1% IR, p = 0.13) or myocardial infarction (4% in both). Adjusted multivariable models confirmed CR was associated with reduced MACE (odds ratio 0.44, 95% confidence interval 0.33 to 0.58, p <0.01), but had no impact on mortality. In conclusion, CR confirmed by post-CABG angiography was associated with improved MACE but not mortality. Repeat revascularization of patients with IR, driven by knowledge of the research angiography results, may have ameliorated potential mortality differences.


Assuntos
Angiografia Coronária , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/mortalidade , Feminino , Hospitais de Veteranos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Método Simples-Cego , Estados Unidos/epidemiologia
14.
Am J Public Health ; 110(9): 1318-1324, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32673113

RESUMO

Objective. To implement an opioid buyback program after ambulatory surgery.Methods. We performed a prospective cohort study of 578 opioid-naïve patients prescribed opioids after ambulatory surgery at a rural US Veterans Affairs (VA) hospital from 2017 to 2018. We reimbursed $5 per unused opioid pill ($50 limit) returned to our VA for proper disposal. We tracked the number of participants, number of unused opioid pills returned, surgeon prescribing, and refill requests.Results. Out of 578 eligible patients, 171 (29.6%) returned 2136.5 unused opioid pills. Information shared with surgeons after 6 months led to a 27% decrease in opioid prescribing without an increase in refills.Conclusions. With this opioid buyback program, rural patients had a safe and convenient place to dispose of unused opioids. Surgeons used information about returns to adjust opioid prescribing after common ambulatory surgeries without an increase in refill requests.Public Health Implications. Although providers prescribe within state opioid guidelines, there will be variations in patient use after ambulatory surgery. An opioid buyback program helped our patients and surgeons decrease unused prescription opioids available for diversion in our rural communities.


Assuntos
Analgésicos Opioides/uso terapêutico , Padrões de Prática Médica , Desvio de Medicamentos sob Prescrição/prevenção & controle , Procedimentos Cirúrgicos Ambulatórios , Estudos de Coortes , Hospitais de Veteranos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Estudos Prospectivos , População Rural , Cirurgiões , Estados Unidos , United States Department of Veterans Affairs
17.
J Surg Res ; 255: 339-345, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32599453

RESUMO

BACKGROUND: The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act established a community care program allowing veterans to receive care outside Veteran Affairs Medical Centers (VAMCs). We sought to compare patient safety and satisfaction indicators from VAMCs and surrounding non-VAMCs (non-VAs). METHODS: We identified VAMCs with at least one non-VA acute care hospital within 25 miles in three geographic regions (West/Southwest, New England, and Deep South). Children's, specialty, and critical access hospitals were excluded. Using publicly available Hospital Compare data, we analyzed VAMC and surrounding non-VA performance in postsurgical patient safety indicator (PSI) events and Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores and hospital star ratings. RESULTS: The 34 VAMCs performed better than 319 surrounding non-VAs in rates of wound dehiscence, accidental lacerations, and perioperative hemorrhage/hematoma as well as composite PSI rating (P < 0.05). VAMCs performed significantly better than non-VAs (18.0 versus 51.4 events per 1000 patients, P < 0.001) in composite surgery-specific PSIs. When comparing mean linear Hospital Consumer Assessment of Healthcare Providers and Systems score star ratings (1-5 scale), VAMCs had similar performance in overall hospital rating compared with non-VAs (3.28 versus 3.38, P = 0.48) and summary rating of hospital stays (2.87 versus 2.92, P = 0.69). When compiled patient satisfaction star ratings were compared, there was no difference (2.96 versus 2.97, P = 0.9). VAMCs performed worse than non-VAs in "would recommend" ratings (2.7 versus 3.13, P = 0.007). CONCLUSIONS: Across disparate regions, VAMCs match or outperform neighboring non-VAs in surgical quality metrics and patient satisfaction ratings. Veterans receiving surgical care at VAMCs may receive equivalent or better care than at non-VAs.


Assuntos
Hospitais de Veteranos/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Humanos , Indicadores de Qualidade em Assistência à Saúde , Estados Unidos
18.
J Surg Res ; 255: 1-8, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32540575

RESUMO

BACKGROUND: Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. METHODS: A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t-test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. RESULTS: OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). CONCLUSIONS: LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA.


Assuntos
Anestesia Geral/estatística & dados numéricos , Anestesia Local/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Idoso , Estudos de Viabilidade , Feminino , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
19.
Medicine (Baltimore) ; 99(24): e20385, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541458

RESUMO

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.


Assuntos
Benchmarking/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Idoso , Algoritmos , Benchmarking/normas , Estudos de Coortes , Grupos Diagnósticos Relacionados/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hispano-Americanos/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/organização & administração
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