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1.
Int J Radiat Oncol Biol Phys ; 106(3): 639-647, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31983560

RESUMO

PURPOSE: We sought to develop a quality surveillance program for approximately 15,000 US veterans treated at the 40 radiation oncology facilities at the Veterans Affairs (VA) hospitals each year. METHODS AND MATERIALS: State-of-the-art technologies were used with the goal to improve clinical outcomes while providing the best possible care to veterans. To measure quality of care and service rendered to veterans, the Veterans Health Administration established the VA Radiation Oncology Quality Surveillance program. The program carries forward the American College of Radiology Quality Research in Radiation Oncology project methodology of assessing the wide variation in practice pattern and quality of care in radiation therapy by developing clinical quality measures (QM) used as quality indices. These QM data provide feedback to physicians by identifying areas for improvement in the process of care and identifying the adoption of evidence-based recommendations for radiation therapy. RESULTS: Disease-site expert panels organized by the American Society for Radiation Oncology (ASTRO) defined quality measures and established scoring criteria for prostate cancer (intermediate and high risk), non-small cell lung cancer (IIIA/B stage), and small cell lung cancer (limited stage) case presentations. Data elements for 1567 patients from the 40 VA radiation oncology practices were abstracted from the electronic medical records and treatment management and planning systems. Overall, the 1567 assessed cases passed 82.4% of all QM. Pass rates for QM for the 773 lung and 794 prostate cases were 78.0% and 87.2%, respectively. Marked variations, however, were noted in the pass rates for QM when tumor site, clinical pathway, or performing centers were separately examined. CONCLUSIONS: The peer-review protected VA-Radiation Oncology Surveillance program based on clinical quality measures allows providers to compare their clinical practice to peers and to make meaningful adjustments in their personal patterns of care unobtrusively.


Assuntos
Institutos de Câncer/normas , Hospitais de Veteranos/normas , Desenvolvimento de Programas , Garantia da Qualidade dos Cuidados de Saúde/normas , Radioterapia (Especialidade)/normas , Carcinoma Pulmonar de Células não Pequenas/radioterapia , Medicina Baseada em Evidências/normas , Humanos , Neoplasias Pulmonares/radioterapia , Masculino , Revisão por Pares , Avaliação de Programas e Projetos de Saúde/normas , Neoplasias da Próstata/radioterapia , Garantia da Qualidade dos Cuidados de Saúde/métodos , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Carcinoma de Pequenas Células do Pulmão/radioterapia , Sociedades Médicas/normas , Estados Unidos , Veteranos
2.
J Clin Ethics ; 30(4): 338-346, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851625

RESUMO

Although tissue plasminogen activator (tPA) is the only medication approved by the United States Food and Drug Administration (FDA) for acute ischemic stroke, there is no consensus about the need for informed consent for its use. As a result, hospitals throughout the U.S. have varying requirements regarding obtaining informed consent from patients for the use of tPA, ranging from no requirement for informed consent to a requirement for verbal or written informed consent. We conducted a study to (1) determine current beliefs about obtaining patients' informed consent for tPA among a large group of stroke clinicians and (2) identify the ethical, clinical, and organizational factors that influence tPA consent practices. Semi-structured interviews were conducted by trained and experienced investigators and research staff to identify key barriers to implementing acute stroke services. Part of the interview explored current beliefs and practices around informed consent for tPA. This was a multicenter study that included 38 Veterans Health Administration (VHA) hospital locations. Participants were 68 stroke team clinicians, serving primarily on the neurology (35 percent) or emergency medicine (41 percent) service. We conducted thematic analysis based on principles of grounded theory to identify codes about consent for tPA. We used interpretive convergence to ensure consistency among the individual investigators' codes and to ensure that all of the investigators agreed on coding and themes. We found that 38 percent of the stroke clinicians did not believe any form of consent was necessary for tPA, 47 percent thought that some form of consent was necessary, and 15 percent were unsure. Clinicians who believed tPA required informed consent were divided on whether consent should be written (40 percent) or verbal (60 percent). We identified three factors describing clinicians' attitudes about consent: (1) legal and policy factors, (2) ethical factors, and (3) medical factors. The lack of consensus regarding consent for tPA creates the potential for delays in treatment, uneasiness among clinicians, and legal liability. The identified factors provide a potential framework to guide discussions about developing a standard of care for acquiring the informed consent of patients for the administration of tPA.


Assuntos
Isquemia Encefálica/terapia , Consentimento Livre e Esclarecido , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Atitude do Pessoal de Saúde , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Hospitais de Veteranos , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Estados Unidos
3.
Med Care ; 57(11): 913-920, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31609847

RESUMO

OBJECTIVE: There is limited knowledge about how general hospitals and Veterans Health Administration (VHA) hospitals fare relative to each other on a broad range of inpatient psychiatry-specific patient safety outcomes.This research compares data from 2 large-scale epidemiological studies of adverse events (AEs) and medical errors (MEs) in inpatient psychiatric units, one in VHA hospitals and the other in community-based general hospitals. METHOD: Retrospective medical record reviews assessed the prevalence of AEs and MEs in a sample of 4371 discharges from 14 community-based general hospitals (derived from 69,081 discharges at 85 hospitals) and a sample of 8005 discharges from 40 VHA hospitals (derived from 92,103 discharges at 105 medical centers). Rates of AEs and MEs across hospital systems were calculated, controlling for relevant patient and hospital characteristics. RESULTS: The overall rate of AEs and MEs in inpatient psychiatric units of VHA hospitals was 7.11 and 1.49 per 100 patient discharges; at community-based acute care hospitals, these rates were 13.48 and 3.01 per 100 patient discharges. The adjusted odds ratio of a patient experiencing an AE and a ME at community-based hospitals as compared with VHA hospitals was 2.11 and 2.08, respectively. CONCLUSION: Although chart reviews may not document the complete nature and outcomes of care, even after controlling for differences in patient and hospital characteristics, psychiatric inpatients at community-based hospitals were twice as likely to experience AEs or MEs as inpatients at VHA hospitals. While community-based hospitals may lag behind VHA hospitals, both hospital systems should continue to pursue evidence-based improvements in patient safety. Future research aimed at changing hospital practices should draw on established strategies for bridging the gap from research to practice in order to improve the quality of care for this vulnerable patient population.


Assuntos
Hospitais Comunitários/estatística & dados numéricos , Hospitais Gerais/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Pacientes Internados/psicologia , Erros Médicos/estatística & dados numéricos , Unidade Hospitalar de Psiquiatria/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Erros Médicos/psicologia , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
4.
Am J Health Syst Pharm ; 76(16): 1248-1253, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369117

RESUMO

PURPOSE: Results of a study to determine the proportion of anticoagulation clinic workload that could be performed by clinical pharmacy technicians (CPTs) and the potential impact on operational efficiency of pharmacist-managed anticoagulation clinics (ACCs) are reported. METHODS: In a quality improvement project involving 11 Veterans Affairs (VA) medical centers, investigators conducted a 3-day time study in pharmacist-managed ACCs followed by scoring of task appropriateness for CPTs via the RAND/UCLA appropriateness method by the VA Anticoagulation Subject Matter Expert (SME) Workgroup. The primary outcome was the percentage of tasks deemed appropriate for a CPT to perform. RESULTS: The Anticoagulation SME Workgroup determined that a wide variety of mainly administrative ACC tasks could be completed by a CPT. At the 11 VA ACCs, an average of 53.4% (range, 39.9-76.1%) of tasks being performed by pharmacists were deemed appropriate for CPTs. The average percentage of total clinic time associated with performing tasks appropriate for a CPT equated to an estimated 1,111 hours per year. Shifting that portion of the annual work hours to a CPT could potentially result in cost avoidance of $55,302. CONCLUSION: At the ACCs evaluated, a significant proportion of tasks (53.4% on average) may be appropriate to assign to CPTs to improve the operational efficiency of these clinics. This finding supports development of business plans for the addition of CPTs in ACCs along with elements to inform crafting of an effective template for ACC structure, including clearly defined CPT roles.


Assuntos
Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/prevenção & controle , Hemorragia/prevenção & controle , Ambulatório Hospitalar/organização & administração , Técnicos em Farmácia/organização & administração , Transtornos da Coagulação Sanguínea/sangue , Monitoramento de Medicamentos/métodos , Monitoramento de Medicamentos/estatística & dados numéricos , Eficiência Organizacional , Hemorragia/sangue , Hemorragia/induzido quimicamente , Hospitais de Veteranos/organização & administração , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Coeficiente Internacional Normatizado , Ambulatório Hospitalar/estatística & dados numéricos , Serviço de Farmácia Hospitalar/organização & administração , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Técnicos em Farmácia/estatística & dados numéricos , Papel Profissional , Avaliação de Programas e Projetos de Saúde , Varfarina/uso terapêutico , Carga de Trabalho/estatística & dados numéricos
6.
Mayo Clin Proc ; 94(8): 1444-1456, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31378227

RESUMO

OBJECTIVE: To compare incident dementia risk among patients who initiated treatment with metformin or sulfonylurea in Veterans Health Affairs (VHA) patients with replication in Kaiser Permanente Washington (KPW) patients to determine whether first-choice antidiabetic medications are associated with reduced risk of dementia. PATIENTS AND METHODS: Cohorts contained 75,187 VHA patients and 10,866 KPW patients, 50 years and older, who initiated monotherapy with metformin or sulfonylurea. Patients were free of dementia diagnoses and any diabetes treatment for 2 years before cohort entry. Variables were extracted from electronic health data from VHA (1999-2015) and KPW (1996-2015), which included diagnosis codes, pharmacy data, laboratory values, and demographic characteristics. Propensity scores and inverse probability of treatment weighting controlled for confounding. RESULTS: Veterans Health Affairs patients were 60.8±6.8 years of age on average, and KPW patients were 63.1±9.5 years of age. In the VHA sample, 72,769 (96.8%) were male; and in the KPW sample, 5480 (50.4%). After adjusting for confounding, metformin initiation was associated with a significantly (P=.02) lower risk of dementia in VHA (hazard ratio, 0.9; 95% CI, 0.9-1.0), with a similar point estimate in KPW (hazard ratio, 0.9; 95% CI, 0.7-1.1). Metformin was not associated with dementia risk in patients 75 years and older. CONCLUSION: Existing epidemiological studies of metformin and incident dementia have been inconsistent. Using a similar study design in 2 patient populations that differed in clinical and demographic characteristics, our results provide robust evidence that metformin use is associated with a modestly lower risk of incident dementia.


Assuntos
Demência/induzido quimicamente , Demência/epidemiologia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Metformina/efeitos adversos , Compostos de Sulfonilureia/efeitos adversos , Fatores Etários , Idoso , Bases de Dados Factuais , Demência/fisiopatologia , Diabetes Mellitus Tipo 2/diagnóstico , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Hospitais de Veteranos , Humanos , Incidência , Masculino , Metformina/uso terapêutico , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Compostos de Sulfonilureia/uso terapêutico , Estados Unidos
7.
Womens Health Issues ; 29 Suppl 1: S15-S23, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31253237

RESUMO

INTRODUCTION: Female veterans smoke cigarettes at high rates compared with both male veterans and nonveteran women. Proactive outreach to smokers may reduce gender disparities in cessation care. The objectives of this study were to compare baseline experiences with VA smoking cessation care for men and women and to assess for gender differences in response to a proactive outreach intervention. METHODS: We conducted a post hoc subgroup analysis of a pragmatic, multisite randomized, controlled trial comparing proactive outreach with usual care (UC). Baseline experiences included physician advice to quit, satisfaction with care, and past-year treatment use. At the 1-year follow-up, treatment use, quit attempts, and 6-month prolonged abstinence for women and men randomized to proactive outreach versus UC were compared using logistic regression. RESULTS: Baseline and follow-up surveys were returned by 138 women and 2,516 men. At baseline, women were less likely than men to report being very or somewhat satisfied with the process of obtaining smoking cessation medications in the VA (47% of women vs. 62% of men), but no less likely to report having used cessation medications from the VA in the past year (39% of women vs. 34% of men). After the intervention, phone counseling and combined therapy increased among both women and men in proactive outreach as compared with UC. At the 1-year follow-up, men in proactive outreach were significantly more likely to report prolonged abstinence than those in UC (odds ratio, 1.65; 95% CI, 1.28-2.14); results for women were in the same direction but not statistically significant (odds ratio, 1.39; 95% CI, 0.48-3.99). CONCLUSIONS: Satisfaction with cessation care in VA remains low. Proactive outreach to smokers was associated with an increased use of cessation therapies, and increased odds of achieving prolonged abstinence. A subgroup analysis by gender did not reveal significant differences in the treatment effect.


Assuntos
Aconselhamento/métodos , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/psicologia , Fumar/psicologia , Fumar/terapia , Veteranos/estatística & dados numéricos , Adulto , Feminino , Hospitais de Veteranos , Humanos , Masculino , Estudos Multicêntricos como Assunto/métodos , Médicos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Abandono do Hábito de Fumar/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologia
8.
Womens Health Issues ; 29 Suppl 1: S32-S38, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31253240

RESUMO

BACKGROUND: Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care. METHODS: Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics. RESULTS: The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women. CONCLUSIONS: It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.


Assuntos
Assistência à Saúde , Obesidade/psicologia , Satisfação do Paciente , Qualidade da Assistência à Saúde , Estereotipagem , Veteranos/psicologia , Adulto , Idoso , Comunicação , Feminino , Hospitais de Veteranos/organização & administração , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Obesidade/terapia , Atenção Primária à Saúde , Autogestão , Estados Unidos , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos , Saúde dos Veteranos
9.
Womens Health Issues ; 29 Suppl 1: S83-S93, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31253247

RESUMO

PURPOSE: Stranger harassment at Veterans Health Administration (VA) facilities is prevalent, affecting one in four women veteran VA primary care users. Harassment interferes with health care quality and may result in veterans forgoing or delaying needed care. To better understand this phenomenon, gender-stratified discussion groups were held with men and women veterans. This article examines gender differences in veterans' perceptions and experiences of harassment on VA grounds. METHODS: We conducted a total of 15 discussion groups at four VA medical centers, eight with men (n = 57) and seven with women (n = 38). Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS: Awareness of harassment was not uniformly high among participants. Although women voiced clear understandings and experiences of specific behaviors constituting harassment (e.g., cat-calls, sexual comments), many men expressed confusion about how to differentiate between harassment, "harmless flirting," and general friendliness; they were unsure which behaviors "cross a line." Furthermore, men placed the onus on women for setting boundaries, whereas women indicated it was not their responsibility to "train" men about acceptable behavior. Men and women agreed that VA staff hold primary responsibility for preventing and managing harassment. CONCLUSIONS: Substantive gender differences in understandings of harassment exist among veteran VA users. To minimize harassment, veterans recommend education of men veteran VA users, and staff-oriented trainings. Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy. Harassment undermines these standards, impeding women's access to VA care and compromising both their health outcomes and health care experiences. Understanding harassment through a gendered lens is a critical step in designing comprehensive initiatives that respond to diverse viewpoints and experiences.


Assuntos
Assédio não Sexual/psicologia , Assédio Sexual/psicologia , Saúde dos Veteranos , Veteranos/psicologia , Adulto , Assistência à Saúde/normas , Feminino , Hospitais de Veteranos/organização & administração , Humanos , Percepção , Atenção Primária à Saúde , Qualidade da Assistência à Saúde , Estados Unidos , United States Department of Veterans Affairs , Saúde da Mulher
10.
Implement Sci ; 14(1): 46, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31053157

RESUMO

BACKGROUND: Controlled implementation trials often randomize the intervention at the site level, enrolling relatively few sites (e.g., 6-20) compared to trials that randomize by subject. Trials with few sites carry a substantial risk of an imbalance between intervened (cases) and non-intervened (control) sites in important site characteristics, thereby threatening the internal validity of the primary comparison. A stepped wedge design (SWD) staggers the intervention at sites over a sequence of times or time waves until all sites eventually receive the intervention. We propose a new randomization method, sequential balance, to control time trend in site allocation by minimizing sequential imbalance across multiple characteristics. We illustrate the new method by applying it to a SWD implementation trial. METHODS: The trial investigated the impact of blended internal-external facilitation on the establishment of evidence-based teams in general mental health clinics in nine US Department of Veterans Affairs medical centers. Prior to randomization to start time, an expert panel of implementation researchers and health system program leaders identified by consensus a series of eight facility-level characteristics judged relevant to the success of implementation. We characterized each of the nine sites according to these consensus features. Using a weighted sum of these characteristics, we calculated imbalance scores for each of 1680 possible site assignments to identify the most sequentially balanced assignment schemes. RESULTS: From 1680 possible site assignments, we identified 34 assignments with minimal imbalance scores, and then randomly selected one assignment by which to randomize start time. Initially, the mean imbalance score was 3.10, but restricted to the 34 assignments, it declined to 0.99. CONCLUSIONS: Sequential balancing of site characteristics across groups of sites in the time waves of a SWD strengthens the internal validity of study conclusions by minimizing potential confounding. TRIAL REGISTRATION: Registered at ClinicalTrials.gov as clinical trials # NCT02543840 ; entered 9/4/2015.


Assuntos
Hospitais de Veteranos/organização & administração , Transtornos Mentais/terapia , Projetos de Pesquisa , Medicina Baseada em Evidências , Humanos , Desenvolvimento de Programas , Melhoria de Qualidade , Estados Unidos , United States Department of Veterans Affairs
11.
Innovations (Phila) ; 14(3): 251-262, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31081708

RESUMO

OBJECTIVE: The majority of minimally invasive surgical aortic valve replacements (MIAVRs) are performed at high-volume cardiac surgery centers. However, outcomes at lower volume federal facilities are not yet reported in the literature and not captured in the national Society of Thoracic Surgeons (STS) database. Our study objective was to describe the evolution of MIAVR at a Veterans Affairs Medical Center (VAMC). METHODS: A single-center retrospective cohort study was performed of 114 patients who underwent MIAVR for isolated aortic valvular disease between January 2011 and August 2018. Preoperative STS risk factors were determined and perioperative outcomes were analyzed. RESULTS: By 2016, 100% of isolated surgical aortic valve replacements were performed as MIAVRs at our VAMC. Introduction of automatic knot-fastening devices, single-shot del Nido cardioplegia, and rapid deployment valves decreased aortic cross-clamp (AXC) times from a median of 96 (interquartile range [IQR]: 84 to 103) to 53 minutes (38 to 61, P < 0.001, Kruskal-Wallis). Thirty-day mortality was 0.9%. Median length of hospital stay was 9 days (7 to 13). Postoperative atrial fibrillation occurred in 54% of patients, stroke occurred in 1.8% of patients, and 7.1% of patients required permanent pacemakers. Transition to rapid deployment valves decreased postoperative mean pressure gradient from median 14 mmHg (10 to 17) to 7 mmHg (4.7 to 10, P < 0.001, Mann-Whitney). At median 1.5-year follow-up echocardiogram, mean gradient was 10.8 mmHg with mild paravalvular leak rate of 1.8%. CONCLUSIONS: Facilitating technologies decreased operative times during MIAVR adoption at our VAMC. For patients with isolated aortic valve pathology, MIAVR can be performed with low morbidity and mortality at lower volume federal institutions, with outcomes comparable to those reported from higher volume centers.


Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/tendências , Hospitais com Baixo Volume de Atendimentos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Idoso , Fibrilação Atrial/epidemiologia , Feminino , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Hospitais de Veteranos , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Esternotomia/métodos , Estados Unidos , United States Department of Veterans Affairs
12.
Am J Trop Med Hyg ; 101(1): 33-39, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31115296

RESUMO

Query fever (Q fever), caused by Coxiella burnetii, was first described in southern California in 1947. It was found to be endemic and enzoonotic to the region and associated with exposure to livestock. We describe a series of 20 patients diagnosed with Q fever at a Veterans Affairs hospital in southern California, with the aim of contributing toward the understanding of Q fever in this region. Demographics, laboratory data, diagnostic imaging, risk factors, and treatment regimens were collected via a retrospective chart review of patients diagnosed with Q fever at our institution between 2000 and 2016. Cases were categorized as acute or chronic and confirmed or probable. The majority presented with an acute febrile illness (90%). There was a delay in ordering diagnostic serology from the time of symptom onset (acute cases, average 31.9 days; chronic cases, average 63 days), and 15% progressed from acute to chronic infection. Of the chronic cases, 22.2% had endocarditis, 22.2% had endovascular infection, and 11.1% had both endocarditis and endovascular infection. The geographic distribution revealed that 20% resided in rural areas. Of the cases of Q fever that died, death attributed to Q fever was associated with an average diagnostic delay of 65.5 days. Acute Q fever is underreported in this region largely because of its often nonspecific clinical presentation.


Assuntos
Antibacterianos/uso terapêutico , Doxiciclina/uso terapêutico , Hidroxicloroquina/uso terapêutico , Febre Q/diagnóstico , Febre Q/epidemiologia , Rifampina/uso terapêutico , Adulto , Idoso , California/epidemiologia , Doença Crônica , Doxiciclina/administração & dosagem , Endocardite Bacteriana/tratamento farmacológico , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/patologia , Hospitais de Veteranos , Humanos , Hidroxicloroquina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Febre Q/tratamento farmacológico , Febre Q/patologia , Estudos Retrospectivos , Rifampina/administração & dosagem
13.
Womens Health Issues ; 29(3): 283-289, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30981559

RESUMO

BACKGROUND: Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans' experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences. METHODS: We conducted 32 qualitative interviews among women veterans ages 18-44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified. RESULTS: Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making. CONCLUSIONS: Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA.


Assuntos
Serviços de Planejamento Familiar/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Mães/psicologia , Assistência Centrada no Paciente/estatística & dados numéricos , Gestantes/psicologia , Veteranos/psicologia , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Mães/estatística & dados numéricos , Gravidez , Estados Unidos , United States Department of Veterans Affairs , Adulto Jovem
14.
J Laparoendosc Adv Surg Tech A ; 29(6): 730-740, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31017517

RESUMO

Background: Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men. Objectives: To identify motivations of males who pursue either MWM or bariatric surgery. Setting: Interviews with males with severe obesity (body mass index ≥35 kg/m2), who participated in a Veteran Affairs weight loss program in the Midwest. Materials and Methods: Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes. Results: Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options. Conclusion: The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.


Assuntos
Cirurgia Bariátrica , Motivação , Obesidade Mórbida/psicologia , Obesidade Mórbida/cirurgia , Obesidade Mórbida/terapia , Programas de Redução de Peso , Idoso , Índice de Massa Corporal , Dieta Redutora , Terapia por Exercício , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Meio-Oeste dos Estados Unidos , Qualidade de Vida , Veteranos , Perda de Peso
15.
Am J Med Sci ; 357(4): 296-301, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30904044

RESUMO

BACKGROUND: Prior research has demonstrated high mortality rates in patients with cirrhosis who contract bacterial infections. The purpose of our study was to explore clinical outcomes such as 90-day mortality, rehospitalization, and intensive care unit (ICU) admission in older veterans with pneumonia and cirrhosis. METHODS: We conducted a retrospective cohort study of hospitalized patients with community-acquired pneumonia at any Departments of Veterans Affairs (VA) hospital over a 10-year period. We included patients 65 years or older who consistently received VA care and who were diagnosed with community-acquired pneumonia. There were 103,997 patients who met the inclusion criteria, and 1,246 patients with cirrhosis. We used multilevel regression models to examine the association between cirrhosis and the outcomes of interest after controlling for potential confounders. RESULTS: Cirrhosis was associated with significantly increased odds of 90-day mortality (odds ratio 1.79, 95% confidence interval, 1.57-2.04). There were also significantly increased odds of rehospitalization within 90-days (1.30, 1.16-1.47). No significant association was found with ICU admission (1.00, 0.83-1.19). CONCLUSIONS: We found an association between cirrhosis and 90-day mortality and rehospitalization in older patients with pneumonia. We suggest that physicians should carefully monitor patients with cirrhosis who develop pneumonia.


Assuntos
Infecções Comunitárias Adquiridas/epidemiologia , Hospitalização/estatística & dados numéricos , Cirrose Hepática/epidemiologia , Pneumonia/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Infecções Comunitárias Adquiridas/etiologia , Hospitais de Veteranos , Humanos , Cirrose Hepática/etiologia , Masculino , Pneumonia/etiologia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Veteranos
16.
MMWR Morb Mortal Wkly Rep ; 68(9): 220-224, 2019 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-30845116

RESUMO

INTRODUCTION: By 2007, all Department of Veterans Affairs medical centers (VAMCs) had initiated a multifaceted methicillin-resistant Staphylococcus aureus (MRSA) prevention program. MRSA and methicillin-susceptible S. aureus (MSSA) infection rates among VAMC inpatients from 2005 to 2017 were assessed. METHODS: Clinical microbiology data from any patient admitted to an acute-care VAMC in the United States from 2005 through 2017 and trends in hospital-acquired MRSA colonization were examined. RESULTS: S. aureus infections decreased by 43% overall during the study period (p<0.001), driven primarily by decreases in MRSA, which decreased by 55% (p<0.001), whereas MSSA decreased by 12% (p = 0.003). Hospital-onset MRSA and MSSA infections decreased by 66% (p<0.001) and 19% (p = 0.02), respectively. Community-onset MRSA infections decreased by 41% (p<0.001), whereas MSSA infections showed no significant decline. Acquisition of MRSA colonization decreased 78% during 2008-2017 (17% annually, p<0.001). MRSA infection rates declined more sharply among patients who had negative admission surveillance MRSA screening tests (annual 9.7% decline) compared with those among patients with positive admission MRSA screening tests (4.2%) (p<0.05). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Significant reductions in S. aureus infection following the VAMC intervention were led primarily by decreases in MRSA. Moreover, MRSA infection declines were much larger among patients not carrying MRSA at the time of admission than among those who were. Taken together, these results suggest that decreased MRSA transmission played a substantial role in reducing overall S. aureus infections at VAMCs. Recent calls to withdraw infection control interventions designed to prevent MRSA transmission might be premature and inadvisable, at least until more is known about effective control of bacterial pathogen transmission in health care settings. Effective S. aureus prevention strategies require a multifaceted approach that includes adherence to current CDC recommendations for preventing not only device- and procedure-associated infections, but also transmission of health care-prevalent strains.


Assuntos
Infecção Hospitalar/epidemiologia , Hospitais de Veteranos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus/isolamento & purificação , Infecção Hospitalar/prevenção & controle , Feminino , Humanos , Controle de Infecções/organização & administração , Masculino , Meticilina/farmacologia , Infecções Estafilocócicas/prevenção & controle , Staphylococcus aureus/efeitos dos fármacos , Estados Unidos/epidemiologia
17.
Semin Thorac Cardiovasc Surg ; 31(3): 434-441, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30849464

RESUMO

Between 2000 and 2008, the mitral valve (MV) repair rate in patients with severe mitral regurgitation at our low-volume Veterans Affairs hospital was 21%. After instituting a multidisciplinary valve team in 2009, we determined whether this rate increased and characterized the outcomes of patients with degenerative disease. We retrospectively reviewed data from 103 MV operations performed at our hospital between 1/2009 and 8/2016. MV pathology was categorized as degenerative, rheumatic, endocarditis, ischemic, hypertrophic cardiomyopathy, or failed prior MV repair. The surgical techniques used for MV repair were reviewed. For the patients with degenerative disease who underwent MV repair, we assessed leaflet involvement and postoperative valve function. For the full cohort, the MV repair rate was 67% and the 30-day mortality rate was 0.97%. Of the 74 patients with degenerative disease, 64 (86.5%) underwent MV repair (none required reoperation). For these patients, the MV repair rate was significantly higher when the surgical approach was sternotomy rather than minimally invasive right minithoracotomy (92.5% vs 71.4%, P = 0.03). After MV repair, 95.3% of the degenerative disease patients had mild or less mitral regurgitation; median echocardiography follow-up time was 555 days. Anatomic features associated with a reduced MV repair rate in patients with degenerative disease were dystrophic leaflet calcification and severe mitral annular calcification. In an institution with a low volume of MV operations, preoperative surgical planning with a multidisciplinary valve team was associated with improved MV repair rates and excellent repair quality in patients with degenerative valve disease.


Assuntos
Implante de Prótese de Valva Cardíaca/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Hospitais de Veteranos/tendências , Anuloplastia da Valva Mitral/tendências , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Equipe de Assistência ao Paciente/tendências , Padrões de Prática Médica/tendências , Idoso , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Recuperação de Função Fisiológica , Estudos Retrospectivos , Índice de Gravidade de Doença , Esternotomia/tendências , Toracotomia/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
18.
J Manag Care Spec Pharm ; 25(3): 411-416, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30816815

RESUMO

BACKGROUND: The establishment of a formulary management system ensures that health care professionals work together in an integrated patient care process to promote clinically sound, safe, and cost-effective medication therapy. Pharmacists have a foundational role within this system. A pharmacist-adjudicated prior authorization drug request (PADR) consult service has the potential to optimize drug therapy by decreasing medication misuse, minimizing adverse drug events (ADEs), and preventing medication errors. OBJECTIVES: To (a) determine cost avoidance associated with pharmacist-adjudicated PADR safety interventions within the Durham Veterans Affairs Health Care System and (b) evaluate cost savings associated with pharmacist-adjudicated PADRs not approved due to a safety intervention, evaluate cost avoidance and direct cost savings based on clinical specialty of pharmacist adjudicating PADR, and characterize severity of avoided ADEs. METHODS: Pharmacist-adjudicated PADRs not approved between July 1, 2016, and June 30, 2017, because of safety interventions were retrospectively reviewed. Cost avoidance was determined by multiplying the probability of ADE occurrence in the absence of PADR safety intervention by the estimated cost avoided based on the type of intervention. Direct cost savings was calculated by totaling the cost of requested medications not approved for each PADR and subtracting the cost of recommended alternative therapies and cost of pharmacist PADR review. All potential ADEs avoided were reviewed by a panel of 3 clinical pharmacists to validate ADE classification and ADE probability and severity scores. Descriptive statistics were used for all analyses. RESULTS: Of the 910 PADRs that were not approved during the study period, 96 met inclusion criteria. Pharmacist-adjudicated PADR safety interventions resulted in a total cost avoidance of $24,485.34 (mean = $255.06) and a direct cost savings of $288,695.63 (mean = $3,007.25). The practice settings of anticoagulation and infectious diseases PADRs resulted in the largest contribution to cost avoidance and direct cost savings, respectively. Prevented ADEs were classified as major for 64.6% of the PADRs. CONCLUSIONS: Pharmacist-adjudicated PADR safety reviews resulted in substantial economic benefit and prevention of major ADEs. This analysis supports the pharmacist's role in a formulary management system to optimize medication therapy. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors. The authors have nothing to disclose.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Farmacêuticos/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Autorização Prévia/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Consultores , Redução de Custos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/economia , Feminino , Formulários de Hospitais como Assunto , Hospitais de Veteranos/economia , Hospitais de Veteranos/organização & administração , Humanos , Masculino , Erros de Medicação/economia , Erros de Medicação/prevenção & controle , Pessoa de Meia-Idade , Farmacêuticos/economia , Serviço de Farmácia Hospitalar/economia , Autorização Prévia/economia , Papel Profissional , Estudos Retrospectivos
20.
Am J Health Syst Pharm ; 76(5): 312-319, 2019 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-30753290

RESUMO

Purpose: Adverse drug events (ADEs) in the U.S. Department of Veterans Affairs (VA) were evaluated, and differences in age group report rates and reported medications in different age groups were assessed. Methods: We utilized the VA Adverse Drug Event Reporting System (ADERS) to assess 10-year age groups regarding ADE reporting rates, event severity, and associated reported medications. Data were derived from 484,351 ADE reports from 395,703 patients included in VA ADERS from 2009 through 2016. Results: Reported rates of ADEs per 10,000 unique users demonstrated a nonlinear relationship with age, peaking in the group aged 60-69 years (148.6 reports/10,000 unique users) and declining thereafter. However, the percentage of adverse events reported as severe consistently rose with age group (3% in patients age 20-29 years versus 6% in patients older than 90 years). The types of medications reported as causative agents shifted over time from predominantly mental health and pain medications in younger veterans (e.g., age 20-29 years) to medications for chronic diseases in older cohorts (e.g., age 60-69 years). Conclusion: An analysis of VA ADE reports revealed a nonlinear relationship between age and events, with events peaking at age 60-69 years. Rates of severe ADEs increased in older age groups. Drugs commonly associated with ADEs tended to be those primarily used for mental health and pain treatment in younger patients and those used to address chronic disease states in older patients.


Assuntos
Sistemas de Notificação de Reações Adversas a Medicamentos/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Hospitais de Veteranos/normas , Índice de Gravidade de Doença , United States Department of Veterans Affairs/normas , Adulto , Sistemas de Notificação de Reações Adversas a Medicamentos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Feminino , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Polimedicação , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto Jovem
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