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1.
BMJ ; 367: l5205, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578187

RESUMO

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Avaliação de Processos (Cuidados de Saúde)/métodos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Anti-Infecciosos/uso terapêutico , Conjuntos de Dados como Assunto , Substituição de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos/uso terapêutico , Inglaterra , Medicina Geral/organização & administração , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Humanos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Avaliação de Processos (Cuidados de Saúde)/estatística & dados numéricos , Medicina Estatal/normas , Fatores de Tempo , Infecções Urinárias/tratamento farmacológico
2.
Ann R Coll Surg Engl ; 101(8): 584-588, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31537105

RESUMO

INTRODUCTION: The National Institute for Health and Care Excellence published a draft consultation update on abdominal aortic aneurysm, which was expected to be published on 7 November 2018. This article analyses the readiness of NHS hospitals and their workforce to embrace the proposed guidelines. METHODS: The trust and individual surgeon-level anonymised data in the public domain for elective, rupture and complex abdominal aortic aneurysm cases were collected and analysed for all the acute care trusts providing these services from the Vascular Society of Great Briton and Ireland's prospective National Vascular Registry database. RESULTS: Of the 95 acute care trusts providing the service for the year 2017, the annual volume of infrarenal abdominal aortic aneurysm (both endovascular and open repairs) ranged between 0 and 137. Of these, 64 (67.36%) trusts had an annual volume of fewer than 60 cases. A total of 366 (approximately 75% of 490) vascular surgeons have performed 10 or fewer open abdominal aortic aneurysm repairs in three years (2014-2016) with a mean operating volume of 1.452 procedures per surgeon per three years (n = 254, median 0, interquartile range, IQR, 0-3, 0.484 procedures per surgeon per year) and about 51% of the vascular surgeons have only performed five or fewer procedures in those three years with a mean operating volume of 3.455 per surgeon per three years (n = 367, median 3, IQR 0-3, 1.151 per surgeon per year). CONCLUSION: The observations show that most UK acute hospitals lack the optimum case volume necessary to embrace the proposed change in the guideline.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Vasculares/normas , Aneurisma da Aorta Abdominal/epidemiologia , Ruptura Aórtica/epidemiologia , Ruptura Aórtica/cirurgia , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Medicina Baseada em Evidências/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Irlanda/epidemiologia , Sistema de Registros , Medicina Estatal/normas , Medicina Estatal/estatística & dados numéricos , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos
3.
Value Health ; 22(6): 693-703, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31198187

RESUMO

BACKGROUND: Direct-acting antivirals are successful in curing hepatitis C virus infection in more than 95% of patients treated for 12 weeks, but they are expensive. Shortened treatment durations, which may have lower cure rates, have been proposed to reduce costs. OBJECTIVES: To evaluate the lifetime cost-effectiveness of different shortened treatment durations for genotype 1 noncirrhotic treatment-naive patients. METHODS: Assuming a UK National Health Service perspective, we used a probabilistic decision tree and Markov model to compare 3 unstratified shortened treatment durations (8, 6, and 4 weeks) against a standard 12-week treatment duration. Patients failing shortened first-line treatment were re-treated with a 12-week treatment regimen. Parameter inputs were taken from published studies. RESULTS: The 8-week treatment duration had an expected incremental net monetary benefit of £7737 (95% confidence interval £3242-£11 819) versus the standard 12-week treatment, per 1000 patients. The 6-week treatment had a positive incremental net monetary benefit, although some uncertainty was observed. The probability that the 8- and 6-week treatments were the most cost-effective was 56% and 25%, respectively, whereas that for the 4-week treatment was 17%. Results were generally robust to sensitivity analyses, including a threshold analysis that showed that the 8-week treatment was the most cost-effective at all drug prices lower than £40 000 per 12-week course. CONCLUSIONS: Shortening treatments licensed for 12 weeks to 8 weeks is cost-effective in genotype 1 noncirrhotic treatment-naive patients. There was considerable uncertainty in the estimates for 6- and 4-week treatments, with some indication that the 6-week treatment may be cost-effective.


Assuntos
Antivirais/economia , Hepatite C Crônica/tratamento farmacológico , Antivirais/uso terapêutico , Carbamatos/economia , Carbamatos/uso terapêutico , Análise Custo-Benefício , Árvores de Decisões , Hepacivirus/efeitos dos fármacos , Hepacivirus/patogenicidade , Compostos Heterocíclicos de 4 ou mais Anéis/economia , Compostos Heterocíclicos de 4 ou mais Anéis/uso terapêutico , Humanos , Compostos Macrocíclicos/economia , Compostos Macrocíclicos/uso terapêutico , Cadeias de Markov , Sofosbuvir/economia , Sofosbuvir/uso terapêutico , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos , Sulfonamidas/economia , Sulfonamidas/uso terapêutico , Reino Unido
4.
Ann R Coll Surg Engl ; 101(7): 463-471, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31155919

RESUMO

INTRODUCTION: Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. METHODS: A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. RESULTS: Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. CONCLUSION: The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.


Assuntos
Hospitais Estaduais/estatística & dados numéricos , Avaliação de Resultados (Cuidados de Saúde)/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Antibioticoprofilaxia/normas , Efeitos Psicossociais da Doença , Inglaterra/epidemiologia , Feminino , Hospitais Estaduais/normas , Humanos , Masculino , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Medicina Estatal/economia , Medicina Estatal/normas , Procedimentos Cirúrgicos Operatórios/normas , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
5.
BMC Health Serv Res ; 19(1): 219, 2019 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-30954074

RESUMO

BACKGROUND: Primary care workload is high and increasing in the United Kingdom. We sought to examine the association between rates of primary care consultation and outcomes in England. METHODS: Cross sectional observational study of routine electronic health care records in 283 practices from the Clinical Practice Research Datalink from April 2013 to March 2014. Outcomes included mortality rate, hospital admission rate, Quality and Outcomes Framework (QOF) performance and patient satisfaction. Relationships between consultation rates (with a general practitioner (GP) or nurse) and outcomes were investigated using negative binomial and ordinal logistic regression models. RESULTS: Rates of GP and nurse consultation (per patient person-year) were not associated with mortality or hospital admission rates: mortality incidence rate ratio (IRR) per unit change in GP/ nurse consultation rate = 1.01, 95% CI [0.98 to 1.04]/ 0.97, 95% CI [0.93 to 1.02]; hospital admission IRR per unit change in GP/ nurse consultation rate = 1.02, 95% CI [0.99 to 1.04]/ 0.98, 95% CI [0.94 to 1.032]. Higher rates of nurse but not GP consultation were associated with higher QOF achievement: OR = 1.91, 95% CI [1.39 to 2.62] per unit change in nurse consultation rate vs. OR = 1.04, 95% CI [0.87 to 1.24] per unit change in GP consultation rate. The association between the rates of GP/ nurse consultations and patient satisfaction was mixed. CONCLUSION: There are few associations between primary care consultation rates and outcomes. Previously identified demographic and staffing factors, rather than practice workload, appear to have the strongest relationships with mortality, admissions, performance and satisfaction. Studies with more detailed patient-level data would be required to explore these findings further.


Assuntos
Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Adulto , Idoso , Estudos Transversais , Inglaterra/epidemiologia , Utilização de Instalações e Serviços , Feminino , Medicina Geral/estatística & dados numéricos , Clínicos Gerais/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Mortalidade , Profissionais de Enfermagem/estatística & dados numéricos , Satisfação do Paciente , Carga de Trabalho/estatística & dados numéricos
6.
Lancet ; 393(10187): 2213-2221, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31030986

RESUMO

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Tratamento de Emergência/mortalidade , Melhoria de Qualidade , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Procedimentos Clínicos/normas , Procedimentos Cirúrgicos do Sistema Digestório/normas , Tratamento de Emergência/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Medicina Estatal/normas , Medicina Estatal/estatística & dados numéricos , Análise de Sobrevida , Reino Unido
7.
J Tissue Viability ; 28(2): 115-119, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30824264

RESUMO

BACKGROUND: Venous leg ulceration is common in older adults in the United Kingdom. The gold-standard treatment is compression therapy. There are several compression bandage and hosiery systems that can be prescribed or purchased, but it was unclear what types of compression systems are currently being used to treat venous leg ulceration within the UK. This online scoping survey of registered nurses sought to (1) to identify what compression systems are available across the UK, (2) how frequently these are in use and (3) if there are any restrictions on their use. RESULTS: The results showed that registered nurses who treat patients with venous leg ulceration use a wide range of compression systems. The most frequently used systems are the 'less bulky' two-layer elastic and inelastic compression bandaging systems whilst two-layer hosiery was used less frequently and four-layer bandaging used infrequently. Nurses report that certain compression systems are less accessible through the usual procurement routes but this appears to be related to concerns about competency in application techniques. CONCLUSIONS: The data in this survey provides some important insights into the issues around the use of compression therapy for venous leg ulceration in the UK. Limiting access to certain types of compression may promote patient safety but limit patient choice. There may be underuse of the types of compression that promote patient independence, such as hosiery, and over-use of potentially sub-therapeutic therapy such as 'reduced compression'. Overall, this study suggests that further consideration is needed about the provision of compression therapy to UK patients with venous leg ulceration to optimise care and patient choice.


Assuntos
Bandagens Compressivas/normas , Enfermeiras e Enfermeiros/psicologia , Úlcera Varicosa/terapia , Estudos de Coortes , Humanos , Perna (Membro)/irrigação sanguínea , Perna (Membro)/fisiopatologia , Enfermeiras e Enfermeiros/tendências , Estudos Retrospectivos , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos , Inquéritos e Questionários , Reino Unido , Úlcera Varicosa/prevenção & controle , Cicatrização/fisiologia
10.
Artigo em Inglês | MEDLINE | ID: mdl-30641889

RESUMO

Housing adaptation is a rehabilitation intervention that removes environmental barriers to help older people accommodate changing needs and age in place. In the UK, funding application for home adaptations to local authorities is subject to several procedural steps, including referral, allocation, assessment, funding and installation. The five stages need to complete in a sequential manner, often cause long delays. This study aims to investigate the timelines across these key stages of the adaptation process and examine the main causes of delays in current practice. A mixed-methods research strategy was employed. A questionnaire survey was first undertaken with all 378 local authorities in England, Scotland and Wales; it was followed by 5 semi-structured interviews and 1 focus group meeting with selected service providers, and 2 case studies of service users. The results showed that the average length of time taken to complete the whole process is relatively long, with the longest waiting time being observed at the funding decision stage. Delays were found in each of the key stages. Main causes of delay include insufficient resources, lack of joint work, legal requirements, shortage of competent contractors and the client's decisions. These issues need to be addressed in order to improve the efficiency and effectiveness of future housing adaptation practice.


Assuntos
Eficiência Organizacional/estatística & dados numéricos , Envelhecimento Saudável , Habitação para Idosos/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões Gerenciais , Humanos , Masculino , Medicina Estatal/organização & administração , Inquéritos e Questionários , Fatores de Tempo , Reino Unido
11.
PLoS One ; 14(1): e0209161, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30601839

RESUMO

The NHS Organ Donor Register (NHS ODR) is a centralised database for U.K. residents wishing to be organ donors. Opt-in membership to the NHS ODR demonstrates an expression of a wish to donate, which can be key in decisions made by family members at time of death. By examining the demographic breakdown of the 24.9 million registrants, campaigns can be better targeted to increase membership among those groups underrepresented on the NHS ODR. Data from the NHS ODR (as of March 2017) was analysed using Chi2 Goodness of Fit analyses and Chi2 Test of Independence for the categorical variables of gender, nation of residency at time of registration, ethnicity, organ preference, registration age and age at registration. Goodness of fit analyses showed significant differences between demographic representation on the NHS ODR compared to the U.K. population. Cramer's V showed significant associations were only of note (above 0.1) for age, ethnicity in the U.K. as a whole and ethnicity in England. Older (70+) and younger people (0-14) were underrepresented and those of White Ethnicity overrepresented on the NHS ODR. Although association strength was weak, more women and less residents of England were present compared to the U.K. population. Tests of independence showed significant differences between age at registration and current age on the register and cornea donation preferences. These results indicate areas for targeting by campaigns to increase NHS ODR membership. By understanding the strength of these associations, resources can be utilised in areas where underrepresentation is larger and will have the most impact to demographics of the NHS ODR. Additionally, by identifying which groups are over and underrepresented, future research can explore the reasons for this in these demographic groups.


Assuntos
Doadores de Tecidos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Demografia , Inglaterra , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Medicina Estatal/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Adulto Jovem
12.
Int J Cancer ; 145(1): 40-48, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30549266

RESUMO

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high-risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high-risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co-ordinating centre ('hub'), for having surgery by the presence of surgical services on-site, and for receiving high dose-rate brachytherapy (HDR-BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91-1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10-1.40), and more likely to receive additional HDR-BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94-12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.


Assuntos
Neoplasias da Próstata/radioterapia , Neoplasias da Próstata/cirurgia , Medicina Estatal/organização & administração , Idoso , Braquiterapia , Serviços Centralizados no Hospital/organização & administração , Serviços Centralizados no Hospital/estatística & dados numéricos , Estudos Transversais , Inglaterra/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Neoplasias da Próstata/epidemiologia , Sistema de Registros , Medicina Estatal/estatística & dados numéricos
13.
Int Q Community Health Educ ; 39(3): 163-173, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30582725

RESUMO

We explored the equity issues in access to maternal health services in Enugu State, Nigeria. We conducted a cross-sectional survey of 1,600 women who had babies within 6 months prior to the survey, drawn from four urban and rural local government areas in Enugu State of Nigeria, using structured questionnaire. Focus group discussions were held with grandmothers and fathers of the new babies. In-depth interviews were held with health workers. Results showed that inequities exist in access to quality health service when the mothers needed health care. The inequities in access to quality antenatal care (ANC) services were driven mainly by the type of localities of the mothers. Mothers who lived in the urban areas had better access ( p = .013). Other factors that facilitated access to better ANC services included being educated ( p = .049), being older ( p = .009), and belonging to the richer wealth quintile ( p < .001). With respect to access to health service when in need of health, differentials were seen with respect to living in urban residence ( p < .001), distance to the health facilities ( p < .001), and being rich ( p < .001). Access to health services was associated with odds ratio of 3.6 (95% CI [2.9, 4.4]) and 1.54 (95% CI [1.3, 2.0]) for living in urban residence and existence of good ANC service points, respectively. Similarly, living in urban areas was associated with an odds ratio of 1.3 (95% CI [1.1, 1.6]) of having access to good ANC services. These inequities in access to health service were also captured in the qualitative data. Suboptimal access to quality health care by segments of the populations poses challenge to universal health coverage in Enugu State. Action is needed to promote coordinated delivery of health services to ensure no one is left behind, irrespective of where they live or the socioeconomic strata they are born into.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Cuidado Pré-Natal/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Nigéria , Qualidade da Assistência à Saúde/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Fatores Socioeconômicos , Adulto Jovem
14.
Artigo em Inglês | MEDLINE | ID: mdl-30562949

RESUMO

Although antiretroviral treatment (ART) access has been universal in recent years, few studies have examined if this policy contributes to the mental health of the patients. This study assessed depression and its relations with health-related quality of life (HRQOL), which is defined as the status of general well-being, physical, emotional, and psychological, among HIV patients. A cross-sectional study was conducted in 482 patients at five outpatient clinics. Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and HRQOL. About one-fifth of patients reported symptoms of depression. According to the result of a multivariate logistic regression model, patients who had a lower number of CD4 cells at the start of ART, who received ART in the clinic without HIV counseling and testing (HCT) services, who had a physical health problem, and who experienced discrimination were more likely to have depression. Depression was associated with significantly decreased HRQOL. Depression is prevalent and significantly negatively associated with HRQOL of HIV/AIDS patients. We recommend screening for depression and intervening in the lives of depressed individuals with respect to those who start ART late, and we also recommend community-based behavioral change campaigns to reduce HIV discrimination.


Assuntos
Depressão/epidemiologia , Infecções por HIV/epidemiologia , Qualidade de Vida , Medicina Estatal/estatística & dados numéricos , Adulto , Antirretrovirais/uso terapêutico , Estudos Transversais , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores Socioeconômicos , Vietnã/epidemiologia
16.
BMC Health Serv Res ; 18(1): 347, 2018 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-29743068

RESUMO

BACKGROUND: Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy. METHODS: The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi-structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data. RESULTS: The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency's intended roll out strategy using passive web-based facilitation appeared to have little impact. CONCLUSIONS: When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention.


Assuntos
Tecnologia Biomédica/organização & administração , Órgãos dos Sistemas de Saúde , Invenções/estatística & dados numéricos , Coleta de Dados , Inglaterra , Humanos , Organizações , Medicina Estatal/estatística & dados numéricos
17.
Aust J Rural Health ; 26(2): 74-79, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29624788

RESUMO

OBJECTIVE: To determine the percentage of research projects funded by the National Health and Medical Research Council in the period 2000-2014 that aimed specifically to deliver health benefits to Australians living in rural and remote areas and to estimate the proportion of total funding this represented in 2005-2014. DESIGN: This is a retrospective analysis of publicly available datasets. SETTING: National Health and Medical Research Council Rural and Remote Health Research 2000-2014. OUTCOME MEASURES: 'Australian Rural Health Research' was defined as: research that focussed on rural or remote Australia; that related to the National Health and Medical Research Council's research categories other than Basic Science; and aimed specifically to improve the health of Australians living in rural and remote areas. Grants meeting the inclusion criteria were grouped according to the National Health and Medical Research Council's categories and potential benefit. Funding totals were aggregated and compared to the total funding and Indigenous funding for the period 2005-2014. RESULTS: Of the 16 651 National Health and Medical Research Council-funded projects, 185 (1.1%) that commenced funding during the period 2000-2014 were defined as 'Australian Rural Health Research'. The funding for Australian Rural Health Research increased from 1.0% of the total in 2005 to 2.4% in 2014. A summary of the funding according to the National Health and Medical Research Council's research categories and potential benefit is presented. CONCLUSION: Addressing the health inequality experienced by rural and remote Australians is a stated aim of the Australian Government. While National Health and Medical Research Council funding for rural health research has increased over the past decade, at 2.4% by value, it appears very low given the extent of the health status and health service deficits faced by the 30% who live in rural Australia.


Assuntos
Pesquisa Biomédica/organização & administração , Serviços de Saúde do Indígena/organização & administração , Serviços de Saúde do Indígena/estatística & dados numéricos , Serviços de Saúde Rural/organização & administração , Serviços de Saúde Rural/estatística & dados numéricos , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos , Austrália , Análise Custo-Benefício , Humanos , Estudos Retrospectivos
18.
J Foot Ankle Res ; 11: 10, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29581729

RESUMO

Background: A national survey recently provided the first description of foot orthotic provision in the United Kingdom. This article aims to profile and compare the foot orthoses practice of podiatrists, orthotists and physiotherapists within the current provision. Method: Quantitative data were collected from podiatrists, orthotists and physiotherapists via an online questionnaire. The topics, questions and answers were developed through a series of pilot phases. The professions were targeted through electronic and printed materials advertising the survey. Data were captured over a 10 month period in 2016. Differences between professions were investigated using Chi squared and Fischer's exact tests, and regression analysis was used to predict the likelihood of each aspect of practice in each of the three professions. Results: Responses from 357 podiatrists, 93 orthotists and 49 physiotherapists were included in the analysis. The results reveal statistically significant differences in employment and clinical arrangements, the clinical populations treated, and the nature and volume of foot orthoses caseload. Conclusion: Podiatrists, orthotists and physiotherapists provide foot orthoses to important clinical populations in both a prevention and treatment capacity. Their working context, scope of practice and mix of clinical caseload differs significantly, although there are areas of overlap. Addressing variations in practice could align this collective workforce to national allied health policy.


Assuntos
Órtoses do Pé/provisão & distribução , Modalidades de Fisioterapia/estatística & dados numéricos , Podiatria/estatística & dados numéricos , Prática Profissional/estatística & dados numéricos , Assistência à Saúde/estatística & dados numéricos , Educação Continuada/métodos , Educação Continuada/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Humanos , Podiatria/educação , Relações Profissional-Paciente , Medicina Estatal/estatística & dados numéricos , Resultado do Tratamento , Reino Unido , Local de Trabalho/estatística & dados numéricos
19.
Emerg Med J ; 35(4): 238-246, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29305379

RESUMO

OBJECTIVE: To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs). METHOD: This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission. RESULTS: There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay. CONCLUSION: Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.


Assuntos
Hospitalização/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fatores de Tempo , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Técnicas de Apoio para a Decisão , Inglaterra , Feminino , Hospitais Urbanos/organização & administração , Hospitais Urbanos/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos
20.
Emerg Med J ; 35(2): 108-113, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29117989

RESUMO

INTRODUCTION: Patients admitted to hospital in an emergency at weekends have been found to experience higher mortality rates than those admitted during the week. The National Health Service (NHS) in England has introduced four priority clinical standards for emergency hospital care with the objective of reducing deaths associated with this 'weekend effect'. This study aimed to determine whether adoption of these clinical standards is associated with the extent to which weekend mortality is elevated. METHODS: We used publicly available data on performance against the four priority clinical standards in 2015 and estimates of Trusts' weekend effects between 2013/2014 and 2015/2016 for 123 NHS Trusts in England. We examined whether adoption of the priority clinical standards was associated with the extent to which weekend mortality was elevated, and changes over a 3 year period in the extent to which mortality was elevated. RESULTS: Levels of achievement of two of the four clinical standards (ongoing review and access to diagnostic services) had small positive associations with the magnitude of the weekend effect in 2015/2016. Levels of achievement of the remaining two standards (time to first consultant review and access to consultant directed interventions) had small negative associations with the magnitude of the weekend effect in 2015/2016. No association was statistically significant. The same pattern was observed in the associations between achievement of the standards and changes in the magnitudes of the weekend effect between 2013/2014 and 2015/2016. DISCUSSION: We found no association between Trusts' performance against any of the four standards and the current magnitude of their weekend effects, or the change in their weekend effects over the past 3 years. These findings cast doubt on whether adoption of seven day clinical standards in the delivery of emergency hospital services will be successful in reducing the weekend effect.


Assuntos
Plantão Médico/normas , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Fatores de Tempo , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Análise de Regressão , Estudos Retrospectivos , Medicina Estatal/organização & administração , Medicina Estatal/estatística & dados numéricos
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