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1.
BMC Infect Dis ; 21(1): 203, 2021 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-33622262

RESUMO

BACKGROUND: Quality of life (QOL) is one of the major factors to assessing the health and wellbeing of People living with HIV (PLWH). Likewise, improved QOL is among the prominent goals of patient treatment. This study was conducted to investigate the QOL of PLWH in Kermanshah, Iran. METHODS: This cross-sectional study was conducted on 364 PLWH of Kermanshah between 2016 and 2017. Outpatients were selected as the sample through the convenience sampling method from HIV Positive Clients of Kermanshah Behavioral Diseases Counseling Center. The reasons for the selection of outpatients include: (a) some patients were substance users, homeless or did not have a fixed address to follow-up; (b) addresses and personal details that were registered on the first admission were incorrect or incomplete; (c) due to financial issues, some were forced to relocate frequently and were difficult to track; (d) some patients were convicts or prisoners, making it hard to find them after their release; (e) some of them were from other provinces, where managing access was not easy/possible. Data was collected using WHOQOL-HIV BREF questionnaire (Persian Version). Data also analyzed with STATA 14, and SPSS 23 using T-test and multiple regression. RESULTS: This study showed that mean (SD) age of PLWH was 40.21 (10.45) years. Females had better QOL than males except for spirituality, religion and personal beliefs. The gender differences disappeared in multivariate results. A significant association was observed between education and the independence, environment, and spirituality domains of QOL. In addition, being married was correlated with overall QOL, psychological and social relationships domains of QOL of PLWH. Drug use was a behavioral factor with negative influence on the QOL. CONCLUSION: This study found that marital status and drug use were the main predictors of various domains of QOL. Drug use was a behavioral factor with a negative influence on the QOL. Hence, it is recommended that health professionals, planners, and policymakers take effective measures to improve the status quo.


Assuntos
Infecções por HIV/psicologia , Qualidade de Vida/psicologia , Adulto , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Estudos Transversais , Feminino , Infecções por HIV/epidemiologia , Humanos , Irã (Geográfico)/epidemiologia , Masculino , Pessoa de Meia-Idade , Psicometria
3.
Cochrane Database Syst Rev ; 1: CD011865, 2021 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-33469932

RESUMO

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.


Assuntos
Instituições de Assistência Ambulatorial/economia , Pessoal de Saúde/economia , Mecanismo de Reembolso/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Capitação , Estudos Controlados Antes e Depois/estatística & dados numéricos , Custos e Análise de Custo , Assistência à Saúde/economia , Assistência à Saúde/normas , Assistência à Saúde/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/normas , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Médicos de Atenção Primária/economia , Médicos de Atenção Primária/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Mecanismo de Reembolso/classificação , Mecanismo de Reembolso/estatística & dados numéricos , Reembolso de Incentivo/economia , Reembolso de Incentivo/normas , Reembolso de Incentivo/estatística & dados numéricos , Salários e Benefícios/economia , Resultado do Tratamento
4.
Sports Health ; 13(1): 91-94, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32662740

RESUMO

BACKGROUND: The preparticipation physical evaluation (PPE) is a requirement for high school sport participation in most states, but its location and role in preventive health care for adolescents is often questioned. HYPOTHESIS: Athletes who had their PPE performed in an office setting, in particular) by their primary care physician (PCP), will have higher human papillomavirus (HPV) immunization rates than those who had their PPE done in a group setting at a mass-participation PPE. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: The PPE forms and immunization records for athletes at a single high school were reviewed to determine the location of PPE, the signing practitioner, and HPV immunization status. RESULTS: A total of 488 athletes (286 males, 202 females) were included; 51% had received at least 1 dose of the HPV vaccine while 39% had completed the series. There was no significant difference in vaccination rates between examination in an office setting versus a group setting. Athletes receiving their PPE at an urgent care facility had significantly lower rates of HPV series completion than all other settings (29% vs 43%; P = 0.004). PPE completion by the athlete's PCP was associated with higher rates of vaccine series completion (46% vs 34%; P = 0.014). CONCLUSION: Athletes who completed their PPE in mass event and office-based settings had similar rates of HPV vaccine series initiation and completion. PPEs done at urgent care facilities were associated with low rates of vaccine series completion, while those done by a PCP were associated with higher rates. CLINICAL RELEVANCE: HPV immunization rates in athletes are low, and the PPE represents a potential opportunity to improve immunization rates.


Assuntos
Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/administração & dosagem , Exame Físico , Atenção Primária à Saúde/estatística & dados numéricos , Esportes , Vacinação/estatística & dados numéricos , Adolescente , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Humanos , Masculino , Michigan , Estudos Retrospectivos , Instituições Acadêmicas
5.
Am J Emerg Med ; 40: 37-40, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33340876

RESUMO

BACKGROUND: Acute alcohol intoxication accounts for a large proportion of potentially unnecessary emergency department visits and expenditure. Sobering centers are a cheaper alternative treatment option for alcohol intoxication and can provide an opportunity to treat the psychosocial aspects of alcohol use disorder. OBJECTIVE OF THE REVIEW: The objective of this review is to analyze the existing literature regarding the use of sobering centers, EMS and their role in transporting to sobering centers, and the appropriate triage of the intoxicated patient. DISCUSSION: Excessive alcohol consumption accounts for an estimated $24.6 billion in healthcare costs and patients are often referred to the emergency department for expensive care. Current literature suggests sobering centers are an alternative to acute hospitalization and are safe, relatively inexpensive, and may facilitate more aggressive connection to resources such as longitudinal rehabilitation programs for the acutely intoxicated patient. EMS plays a pivotal role in triage and transportation of intoxicated individuals, but demonstration of outcomes in lacking. CONCLUSIONS: Sobering centers are a cost effective alternative to emergency department visits for acute alcohol intoxication and further research is required to identify safe, effective protocols for EMS to triage patients to appropriate treatment destinations.


Assuntos
Intoxicação Alcoólica/terapia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Triagem
6.
Am Heart J ; 233: 122-131, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33352187

RESUMO

BACKGROUND: Recurrent congestion in cardiac amyloidosis (CA) remains a management challenge, often requiring high dose diuretics and frequent hospitalizations. Innovative outpatient strategies are needed to effectively manage heart failure (HF) in patients with CA. Ambulatory diuresis has not been well studied in restrictive cardiomyopathy. Therefore, we aimed to examine the outcomes of an ambulatory diuresis clinic in the management of congestion related to CA. METHODS AND RESULTS: We retrospectively studied patients with CA seen in an outpatient HF disease management clinic for (1) safety outcomes of ambulatory intravenous (IV) diuresis and (2) health care utilization. Forty-four patients with CA were seen in the clinic a total of 203 times over 6 months. Oral diuretics were titrated at 96 (47%) visits. IV diuretics were administered at 56 (28%) visits to 17 patients. There were no episodes of severe acute kidney injury or symptomatic hypotension. There was a significant decrease in emergency department and inpatient visits and associated charges after index visit to the clinic. The proportion of days hospitalized per 1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, P< .001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, P< .001) pre- vs post-index visit to the clinic. CONCLUSIONS: We demonstrate the feasibility of ambulatory IV diuresis in patients with CA. Our findings also suggest that use of a HF disease management clinic may reduce acute care utilization in patients with CA. Leveraging multidisciplinary outpatient HF clinics may be an effective alternative to hospitalization in patients with HF due to CA, a population who otherwise carries a poor prognosis and contributes to high health care burden.


Assuntos
Instituições de Assistência Ambulatorial , Amiloidose/complicações , Cardiomiopatias/complicações , Diuréticos/uso terapêutico , Insuficiência Cardíaca/terapia , Idoso , Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Diurese , Diuréticos/administração & dosagem , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Insuficiência Cardíaca/etiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos
7.
MMWR Morb Mortal Wkly Rep ; 69(50): 1925-1929, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33332298

RESUMO

As of December 14, 2020, children and adolescents aged <18 years have accounted for 10.2% of coronavirus disease 2019 (COVID-19) cases reported in the United States.* Mitigation strategies to prevent infection with SARS-CoV-2, the virus that causes COVID-19, among persons of all ages, are important for pandemic control. Characterization of risk factors for SARS-CoV-2 infection among children and adolescents can inform efforts by parents, school and program administrators, and public health officials to reduce SARS-CoV-2 transmission. To assess school, community, and close contact exposures associated with pediatric COVID-19, a case-control study was conducted to compare exposures reported by parents or guardians of children and adolescents aged <18 years with SARS-CoV-2 infection confirmed by reverse transcription-polymerase chain reaction (RT-PCR) testing (case-patients) with exposures reported among those who received negative SARS-CoV-2 RT-PCR test results (control participants). Among 397 children and adolescents investigated, in-person school or child care attendance ≤14 days before the SARS-CoV-2 test was reported for 62% of case-patients and 68% of control participants and was not associated with a positive SARS-CoV-2 test result (adjusted odds ratio [aOR] = 0.8, 95% confidence interval [CI] = 0.5-1.3). Among 236 children aged ≥2 years who attended child care or school during the 2 weeks before SARS-CoV-2 testing, parents of 64% of case-patients and 76% of control participants reported that their child and all staff members wore masks inside the facility (aOR = 0.4, 95% CI = 0.2-0.8). In the 2 weeks preceding SARS-CoV-2 testing, case-patients were more likely to have had close contact with a person with known COVID-19 (aOR = 3.2, 95% CI = 2.0-5.0), have attended gatherings† with persons outside their household, including social functions (aOR = 2.4, 95% CI = 1.1-5.5) or activities with other children (aOR = 3.3, 95% CI = 1.3-8.4), or have had visitors in the home (aOR = 1.9, 95% CI = 1.2-2.9) than were control participants. Close contacts with persons with COVID-19 and gatherings contribute to SARS-CoV-2 infections in children and adolescents. Consistent use of masks, social distancing, isolation of infected persons, and quarantine of those who are exposed to the virus continue to be important to prevent COVID-19 spread.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , /diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , /transmissão , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Mississippi/epidemiologia , Fatores de Risco
8.
Medicine (Baltimore) ; 99(52): e23942, 2020 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-33350799

RESUMO

ABSTRACT: The levels of indoor air pollutants are increasing. However, the indoor air quality of only operating rooms, intensive care units, and radiology departments is usually monitored in hospitals. Hence, we aimed to evaluate the indoor air quality of an otorhinolaryngology outpatient clinic and compare air quality indices among different areas in a hospital.We prospectively measured indoor air quality using air quality sensors in different areas of a hospital from February 1, 2019 to January 31, 2020. Carbon dioxide (CO2), total volatile organic compounds (VOCs), particulate matter with diameter of <2.5 µm (PM2.5), and nitrogen dioxide concentrations were measured in the otorhinolaryngology clinic, orthopedic clinic, and reception area. The intervention efficacy was compared between otorhinolaryngology clinics employing and not employing air-cleaners.The overall concentrations of CO2, VOCs, and PM2.5 in the otorhinolaryngology clinic were significantly higher than those in the orthopedic clinic or reception area. The indoor air quality was the worst in winter. The intervention effect was observed only in PM2.5 concentrations in otorhinolaryngology clinics employing an air-cleaner.Medical practitioners and patients are frequently exposed to ambient indoor air pollution in otorhinolaryngology clinics. Hence, health-related strategies to protect against ambient indoor air pollution in otorhinolaryngology clinics are warranted.


Assuntos
Poluição do Ar em Ambientes Fechados/análise , Poluição do Ar/análise , Instituições de Assistência Ambulatorial , Dióxido de Carbono/análise , Hospitais , Dióxido de Nitrogênio/análise , Otolaringologia , Compostos Orgânicos Voláteis/análise , Poluentes Atmosféricos , Instituições de Assistência Ambulatorial/normas , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Monitoramento Ambiental/métodos , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Determinação de Necessidades de Cuidados de Saúde , Estações do Ano
9.
BMJ Open ; 10(10): e041514, 2020 10 23.
Artigo em Inglês | MEDLINE | ID: mdl-33099501

RESUMO

OBJECTIVE: The COVID-19 pandemic is having major implications for stroke care with a documented significant fall in hospital acute stroke admissions. We investigated whether COVID-19 has resulted in a decreased number of referrals to the transient ischaemic attack (TIA) clinics across the North West London region. SETTING AND DESIGN: All the TIA clinical leads of the North West London region received an invitation by email to participate in an online survey in May 2020. The survey questionnaire aimed to assess the number of patients with suspected TIA consecutively referred to each of the TIA clinics of the North West London region between 1 March and 30 April 2020, the COVID-19 period, and between 1 March and 30 April 2019. RESULTS: We had a response rate of 100%. During the COVID-19 period, the TIA clinics of the North West London region received 440 referrals compared with 616 referrals received between 1 March and 30 April 2019 with a fall in the number of the referrals by 28.6%. In April 2020 compared with April 2019, the number of the referrals declined by 40.1%. CONCLUSIONS: This multicentre analysis documented a significant reduction in the number of patients referred with suspected TIA to the specialised rapid access outpatient clinics in the North West London region during the COVID-19 pandemic. Future studies are needed to confirm our findings and to better characterise the incidence of cerebrovascular disease during the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/epidemiologia , Ataque Isquêmico Transitório , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/estatística & dados numéricos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Betacoronavirus , Estudos Transversais , Hospitalização , Humanos , Incidência , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Londres/epidemiologia , Pandemias , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde
11.
Anesth Analg ; 131(5): 1557-1565, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079879

RESUMO

BACKGROUND: In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift. METHODS: We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010-2018. Inferential analyses were performed comparing 2010-2011 with 2017-2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year. RESULTS: Statewide, comparing 2010-2011 with 2017-2018, among children 1-17 years, pediatric hospitals' caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was -0.49 cases per workday (99% confidence interval, -0.87 to -0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010-2011 with 2017-2018, among 3 age cohorts (1-5, 6-12, and 13-17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1-5 years vs 6-17 years was 0.00 cases per workday (99% confidence interval, -0.13 to +0.14). CONCLUSIONS: The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Hospitais Gerais/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Adolescente , Fatores Etários , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Florida , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Carga de Trabalho
12.
Plast Reconstr Surg ; 146(4): 913-919, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32970013

RESUMO

BACKGROUND: Even before seeing a physician, patients must first gain access to the hospital system. At large hospitals with high patient volumes, access to specialty care can pose a particular challenge. This study examines the effects of specific initiatives to increase clinic capacity, appointment use, and ease of scheduling on both patient satisfaction and hospital revenue. METHODS: In 2017, a task force at a large, multidisciplinary pediatric hospital instituted a number of initiatives to increase patient access to ambulatory specialty clinics. Clinic sessions were standardized to a 4-hour template, and unscheduled, "held" appointment slots were required to be made available ("flipped") 72 hours before the appointment. A patient-centered electronic scheduling platform was also implemented. Patient satisfaction was assessed using Press Ganey scores. Revenue estimates were calculated for increases in "new" and "return" patient appointments. RESULTS: Total new appointment slots increased by over 44 percent, with over 53,000 appointments added annually. The number of held appointment slots declined by 93 percent. A total of 17,996 annual appointments were added in surgical subspecialties, and an additional 14,756 more surgical appointments were completed. Over 2000 appointments were scheduled by means of the online patient portal. Press Ganey "ease-of-scheduling" scores increased from 57 percent to 72 percent over the intervention period. Hospitalwide, these initiatives generated an estimated $8.3 million in revenue opportunity. CONCLUSION: Standardizing clinic sessions and optimizing clinic availability generates new appointment opportunities, improves patient experience, and increases hospital revenue.


Assuntos
Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/organização & administração , Agendamento de Consultas , Eficiência Organizacional/economia , Hospitais Pediátricos/economia , Hospitais Pediátricos/organização & administração , Satisfação do Paciente/estatística & dados numéricos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Criança , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Estudos Retrospectivos
13.
Ann Surg ; 272(4): 548-553, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932304

RESUMO

OBJECTIVE: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition. METHODS: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types. RESULTS: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29). CONCLUSIONS: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Cobertura do Seguro , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Humanos , Medicaid , Estados Unidos
14.
Ann Afr Med ; 19(3): 153-163, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32820726

RESUMO

It is now known that thrombotic disorders such as venous thromboembolism, ischemic stroke, and myocardial infarction contribute significantly to global morbidity and mortality. Anticoagulation service must respond to this new development. Warfarin has continued to provide the backbone for anticoagulation service for decades but with considerable drawbacks. The introduction of nonVitamin K oral anticoagulants (NOACs) has created new challenges. This article seeks to discuss how the establishment of appropriate models of anticoagulation could contain the draw backs of the old anticoagulants and improve on the compliance, availability, affordability, and accessibility of newer anticoagulants. Successful anticoagulation has always been defined by a scientific balancing of the risk of thrombosis and the complication of hemorrhage. To be able to maintain such optimal anticoagulation requires rational drug prescription (physician factor), institutelization of monitoring of therapy (anticoagulation clinic factor) as well as active participation of patients receiving therapy (patient factor). New models of service can be created out of this triad in a bid to replace the old routine medical care model. New models of anticoagulation service should include appropriately trained professionals such as Physicians, Pharmacists, Clinical Pharmacologists, Nurses, and Laboratory Scientists who are knowledgeable in diagnostic, management, and monitoring of anticoagulation. The different models of anticoagulation service discussed in this article clearly demonstrate the need for restructuring of this life saving service particularly in the era of NOAC. Newer models of care that should provide safe, efficacious, and cost-effective services are needed.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Anticoagulantes/uso terapêutico , Prescrições de Medicamentos , Tromboembolia/prevenção & controle , Varfarina/uso terapêutico , Administração Oral , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Anticoagulantes/administração & dosagem , Humanos , Qualidade da Assistência à Saúde , Tromboembolia/tratamento farmacológico , Resultado do Tratamento
15.
Age Ageing ; 49(6): 907-914, 2020 10 23.
Artigo em Inglês | MEDLINE | ID: mdl-32821909

RESUMO

BACKGROUND: During the current COVID-19 health crisis virtual geriatric clinics have become increasingly utilised to complete outpatient consultations, although concerns exist about feasibility of such virtual consultations for older people. The aim of this rapid review is to describe the satisfaction, clinic productivity, clinical benefit, and costs associated with the virtual geriatric clinic model of care. METHODS: A rapid review of PubMed, MEDLINE and CINAHL databases was conducted up to April 2020. Two independent reviewers extracted the information. Four subdomains were focused on: satisfaction with the virtual geriatric clinic, clinic productivity, clinical benefit to patients, costs and any challenges associated with the virtual clinic process. RESULTS: Nine studies with 975 patients met our inclusion criteria. All were observational studies. Seven studies reported patients were satisfied with the virtual geriatric clinic model of care. Productivity outcomes included reports of cost-effectiveness, savings on transport, and improved waiting list metrics. Clinical benefits included successful polypharmacy reviews, and reductions in acute hospitalisation rates. Varying challenges were reported for both clinicians and patients in eight of the nine studies. Hearing impairments and difficulty with technology added to anxieties experienced by patients. Physicians missed the added value of a thorough physical examination and had concerns about confidentiality. CONCLUSION: Virtual geriatric clinics demonstrate evidence of productivity, benefit to patients, cost effectiveness and patient satisfaction with the treatment provided. In the current suboptimal pandemic climate, virtual geriatric clinics may allow Geriatricians to continue to provide an outpatient service, despite the encountered inherent challenges.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Betacoronavirus , Infecções por Coronavirus/terapia , Transmissão de Doença Infecciosa/prevenção & controle , Pneumonia Viral/terapia , Encaminhamento e Consulta , Telemedicina/métodos , Idoso , Infecções por Coronavirus/epidemiologia , Humanos , Pandemias , Satisfação do Paciente , Pneumonia Viral/epidemiologia
16.
PLoS One ; 15(8): e0236169, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32745081

RESUMO

In line with the Sustainable Development Goals (SDGs) and the target for achieving Universal Health Coverage (UHC), state level initiatives to promote health with "no-one left behind" are underway in India. In Kerala, reforms under the flagship Aardram mission include upgradation of Primary Health Centres (PHCs) to Family Health Centres (FHCs, similar to the national model of health and wellness centres (HWCs)), with the proactive provision of a package of primary care services for the population in an administrative area. We report on a component of Aardram's monitoring and evaluation framework for primary health care, where tracer input, output, and outcome indicators were selected using a modified Delphi process and field tested. A conceptual framework and indicator inventory were developed drawing upon literature review and stakeholder consultations, followed by mapping of manual registers currently used in PHCs to identify sources of data and processes of monitoring. The indicator inventory was reduced to a list using a modified Delphi method, followed by facility-level field testing across three districts. The modified Delphi comprised 25 participants in two rounds, who brought the list down to 23 approved and 12 recommended indicators. Three types of challenges in monitoring indicators were identified: appropriateness of indicators relative to local use, lack of clarity or procedural differences among those doing the reporting, and validity of data. Further field-testing of indicators, as well as the revision or removal of some may be required to support ongoing health systems reform, learning, monitoring and evaluation.


Assuntos
Reforma dos Serviços de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Desenvolvimento Sustentável , Cobertura Universal do Seguro de Saúde/organização & administração , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Academias de Ginástica/organização & administração , Academias de Ginástica/estatística & dados numéricos , Reforma dos Serviços de Saúde/estatística & dados numéricos , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/estatística & dados numéricos , Promoção da Saúde/organização & administração , Promoção da Saúde/estatística & dados numéricos , Humanos , Índia , Atenção Primária à Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/estatística & dados numéricos
17.
Saudi Med J ; 41(7): 757-762, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32601646

RESUMO

OBJECTIVES: To investigate the presence of toxoplasmosis, rubella, cytomegalovirus, and herpes (TORCH) infections in women attending at the antenatal care clinic in Abha, Kingdom of Saudi Arabia (KSA). Methods: A total of 190 blood samples were collected from Abha maternity hospital in Aseer region, KSA, from February 2018 to May 2019 and screened with the TORCH panel (toxoplasmagondii [IgG/IgM], cytomegalovirus [CMV] [IgG/IgM], rubella [IgG/IgM], and herpes simplex type 1 and 2 [IgG/IgM]). RESULTS: The mean age was 31.42±6.514 years and gestational age was 32.48±6.168 weeks. Serum IgG was positive for Toxoplasma gondii (T. gondii) (27.4%), herpes simplex type 1 (HSV-1) (94.7%), herpes simplex type 2 (HSV-2) (0.5%), CMV (100%), and rubella (88.9%). Serum IgM was positive only for CMV (9.5%). Though, there was an association between abortions from previous pregnancies (26.5%), intrauterine death (5.8%), premature labor (3.2%), microcephaly (1.6%), other congenital diseases (1.6%) and low birth weight (0.5%) with current IgG positivity for TORCH infections, the results were not statistically significant. CONCLUSION: Seropositivity for IgG antibodies correlate with TORCH-associated pregnancy complications in Abha, KSA; however, IgM positive CMV pregnant cases warrant further systematic investigation to understand the implications of CMV on outcomes during pregnancy.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Infecções por Citomegalovirus/epidemiologia , Herpes Simples/epidemiologia , Maternidades/estatística & dados numéricos , Complicações Infecciosas na Gravidez/epidemiologia , Cuidado Pré-Natal , Rubéola (Sarampo Alemão)/epidemiologia , Toxoplasmose/epidemiologia , Adulto , Feminino , Humanos , Gravidez , Arábia Saudita/epidemiologia , Toxoplasma , Toxoplasmose/parasitologia , Adulto Jovem
18.
Neurology ; 95(7): 305-311, 2020 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-32611634

RESUMO

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.


Assuntos
Infecções por Coronavirus/terapia , Neurologia/métodos , Pneumonia Viral/terapia , Telemedicina/métodos , Comunicação por Videoconferência/estatística & dados numéricos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Atitude do Pessoal de Saúde , Betacoronavirus , Humanos , Pandemias , Desenvolvimento de Programas/métodos
19.
PLoS Comput Biol ; 16(7): e1007941, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32644990

RESUMO

Individuals in low socioeconomic brackets are considered at-risk for developing influenza-related complications and often exhibit higher than average influenza-related hospitalization rates. This disparity has been attributed to various factors, including restricted access to preventative and therapeutic health care, limited sick leave, and household structure. Adequate influenza surveillance in these at-risk populations is a critical precursor to accurate risk assessments and effective intervention. However, the United States of America's primary national influenza surveillance system (ILINet) monitors outpatient healthcare providers, which may be largely inaccessible to lower socioeconomic populations. Recent initiatives to incorporate Internet-source and hospital electronic medical records data into surveillance systems seek to improve the timeliness, coverage, and accuracy of outbreak detection and situational awareness. Here, we use a flexible statistical framework for integrating multiple surveillance data sources to evaluate the adequacy of traditional (ILINet) and next generation (BioSense 2.0 and Google Flu Trends) data for situational awareness of influenza across poverty levels. We find that ZIP Codes in the highest poverty quartile are a critical vulnerability for ILINet that the integration of next generation data fails to ameliorate.


Assuntos
Viés , Influenza Humana , Vigilância da População , Fatores Socioeconômicos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Bases de Dados Factuais , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Influenza Humana/complicações , Influenza Humana/epidemiologia , Influenza Humana/terapia , Estados Unidos/epidemiologia
20.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32616629

RESUMO

OBJECTIVES: To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS: We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS: Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS: School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.


Assuntos
Corticosteroides/uso terapêutico , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Ambulatório Hospitalar/estatística & dados numéricos , Pneumonia/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Sinusite/tratamento farmacológico , Adolescente , Assistência Ambulatorial , Criança , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Fidelidade a Diretrizes , Humanos , Modelos Logísticos , Masculino , Medicaid , Guias de Prática Clínica como Assunto , South Carolina , Estados Unidos
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