Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 14.013
Filtrar
1.
Sr Care Pharm ; 34(8): 514-519, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31462355

RESUMO

OBJECTIVE: The aim of this study was to evaluate prescribing practices for elderly patients started on apixaban in multiple practice settings.
DESIGN: Retrospective, chart review.
SETTING: One outpatient and three inpatient settings in Arizona and Massachusetts.
PATIENT, PARTICIPANTS: Patients who received a new order for apixaban between July 1, 2015, and December 31, 2016. Inclusion criteria included adults 65 years of age and older who were receiving apixaban for atrial fibrillation or venous thromboembolism (VTE) at a current treatment dose.
There were 1,045 patients included, the average age was 78 years, 52% were male, and 90% had atrial fibrillation.
MAIN OUTCOME MEASURE: Appropriate prescribing of apixaban based on Food and Drug Administration (FDA)-labeling (age, weight, serum creatinine).
RESULTS: Six patients who were on hemodialysis were excluded from the analysis, leaving 1,039 patients to be analyzed. 16.2% (168/1,039) of patients had an incorrect dose of apixaban prescribed based on their indication. Of those, 75% (126/168) were taking the medication for atrial fibrillation and 25% (42/168) for VTE. For those with atrial fibrillation (n = 126), the majority of inappropriate orders resulted from doses that were lower than indicated (113/126).
CONCLUSION: This research suggests that elderly patients may receive inappropriately lower doses of apixaban than indicated, which may decrease the effectiveness of the medication. This research supports the fact that pharmacists can play a vital role in anticoagulation stewardship by verifying apixaban doses for accuracy.


Assuntos
Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Idoso , Anticoagulantes , Arizona , Feminino , Humanos , Masculino , Massachusetts , Estudos Retrospectivos
2.
J Environ Manage ; 249: 109380, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31434050

RESUMO

This article aims to understand decision making under uncertainty and risk, with a case study on Cape Cod, Massachusetts. Decision makers need to consider imperfect information on the cost and effectiveness of advanced nitrogen-removing on-site wastewater treatment systems as options to mitigate water quality degradation. Research included modeling nitrogen load reduction to impaired coastal waters from seven treatment system technologies and eliciting expert knowledge on their costs. Predictions of nitrogen load removal and cost for each technology incorporated variation in effectiveness and uncertainty in household water use, costs, and expert confidence in costs. The predictions were evaluated using the Pareto efficiency concept to reveal tradeoffs between cost and effectiveness. The stochastic dominance index was used to identify preferred technologies for risk-averse decision making, assuming no further learning is possible. Lastly, the predictions were combined into a cost-effectiveness metric to estimate the expected payoff of implementing the best treatment system in the face of uncertainty and the expected payoff of learning which treatment systems are most cost-effective over time. The expected value of perfect information was calculated as the difference between the expected payoffs. Three technologies revealed Pareto efficient tradeoffs between cost and effectiveness, whereas one technology was the preferred risk-averse option in the absence of future learning. There was a high expected value of perfect information, which could motivate adaptive management on Cape Cod. This research demonstrated decision analysis methods to guide future research and decision making toward meeting water quality objectives and reducing uncertainty.


Assuntos
Tomada de Decisões , Nitrogênio , Análise Custo-Benefício , Massachusetts , Incerteza
3.
Forensic Sci Int ; 302: 109903, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31400618

RESUMO

First used over 50 years ago, forensic palynology is an important tool for law enforcement agencies. In most countries that use forensic palynology, microscopic pollen grains and spores are traditionally used in criminal investigations to link suspects to crime scenes or items. While still underutilized in many parts of the world, forensic palynology is increasingly being used to determine the region of origin, or geolocation, for persons and items of interest. Drawing upon the experience of the authors using trace pollen and spores to geolocate forensic samples, the types, methods, and variables of this type of analysis are discussed and demonstrated using the Baby Doe case from Massachusetts, USA as a case study. This is not an exhaustive list and every forensic sample is unique so the methods and experience presented here are intended to be a guide for future forensic and anti-terrorism investigations as forensic palynology becomes more commonplace in law enforcement agencies around the world.


Assuntos
Botânica , Vítimas de Crime , Ciências Forenses/métodos , Homicídio , Pólen , Esporos , Pré-Escolar , Vestuário , Ecossistema , Cabelo , Humanos , Massachusetts , Manejo de Espécimes
4.
Rev Fac Cien Med Univ Nac Cordoba ; 76(3): 142-147, 2019 08 29.
Artigo em Espanhol | MEDLINE | ID: mdl-31465180

RESUMO

Introduction: The analysis of injuries caused by traffic from a physical and mathematical perspective can help improve road safety strategies. Objective: Predict the dynamics of traffic fatalities in the states of Maryland and Massachusetts for the years 2004 and 2014 in the context of probabilistic random walk. Methods: An analysis was made of the number of total fatalities caused by traffic per year, in the states of Maryland and Massachusetts between the years 1994-2003 and 1994-2013. The behavior of these values was analyzed as a probabilistic random walk; for this, the probabilistic lengths were found for each year, during the period studied and four probability spaces were analyzed, with which it was possible to analyze their behavior, to establish a prediction of the number of total fatalities caused by traffic for the years 2004 and 2014. Results: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Main conclusion: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Conclusions: the behavior of traffic fatalities in Maryland and Massachusetts presented a predictable self-organization from the context of probabilistic random walk, constituting a useful tool for analyzing the operation of road safety strategies.


Assuntos
Acidentes de Trânsito/mortalidade , Acidentes de Trânsito/tendências , Humanos , Maryland/epidemiologia , Massachusetts/epidemiologia , Teoria da Probabilidade
6.
N Engl J Med ; 381(3): 252-263, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31314969

RESUMO

BACKGROUND: Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). METHODS: Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States. RESULTS: During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets. CONCLUSIONS: During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).


Assuntos
Planos de Seguro Blue Cross Blue Shield , Gastos em Saúde/tendências , Qualidade da Assistência à Saúde , Reembolso de Incentivo/economia , Planos de Seguro Blue Cross Blue Shield/organização & administração , Massachusetts , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/tendências , Encaminhamento e Consulta/tendências , Mecanismo de Reembolso , Estados Unidos
9.
J Opioid Manag ; 15(3): 183-191, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343720

RESUMO

OBJECTIVE: To characterize primary care physicians' (PCPs') perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. DESIGN: Qualitative. SETTING: Department of Veterans Affairs (VA). PARTICIPANTS: Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. METHODS: Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs' experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. RESULTS: PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. CONCLUSIONS: PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs' perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides , Médicos de Atenção Primária/psicologia , Veteranos , Humanos , Massachusetts , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Percepção , Veteranos/estatística & dados numéricos
10.
Environ Pollut ; 252(Pt B): 1942-1952, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31227351

RESUMO

Understanding the factors that affect spatial differences in PM2.5 composition is crucial for implementing emissions control and health policies. Although previous studies have explored modeling of spatial patterns as a tool to improve human exposure assessment, little work has employed a multivariate clustering approach to identify spatial patterns in particle composition. In this study, we used this approach to assess the spatial patterns of ambient PM2.5 elemental concentrations in Eastern Massachusetts in the United States. To distinguish one cluster of sites from another, we considered air pollution sources and geodemographic variables. We evaluated spatial patterns for 11 elemental components of ambient PM2.5, which included S, K, Ca, Fe, Zn, Cu, Ti, Al, Pb, V, and Ni. The analyses for S, Ca, Cu, Ti, Al, and Pb resulted in: 2 clusters for Fe, Zn, V, and Ni; 3 clusters; and for 12 clusters for K. Overall, our findings suggest substantial variation of clusters among PM2.5 components. In addition, land use, population density, and daily traffic were used as variables to more effectively characterize clusters of sites. We used R2 values to estimate the effectiveness of each variable in characterizing clusters. Larger R2 values indicate better the discrimination among the sites. For example, population density had the highest R2 value when the analysis was performed for S, Ca, Zn, Ti, Al, Pb, and V; land use presented the highest R2 value for Cu, V, and Ni; and, traffic showed the highest R2 value for PM2.5 mass concentration. This study improves the ability to model both the between- and within-area variability of source emissions and pollution regime, using concentrations of PM2.5 components.


Assuntos
Poluentes Atmosféricos/análise , Poluição do Ar/análise , Monitoramento Ambiental/métodos , Material Particulado/análise , Emissões de Veículos/análise , Análise por Conglomerados , Humanos , Massachusetts , Análise Espacial , Estados Unidos
12.
Scand J Trauma Resusc Emerg Med ; 27(1): 51, 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31039813

RESUMO

BACKGROUND: Sepsis is a common critical condition caused by the body's overwhelming response to certain infective agents. Many biomarkers, including the serum lactate level, have been used for sepsis diagnosis and guiding treatment. Recently, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recommended the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) rather than lactate for screening sepsis and assess prognosis. Here, we aim to explore and compare the prognostic accuracy of the lactate level, the SOFA score and the qSOFA score for mortality in septic patients using the public Medical Information Mart for Intensive Care III database (MIMIC III). METHODS: The baseline characteristics, laboratory test results and outcomes for sepsis patients were retrieved from MIMIC III. Survival was analysed by the Kaplan-Meier method. Univariate and multivariate analysis was performed to identify predictors of prognosis. Receiver operating characteristic curve (ROC) analysis was conducted to compare lactate with SOFA and qSOFA scores. RESULTS: A total of 3713 cases were initially identified. The analysis cohort included 1865 patients. The 24-h average lactate levels and the worst scores during the first 24 h of ICU admission were collected. Patients in the higher lactate group had higher mortality than those in the lower lactate group. Lactate was an independent predictor of sepsis prognosis. The AUROC of lactate (AUROC, 0.664 [95% CI, 0.639-0.689]) was significantly higher than that of qSOFA (AUROC, 0.547 [95% CI, 0.521-0.574]), and it was similar to the AUROC of SOFA (AUROC, 0.686 [95% CI, 0.661-0.710]). But the timing of lactate relative to SOFA and qSOFA scores was inconsistent. CONCLUSION: Lactate is an independent prognostic predictor of mortality for patients with sepsis. It has superior discriminative power to qSOFA, and shows discriminative ability similar to that of SOFA.


Assuntos
Cuidados Críticos/métodos , Ácido Láctico/sangue , Sepse/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Curva ROC , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/mortalidade , Taxa de Sobrevida/tendências
13.
Am Econ Rev ; 109(4): 1530-67, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30990593

RESUMO

How much are low- income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts' subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low- income adults. As subsidies decline, insurance take- up falls rapidly, dropping about 25 percent for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower- cost, indicating adverse selection into insurance. But across the entire distribution we can observe (approximately the bottom 70 percent of the willingness to pay distribution) enrollees' willingness to pay is always less than half of their own expected costs that they impose on the insurer. As a result, we estimate that take- up will be highly incomplete even with generous subsidies. If enrollee premiums were 25 percent of insurers' average costs, at most half of potential enrollees would buy insurance; even premiums subsidized to 10 percent of average costs would still leave at least 20 percent uninsured. We briefly consider potential explanations for these findings and their normative implications.


Assuntos
Comportamento do Consumidor/economia , Custo Compartilhado de Seguro/economia , Renda , Seguro Saúde/economia , Pobreza , Adulto , Humanos , Cobertura do Seguro , Massachusetts , Modelos Teóricos
14.
J Ment Health Policy Econ ; 22(1): 3-13, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30991351

RESUMO

BACKGROUND: Many clients with substance use disorders (SUD) have multiple admissions to a 24-hour level of care for detoxification without ever progressing to SUD treatment. In the US, health insurers have become concerned about the high costs and ineffective results of repeat detox admissions. For other diseases, health systems increasingly target high-risk, high-cost patients with individually tailored interventions delivered by `navigators' who help patients negotiate the complex health care system. Patient incentives are another increasingly common intervention. AIMS OF THE STUDY: (i) To examine how health care spending was affected by an intervention intended to improve entry to SUD treatment among clients who had multiple detox admissions. (ii) To see whether spending effects, overall and by type of service, differed by intervention arm. (iii) To assess whether the intervention resulted in net savings from the payer perspective, after subtracting implementation costs. METHODS: The intervention was implemented in a segment of the Massachusetts Medicaid population, and used Recovery Support Navigators (RSNs) who were trained to effectively engage and connect clients with SUD to follow-up care and community resources. Services were funded using a flat daily rate per client. Additionally, in one of the two intervention arms, clients were offered successive incentive payments for meeting pre-specified milestones to reinforce recovery-oriented behaviors. For this paper, multivariate analyses of claims and administrative data were used to measure the intervention's effect on health care spending, and to estimate net savings to the payer. RESULTS: Health care spending grew 1.6 percentage points more slowly for intervention-enrolled members than for others, implying gross savings of $68 per member per month. After subtracting intervention-related costs, net savings were estimated at $57 per member per month. The intervention was also associated with shifts in the health care service mix from more to less acute settings. DISCUSSION: While the results for total spending did not reach statistical significance, they suggest some potential for insurers to reduce the health care costs associated with repeat detox utilization by using a navigator-based intervention. Analyses reported elsewhere found that this intervention had favorable effects on rates of initiation of SUD treatment. Limitations of the study include the fact that neither subjects nor sites were randomized between study groups; lack of data on crime or productivity outcomes; low participant use of RSN services; and a policy change which altered the participant pool and truncated follow-up for some. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest some potential for payers to reduce the health care costs associated with repeat detox by using a navigator-based intervention. To the extent that this results in shifting resources from repeat detox to actual treatment, the result should provide longer term benefit to the population coping with SUD. IMPLICATIONS FOR HEALTH POLICY: These results may encourage Medicaid and other payers to further experiment with similar interventions using navigators to decrease health care costs and improved the lives of SUD patients. IMPLICATIONS FOR FURTHER RESEARCH: It could be informative to test similar navigator interventions for detox patients in other settings where enrollment periods are longer.


Assuntos
Continuidade da Assistência ao Paciente , Custos de Cuidados de Saúde/estatística & dados numéricos , Medicaid/economia , Navegação de Pacientes , Transtornos Relacionados ao Uso de Substâncias/economia , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Redução de Custos , Gastos em Saúde , Humanos , Massachusetts , Navegação de Pacientes/economia , Navegação de Pacientes/métodos , Navegação de Pacientes/estatística & dados numéricos , Estados Unidos
15.
Med Ref Serv Q ; 38(1): 41-55, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30942679

RESUMO

The reasons for implementing and the advantages of switching to the Reference Analytics system, a part of the Springshare LibAnswers platform, for collecting reference statistics at a three-campus university library are described. The benefits of using this web-based product are highlighted based on the comparison with the previously used analytical tools and the annual statistical data. Transitioning to Reference Analytics allowed librarians to take advantage of such features, as seamless access to reference transactions, easy customization, cross-tabulation, and data visualization, proving beneficial for overall library reference services.


Assuntos
Ciência de Dados/métodos , Internet , Bibliotecas Médicas/estatística & dados numéricos , Serviços de Biblioteca/estatística & dados numéricos , Obras Médicas de Referência , Software , Interface Usuário-Computador , Humanos , Massachusetts , Estudos de Casos Organizacionais
17.
Biol Bull ; 236(2): 97-107, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30933642

RESUMO

Acoustic communication is vital across many taxa for mating behavior, defense, and social interactions. Male oyster toadfish, Opsanus tau, produce courtship calls, or "boatwhistles," characterized by an initial broadband segment (30-50 ms) and a longer tone-like second part (200-650 ms) during mating season. Male calls were monitored continuously with an in situ SoundTrap hydrophone that was deployed in Eel Pond, Woods Hole, Massachusetts, during the 2015 mating season. At least 10 vocalizing males were positively identified by their unique acoustic signatures. This resident population was tracked throughout the season, with several individuals tracked for extended periods of time (72 hours). Toadfish began calling in mid-May when water temperature reached 14.6 °C with these early-season "precursor" boatwhistles that were shorter in duration and contained less distinct tonal segments compared to calls later in the season. The resident toadfish stopped calling in mid-August, when water temperature was about 25.5 °C. The pulse repetition rate of the tonal part of the call was significantly related to ambient water temperature during both short-term (hourly) and long-term (weekly) monitoring. This was the first study to monitor individuals in the same population of oyster toadfish in situ continuously throughout the mating season.


Assuntos
Batracoidiformes/fisiologia , Vocalização Animal , Animais , Masculino , Massachusetts , Estações do Ano , Comportamento Sexual Animal , Espectrografia do Som , Temperatura Ambiente
18.
J Clin Nurs ; 28(15-16): 2934-2945, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31013392

RESUMO

AIMS AND OBJECTIVES: To validate Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) items using item response theory (IRT) models and conduct differential item functioning (DIF) analysis to test the item functioning among nurse practitioners (NPs) practicing in different U.S. states with variable regulations governing NP practice. BACKGROUND: Nurse Practitioner Primary Care Organizational Climate Questionnaire is the only NP-specific tool measuring NP work environment and is being used in different U.S. states with variable NP scope of practice regulations and internationally to produce evidence about NP work environments within their organisations. DESIGN: Cross-sectional survey design was used to collect data from 278 primary care NPs in New York (NY) and 314 NPs in Massachusetts (MA). METHODS: NPs completed the 29-item NP-PCOCQ. Data collection involved an online survey in NY and a mail survey in MA in 2012. We used Samejima's graded response model for IRT and ordinal logistic regression for DIF analysis. A STROBE checklist was completed. RESULTS: IRT models yielded discrimination parameters ranging from 0.98-4.65 in NY and 1.25-6.94 in MA. Item difficulty parameters were within -3 to +3 range, suggesting a fair range of item difficulties exist in the scale. Only five of the 29 items on NP-PCOCQ exhibited DIF, suggesting some other state-related factor besides the measured construct influenced item responses; thus, the items were removed. CONCLUSION: Our findings indicate that a shortened, 24-item NP-PCOCQ is capable of measuring organisational climate of NPs practicing in different U.S. states. NP-PCOCQ can be used in future research to measure NP work environment. RELEVANCE TO CLINICAL PRACTICE: The tool can also be used by practice administrators to assess NP work environment and identify deficiencies to address them. This evidence about NP work environment can be used by practice administrators to promote favourable work environments for NPs to deliver high-quality care.


Assuntos
Profissionais de Enfermagem/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Local de Trabalho/psicologia , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Massachusetts , Pessoa de Meia-Idade , New York , Profissionais de Enfermagem/organização & administração , Relações Médico-Enfermeiro , Pesquisa Qualitativa , Inquéritos e Questionários
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA