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2.
Orthop Clin North Am ; 51(2): 235-239, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32138861

RESUMO

To determine if orthopedic surgeons are more efficient than nonsurgical providers at care of operative injuries in walk-in clinics, patients in a walk-in clinic for evaluation of acute injury who subsequently had surgical treatment of isolated distal radial fracture were compared based on whether the initial visit was with a surgical or nonsurgical provider. Initial evaluation in a walk-in orthopedic clinic setting versus a conventional hand surgeon's clinic was associated with longer delay between initial evaluation and surgical treatment, but this difference may not be significant. Evaluation by a nonsurgical provider was not associated with increased duration to definitive treatment.


Assuntos
Fraturas do Rádio/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Instituições de Assistência Ambulatorial , Feminino , Fixação Interna de Fraturas , Consolidação da Fratura , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas do Rádio/terapia , Tempo para o Tratamento , Adulto Jovem
4.
Chirurgia (Bucur) ; 115(1): 69-79, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32155401

RESUMO

Background: Basal cell carcinoma (BCC) and Squamous cell carcinoma (SCC) are the most frequent skin cancers with a continuous increasing incidence and a cause of economic impact. Mohs micrographic surgery (MMS) is known as the gold-standard of treatment of non-melanoma skin cancer. Methods: The files of the patients treated with MMS were analysed during a 6 year period (2014-2019) and demographic information was extracted in addition to the information on tumor histology, localization of tumors, number of stages required for a complete removal of the tumors, and the evolution of the patients. We also analysed the information regarding the number and type of reconstructions performed. Results: Over the course of 6 years, 1,356 cutaneous tumors were treated in our clinic by means of MMS. BCC represented 80.5%, SCC 17.6%, and other tumors such as melanoma in situ, DFSP, Extramammary Paget's Disease - being 1.9% of the number of other treated tumors. During the period under review, only 4 cases of post-Mohs Micrographic Surgery recurrence have been recorded, with a cure rate of over 99.7%. Conclusions: Mohs micrographic surgery is an efficient treatment method in removing cutaneous carcinoma as well as tumors with special indications with a low recurrence rate therefore reducing the need of successive surgical interventions.


Assuntos
Cirurgia de Mohs , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Instituições de Assistência Ambulatorial , Humanos , Cirurgia de Mohs/métodos , Romênia , Resultado do Tratamento
5.
Bone Joint J ; 102-B(2): 148-154, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32009438

RESUMO

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called 'stem cell' preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers. Cite this article: Bone Joint J 2020;102-B(2):148-154.


Assuntos
Instituições de Assistência Ambulatorial/normas , Publicidade Direta ao Consumidor/normas , Marketing de Serviços de Saúde/normas , Doenças Musculoesqueléticas/cirurgia , Segurança do Paciente/normas , Transplante de Células-Tronco/normas , Instituições de Assistência Ambulatorial/legislação & jurisprudência , Qualidade de Produtos para o Consumidor/legislação & jurisprudência , Qualidade de Produtos para o Consumidor/normas , Publicidade Direta ao Consumidor/legislação & jurisprudência , Publicidade Direta ao Consumidor/tendências , Humanos , Marketing de Serviços de Saúde/legislação & jurisprudência , Marketing de Serviços de Saúde/tendências , Segurança do Paciente/legislação & jurisprudência , Guias de Prática Clínica como Assunto/normas , Transplante de Células-Tronco/legislação & jurisprudência , Transplante de Células-Tronco/tendências , Reino Unido , Estados Unidos
8.
Rev Med Suisse ; 16(678): 128-132, 2020 Jan 22.
Artigo em Francês | MEDLINE | ID: mdl-31967755

RESUMO

General internal medicine is particularly concerned by the shift from stationary to ambulatory care, a shift that unfortunately is more often discussed from an economic perspective than from the angle of evidence. This article presents the results of studies and reviews published in 2019 that investigated the effectiveness of ambulatory instead of stationary care.


Assuntos
Assistência Ambulatorial , Medicina Geral , Medicina Interna , Instituições de Assistência Ambulatorial , Medicina Geral/tendências , Humanos , Medicina Interna/tendências
9.
J Dent Educ ; 84(1): 57-61, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31977088

RESUMO

The aims of this study were to describe patient utilization of an urgent care clinic (UCC) in a dental school for one year and to assess dental students' perceptions of the benefits of training in this clinic. Aggregate clinic data from July 3, 2017, through July 6, 2018, were used to determine number of patients, number of new patients, number of new patients who elected to transfer their primary dental care to the university, number who were seen for a follow-up, and service/clinic to which each patient was referred. Student evaluations were used to determine the benefits students perceived in their training in the UCC. Results showed that 1,674 patients were seen in the UCC during the study period. Of these, 67% were new patients, and 53% of these new patients opted to transfer their primary dental care to the university. An average of 7.03 patients were treated per day, and 2.48 new patients per day were generated for the predoctoral student clinic. The most common referrals were to oral surgery (37%), endodontics (30%), and the predoctoral dental clinic (28%). Among these patients, 39% scheduled follow-up appointments, and the attendance rate was 69%. About 80% of eligible students (40/50) completed the questionnaire, and many provided optional comments. Over 80% of the responding students responded favorably regarding the learning experiences and assessments during the UCC rotation. This study found that establishment of the UCC increased the pool of patients and provided students the necessary experiences in triaging and treating dental emergencies.


Assuntos
Faculdades de Odontologia , Estudantes de Odontologia , Instituições de Assistência Ambulatorial , Atitude do Pessoal de Saúde , Educação em Odontologia , Humanos
10.
Medicine (Baltimore) ; 99(2): e18679, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914062

RESUMO

This study aimed to correlate hypoglycemic risk exposures (HREs) with low blood glucose value (BGV) in ambulatory patients to inform selection of a glucose critical action value (CAV).This was a retrospective study of ambulatory patients with at least 1 serum glucose ≤70 mg/dL obtained at 2 laboratories within the Johns Hopkins Health System over 3.8 years. Multivariable logistic regression was used to evaluate association of BGV cut-offs of <60, <54, <50, and <45 mg/dL with HREs. HREs were classified as "high hypoglycemic risk" (HHR), "moderate hypoglycemic risk" (MHR), "low hypoglycemic risk" (LHR), and "no hypoglycemic risk" (NHR).A total of 5404 patient samples of BG ≤70 mg/dL were analyzed, of which 30.3%, 23.2%, 28.5%, 18.0% occurred in NHR, LHR, MHR, and HHR groups, respectively. An inverse relationship was noted between BGV cut-offs and HHR, but no association was observed for LHR or MHR. After adjusting for age, sex, and race, there was an inverse association between BG thresholds and the odds of HHR. For classification of HHR, BGV cut-offs of <60, <54, <50, and <45 mg/dL correctly classified 71.2%, 69.8%, 68.8%, and 67.2% of BG samples, achieved false-positive rates of 13.6%, 4.7%, 1.7%, and 0.5% and positive likelihood ratios of 3.3, 6.0, 11.2, and 23.4, respectively.Nearly 70% of low BGVs occurred in patients with at least 1 HRE, but only ∼20% occurred in HHR patients. Given their high positive likelihood ratios, BGVs <54 or <50 mg/dL are reasonable candidates for CAVs that would allow sufficient clinician response time while minimizing false-positive alerts.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Glicemia/análise , Hipoglicemia/epidemiologia , Adulto , Idoso , Comorbidade , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/epidemiologia , Reações Falso-Positivas , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Estudos Retrospectivos , Fatores de Risco
11.
J Forensic Nurs ; 16(1): 16-21, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31567656

RESUMO

The nonavalent human papilloma virus (HPV) vaccination prophylactically contributes to the prevention of nine types of HPV-associated oral and genital cancers. HPV vaccination rates remain lower than the national Healthy People 2020 goal of 80%. Victims of pediatric sexual abuse are at a higher risk for acquiring and developing HPV-related outcomes. Current research supports vaccination after sexual abuse as soon as eligible and suggests utilizing multiple types of medical encounters to increase vaccination rates.An institutional-review-board-approved quality improvement project was developed to determine the impact of promoting and providing HPV vaccination during the medical encounter after pediatric sexual abuse in a child protection team (CPT) clinic. Twenty percent of the 111 total clinic patients evaluated in the preintervention period and 21% of the 99 patients evaluated in the postintervention period were HPV vaccine eligible, illustrating a significant opportunity for impact. During the intervention period, 62% of patients who were vaccine eligible and presented for their CPT clinic visit received HPV vaccine. Barriers to vaccination in the outpatient CPT clinic setting included high appointment no-show rates, high social and medical visit complexity, and absence of an appropriate consenting caretaker. Implications for forensic nursing practice are discussed.


Assuntos
Abuso Sexual na Infância , Vítimas de Crime , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus , Vacinação/estatística & dados numéricos , Instituições de Assistência Ambulatorial , Cuidadores , Criança , Feminino , Enfermagem Forense , Humanos , Masculino , Pacientes não Comparecentes , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade
12.
Ann Otol Rhinol Laryngol ; 129(3): 238-244, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31640405

RESUMO

OBJECTIVES: Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic. METHODS: The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student's t-test. RESULTS: A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all P > .05). There was also no difference in patients' likelihood of recommending the provider's office (P = .91). Overall provider rating (0-10 scale) was high without scribes (9.48 ± 1.06) and was unchanged by the presence of scribes (9.53 ± 0.8) (P = .97). CONCLUSION: Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.


Assuntos
Documentação , Registros Eletrônicos de Saúde , Satisfação do Paciente/estatística & dados numéricos , Instituições de Assistência Ambulatorial , Boston , Humanos , Relações Médico-Paciente , Estudos Retrospectivos , Inquéritos e Questionários , Fatores de Tempo
13.
Arthritis Care Res (Hoboken) ; 72(2): 184-192, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31595710

RESUMO

OBJECTIVE: To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation. METHODS: We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design. RESULTS: A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider. CONCLUSION: In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA.


Assuntos
Analgésicos/administração & dosagem , Aconselhamento/tendências , Osteoartrite do Joelho/terapia , Manejo da Dor/tendências , Modalidades de Fisioterapia/tendências , Comportamento de Redução do Risco , Idoso , Instituições de Assistência Ambulatorial , Estudos de Coortes , Aconselhamento/métodos , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/tendências , Osteoartrite do Joelho/diagnóstico , Manejo da Dor/métodos , Inquéritos e Questionários
14.
Support Care Cancer ; 28(1): 295-301, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31044305

RESUMO

BACKGROUND: An international panel achieved consensus on 9 need-based and 2 time-based major referral criteria to identify patients appropriate for outpatient palliative care referral. To better understand the operational characteristics of these criteria, we examined the proportion and timing of patients who met these referral criteria at our Supportive Care Clinic. METHODS: We retrieved data on consecutive patients with advanced cancer who were referred to our Supportive Care Clinic between January 1, 2016, and February 18, 2016. We examined the proportion of patients who met each major criteria and its timing. RESULTS: Among 200 patients (mean age 60, 53% female), the median overall survival from outpatient palliative care referral was 14 (95% confidence interval 9.2, 17.5) months. A majority (n = 170, 85%) of patients met at least 1 major criteria; specifically, 28%, 30%, 20%, and 8% met 1, 2, 3, and ≥ 4 criteria, respectively. The most commonly met need-based criteria were severe physical symptoms (n = 140, 70%), emotional symptoms (n = 36, 18%), decision-making needs (n = 26, 13%), and brain/leptomeningeal metastases (n = 25, 13%). For time-based criteria, 54 (27%) were referred within 3 months of diagnosis of advanced cancer and 63 (32%) after progression from ≥ 2 lines of palliative systemic therapy. The median duration from patient first meeting any criterion to palliative care referral was 2.4 (interquartile range 0.1, 8.6) months. CONCLUSIONS: Patients were referred early to our palliative care clinic and a vast majority (85%) of them met at least one major criteria. Standardized referral based on these criteria may facilitate even earlier referral.


Assuntos
Assistência Ambulatorial/organização & administração , Neoplasias/terapia , Cuidados Paliativos/organização & administração , Seleção de Pacientes , Encaminhamento e Consulta/organização & administração , Adulto , Idoso , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Pré-Escolar , Consenso , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Neoplasias/patologia , Pacientes Ambulatoriais , Cuidados Paliativos/métodos , Cuidados Paliativos/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos
15.
Curr Opin Ophthalmol ; 31(1): 28-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31770164

RESUMO

PURPOSE OF REVIEW: This article reviews the various challenges in infection control in eye clinics and successful measures taken to prevent nosocomial infections. RECENT FINDINGS: The Center for Disease Control recommends hand-washing when hands are visibly soiled, and after direct contact with patients, and inanimate objects such as medical equipment. Published studies have identified poor hygiene in clinical settings as a major cause of nosocomial outbreaks, particularly in cases of epidemic keratoconjunctivitis (EKC). Some studies of EKC outbreaks are able to support direct observation of hygiene lapses with molecular analysis that can match viral strains on particular instruments to those found in infected patients. Although most studies are about adenoviral infection and tonometer use, researchers have found viral and bacterial loads on other common surfaces, indicating a need for further research. SUMMARY: Proper hygiene in eye clinics requires special attention because of the potential to examine many patients at a time and because multiple instruments are often used during a single exam. Studies reinforce the link between hygiene and outbreak prevention, and more research can be done to determine the specific links between certain instruments and nosocomial infections.


Assuntos
Infecção Hospitalar/prevenção & controle , Desinfecção/métodos , Higiene das Mãos , Controle de Infecções/métodos , Oftalmologia/instrumentação , Esterilização/métodos , Instituições de Assistência Ambulatorial/normas , Humanos , Oftalmologia/normas
16.
Maturitas ; 131: 65-71, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31787149

RESUMO

OBJECTIVES: To investigate the prevalence of potentially inappropriate prescribing (PIP) according to the revised STOPP/START criteria in older patients with falls and syncope. STUDY DESIGN: We included consecutive patients with falls and syncope aged ≥65 years at the day clinic of the Northwest Clinics, the Netherlands, from 2011 to 2016. All medication use before and after the visit was retrospectively investigated using the revised STOPP/START criteria. MAIN OUTCOME MEASURES: The prevalence/occurrence of PIP before the visit, persistent PIP after the visit, and unaddressed persistent PIP not explained in the patient's chart. RESULTS: PIP was present in 98 % of 374 patients (mean age 80 (SD ±â€¯7) years; 69 % females). 1564 PIP occurrences were identified. 1015 occurrences persisted (in 91 % of patients). 690 occurrences (in 80 % of patients) were not explained in the patient's chart. The most frequent unaddressed persistent forms of PIP were prescriptions of vasodilator drugs for patients with orthostatic hypotension (16 %), and benzodiazepines for >4 weeks (10 %) or in fall patients (8 %), and omission of vitamin D (28 %), antihypertensive drugs (24 %), and antidepressants (17 %). 54 % of all medication changes were initiated for reasons beyond the scope of the STOPP/START criteria. CONCLUSIONS: Almost every patient in our study population suffered from PIP. In 80 %, PIP continued after the clinical visit, without an explanation in the patient's chart. The most frequent PIP concerned medication that increased the risk of falls or syncope, specifically vasodilator drugs and benzodiazepines. Physicians should be aware of PIP in older patients with falls and syncope. Further studies should investigate whether a structured medication review may improve clinical outcomes.


Assuntos
Acidentes por Quedas/prevenção & controle , Prescrição Inadequada/estatística & dados numéricos , Lista de Medicamentos Potencialmente Inapropriados , Síncope/complicações , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Benzodiazepinas/efeitos adversos , Feminino , Humanos , Masculino , Países Baixos , Prevalência , Estudos Retrospectivos , Vasodilatadores/efeitos adversos
17.
Medicine (Baltimore) ; 98(49): e18085, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804318

RESUMO

This was a prospective cohort study with a short-term follow-up. To explore whether age is a factor in the prognosis following high ligation and stripping (HLS) performed in an ambulatory care center. This study included 170 patients who underwent their first HLS for varicose veins in an ambulatory center from November 2016 to October 2017 at West China Hospital. The patients were categorized as two groups: the ≤60 years old group and the >60 years old group. We collected the two age groups data included Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Venous Clinical Severity Score (VCSS), Visual Analogue Score (VAS), Aberdeen Varicose Veins Questionnaire (AVVQ), Quality of Recovery (QoR-15), and postoperative complications at predetermined time points. The clinical correlation between age and prognosis following HLS in an ambulatory care center was prospectively studied after adjusting for potential confounders. The distribution of age and prognosis were also compared in the AVVQ improvement and VCSS improvement of patients at 6 weeks and 6 months after surgery. Our research comprised a total of 170 patients (236 limbs), of which 86 (50.6%) patients were female and 66 (38.8%) patients received bilateral procedures. After multivariable risk adjustment for potential confounding factors, we observed that age was not associated with the improvement of AVVQ (OR 0.3, 95%CI (1.3, 0.7), P = .54) and VCSS (OR 0.2, 95%CI (0.2, 0.6) P = .38) at 6 months after HLS, as well as AVVQ (OR 0.5,95%CI (1.2, 2.2), P = .57) at 6 weeks after HLS. However, at 6 weeks after HLS, age was related to the improvement of VCSS (OR -0.6, 95%CI (1.2, 0.1), P = .03), with the >60 years old group having a lower VCSS improvement compared to the 60 years old group. In postoperative complications, there were no significant differences in terms of complications between the two age groups (all P value >.05). Therefore, in our opinion, age is not a barrier for good outcomes following HLS in an ambulatory care center.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Ligadura/métodos , Qualidade de Vida , Varizes/cirurgia , Adulto , Fatores Etários , Idoso , China , Feminino , Humanos , Ligadura/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Índice de Gravidade de Doença
18.
BMJ ; 367: l6461, 2019 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-31826860

RESUMO

OBJECTIVES: To identify the frequency with which antibiotics are prescribed in the absence of a documented indication in the ambulatory care setting, to quantify the potential effect on assessments of appropriateness of antibiotics, and to understand patient, provider, and visit level characteristics associated with antibiotic prescribing without a documented indication. DESIGN: Cross sectional study. SETTING: 2015 National Ambulatory Medical Care Survey. PARTICIPANTS: 28 332 sample visits representing 990.9 million ambulatory care visits nationwide. MAIN OUTCOME MEASURES: Overall antibiotic prescribing and whether each antibiotic prescription was accompanied by appropriate, inappropriate, or no documented indication as identified through ICD-9-CM (international classification of diseases, 9th revision, clinical modification) codes. Survey weighted multivariable logistic regression was used to evaluate potential risk factors for receipt of an antibiotic prescription without a documented indication. RESULTS: Antibiotics were prescribed during 13.2% (95% confidence interval 11.6% to 13.7%) of the estimated 990.8 million ambulatory care visits in 2015. According to the criteria, 57% (52% to 62%) of the 130.5 million prescriptions were for appropriate indications, 25% (21% to 29%) were inappropriate, and 18% (15% to 22%) had no documented indication. This corresponds to an estimated 24 million prescriptions without a documented indication. Being an adult male, spending more time with the provider, and seeing a non-primary care specialist were significantly positively associated with antibiotic prescribing without an indication. Sulfonamides and urinary anti-infective agents were the antibiotic classes most likely to be prescribed without documentation. CONCLUSIONS: This nationally representative study of ambulatory visits identified a large number of prescriptions for antibiotics without a documented indication. Antibiotic prescribing in the absence of a documented indication may severely bias national estimates of appropriate antibiotic use in this setting. This study identified a wide range of factors associated with antibiotic prescribing without a documented indication, which may be useful in directing initiatives aimed at supporting better documentation.


Assuntos
Instituições de Assistência Ambulatorial , Antibacterianos/farmacologia , Uso de Medicamentos/normas , Prescrição Inadequada/estatística & dados numéricos , Padrões de Prática Médica , Estudos Transversais , Humanos , Fatores de Risco , Estados Unidos
19.
S Afr Med J ; 109(12): 963-970, 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31865960

RESUMO

BACKGROUND: The reported prevalence of low testosterone among men with type 2 diabetes mellitus (T2DM) is high. However, there is a dearth of information on the prevalence of androgen deficiency symptoms and low serum testosterone levels in men with T2DM from sub-Saharan Africa. Scanty data are available from Nigeria, Ghana and South Africa (SA). OBJECTIVES: To determine the prevalence of low serum testosterone and associated risk factors and the prevalence of androgen deficiency symptoms in men with T2DM. METHODS: In a cross-sectional observational study, androgen deficiency symptoms in men with T2DM attending two outpatient diabetes clinics in Durban, KwaZulu-Natal Province, SA, were assessed using the Ageing Males' Symptoms Scale (AMS) questionnaire and direct enquiry. Serum total testosterone (TT), sex hormone-binding globulin (SHBG), luteinising hormone (LH), fructosamine, serum lipids and glycated haemoglobin (HbA1c) were measured and free testosterone (FT) was calculated. TT, SHBG and FT levels were measured in control subjects with no history of diabetes. RESULTS: There were 148 men with T2DM in the study group and 50 control subjects in the control group. In the study group, the majority were black Africans (58.8%); Indians (39.2%) and whites (2.0%) constituted the remainder. The mean (standard deviation (SD)) age was 57.5 (11.2) years, the mean duration of diabetes 11.4 (8.9) years and the mean HbA1c 8.6% (1.9%). Of the study group, 85.8% had metabolic syndrome. Mean TT, SHBG and FT and median LH (interquartile range) in the study group were within normal ranges. However, mean (SD) serum TT and FT were lower in the study group than in the control subjects (14.5 (5.8) v. 18.8 (7.2) nmol/L; p<0.001 and 265.9 (90.4) v. 351.7 (127.3) pmol/L; p<0.001, respectively). The prevalence of low serum total testosterone (LSTT) and low serum free testosterone (LSFT) in the study group was 35.8% and 16.2%, respectively. The prevalence of androgen deficiency symptoms using the AMS questionnaire was 74.5% and correlated poorly with LSTT or LSFT. In multivariate analysis, LSFT was significantly associated with age (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.02 - 1.218; p=0.043) and waist circumference (WC) (OR 1.033, 95% CI 0.999 - 1.068; p=0.059). LSTT was associated with body mass index (BMI) only (OR 1.138, 95% CI 1.063 - 1.218; p<0.0001). TT correlated inversely with BMI, WC and the number of metabolic syndrome criteria. FT correlated inversely with BMI, WC and WHR. CONCLUSIONS: There was a high prevalence of LSTT, LSFT and androgen deficiency symptoms in this study. Serum TT and FT were lower in men with T2DM than in control subjects. Risk factors associated with LSFT or LSTT included higher BMI and WC and older age. The AMS score was a poor predictor of low testosterone. More research is required locally before any screening policy can be recommended.


Assuntos
Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/epidemiologia , Testosterona/sangue , Testosterona/deficiência , Fatores Etários , Idoso , Instituições de Assistência Ambulatorial , Índice de Massa Corporal , Estudos de Casos e Controles , Estudos Transversais , Frutosamina/sangue , Hemoglobina A Glicada/metabolismo , Humanos , Lipídeos/sangue , Hormônio Luteinizante/sangue , Masculino , Síndrome Metabólica/sangue , Síndrome Metabólica/epidemiologia , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Globulina de Ligação a Hormônio Sexual/metabolismo , África do Sul/epidemiologia , Inquéritos e Questionários , Avaliação de Sintomas , Circunferência da Cintura
20.
BMC Health Serv Res ; 19(1): 965, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842881

RESUMO

BACKGROUND: The Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model. METHODS: A cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test. RESULTS: The monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685-2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00-9.33) vs 2.0 (IQR: 1.67-2.92)], and fewer medical officers per clinic [median 1 (IQR: 1-1) vs 3.5 (IQR:2-4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27-31)]; 77% [30/39 (IQR: 27-34)]; 77% [30/39 (IQR: 28-34)]; and 80% [35/44 (IQR: 30-37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117-132); WR was 80% (126/158, IQR, 123-132) while DKK was 74% (117/158, IQR, 106-130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2-5 h) waiting times and one stream of care for acute and chronic services. CONCLUSION: There was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Doença Crônica/terapia , Assistência à Saúde/organização & administração , Gerenciamento Clínico , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Pessoal de Saúde , Humanos , Atenção Primária à Saúde/organização & administração , África do Sul
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