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1.
Bone Joint J ; 101-B(10): 1230-1237, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31564152

RESUMO

AIMS: The aim of this study was to assess the effect of posterior cruciate ligament (PCL) resection on flexion-extension gaps, mediolateral soft-tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilized (PS) total knee arthroplasty (TKA). PATIENTS AND METHODS: This prospective study included 110 patients with symptomatic osteoarthritis of the knee undergoing primary robot-assisted PS TKA. All operations were performed by a single surgeon using a standard medial parapatellar approach. Optical motion capture technology with fixed femoral and tibial registration pins was used to assess gaps before and after PCL resection in extension and 90° knee flexion. Measurements were made after excision of the anterior cruciate ligament and prior to bone resection. There were 54 men (49.1%) and 56 women (50.9%) with a mean age of 68 years (sd 6.2) at the time of surgery. The mean preoperative hip-knee-ankle deformity was 4.1° varus (sd 3.4). RESULTS: PCL resection increased the mean flexion gap significantly more than the extension gap in the medial (2.4 mm (sd 1.5) vs 1.3 mm (sd 1.0); p < 0.001) and lateral (3.3 mm (sd 1.6) vs 1.2 mm (sd 0.9); p < 0.01) compartments. The mean gap differences after PCL resection created significant mediolateral laxity in flexion (gap difference: 1.1 mm (sd 2.5); p < 0.001) but not in extension (gap difference: 0.1 mm (sd 2.1); p = 0.51). PCL resection significantly improved the mean FFD (6.3° (sd 4.4) preoperatively vs 3.1° (sd 1.5) postoperatively; p < 0.001). There was a strong positive correlation between the preoperative FFD and change in FFD following PCL resection (Pearson's correlation coefficient = 0.81; p < 0.001). PCL resection did not significantly affect limb alignment (mean change in alignment: 0.2° valgus (sd 1.2); p = 0.60). CONCLUSION: PCL resection creates flexion-extension mismatch by increasing the flexion gap more than the extension gap. The increase in the lateral flexion gap is greater than the increase in the medial flexion gap, which creates mediolateral laxity in flexion. Improvements in FFD following PCL resection are dependent on the degree of deformity before PCL resection. Cite this article: Bone Joint J 2019;101-B:1230-1237.


Assuntos
Artroplastia do Joelho/métodos , Instabilidade Articular/prevenção & controle , Osteoartrite do Joelho/cirurgia , Ligamento Cruzado Posterior/cirurgia , Amplitude de Movimento Articular/fisiologia , Procedimentos Cirúrgicos Robóticos/métodos , Fatores Etários , Idoso , Análise de Variância , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Feminino , Seguimentos , Humanos , Prótese do Joelho , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Melhoria de Qualidade , Medição de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Fatores Sexuais , Resultado do Tratamento
2.
J Clin Ethics ; 30(3): 284-296, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31573973

RESUMO

Scholars and professional organizations in bioethics describe various approaches to "quality assessment" in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes "quality" in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, iin this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction.


Assuntos
Bioética , Ética Clínica , Assistência à Saúde , Humanos , Melhoria de Qualidade
5.
Medicine (Baltimore) ; 98(36): e17068, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31490405

RESUMO

INTRODUCTION: Current treatment of pediatric distal metaphyseal tibial/fibular fractures is challenging due to poor skin and soft tissue coverage and limited blood supply to the distal tibia area in children. It remains unknown whether the SK combined external fixator (made by Double Medical Technology Inc., China) is effective for the treatment of distal metaphyseal tibia/fibula fractures in children. HYPOTHESIS: We hypothesized that SK combined external fixator could achieve satisfying outcomes for pediatric distal metaphyseal tibia/fibula fractures. PATIENTS AND METHODS: A total of 19 pediatric patients with a median age of 6 years (range: 3.8-12.0 years), who had distal tibia/fibula metaphyseal fractures and attended our hospital between January 2017 and November 2017, were evaluated. All patients with tibia fracture had closed reduction and percutaneously fixed SK combined external fixators. Radiographs were taken at an average of every 4 weeks to evaluate the healing of the fracture. Complications were recorded, and the stability of the pin clamp and rod were also checked. Follow-up was conducted for up to 13 months. All patients provided informed consent for publication of the case. RESULTS: All patients achieved a satisfactory clinical outcome at the final follow-up. Weight-bearing exercises were started at post-operative 2 weeks. Bone union was obtained at 8 weeks post-operation on average. No delayed healing or nonunion was observed, although one case of pin site infection and three cases of pin clamp loosening occurred. DISCUSSION: Three-dimensional SK combined external fixators are light, easy to apply, minimally invasive, and result in low rates of complications. They provide excellent stability for pediatric distal tibia/fibula metaphyseal fractures. LEVEL OF EVIDENCE: IV.


Assuntos
Fixadores Externos , Fixação de Fratura/instrumentação , Fraturas da Tíbia/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Melhoria de Qualidade , Estudos Retrospectivos
6.
N C Med J ; 80(5): 301-305, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31471515

RESUMO

Federal managed care rules require that the services delivered through Medicaid prepaid health plans are available, accessible, and continually being evaluated for improvement. Working with stakeholders, NC Medicaid created a Quality Strategy that serves as a roadmap to measure and oversee performance. NC Medicaid will make a variety of quality reports available including network access, annual quality measures, and provider survey results.


Assuntos
Programas de Assistência Gerenciada/organização & administração , Medicaid/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Humanos , North Carolina , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Estados Unidos
9.
Am Surg ; 85(8): 821-829, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560301

RESUMO

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel "Headstrike" protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the "Headstrike" protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all "Headstrike" activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a "Headstrike" during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the "Headstrike" protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Anticoagulantes/administração & dosagem , Protocolos Clínicos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Idoso , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , Centros de Traumatologia , Resultado do Tratamento
10.
Am Surg ; 85(8): 858-860, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560303

RESUMO

International guidelines state that early laparoscopic cholecystectomy (ELC) is appropriate for all severity grades of acute cholecystitis and leads to reduced hospital stays and costs. A multicenter prospective randomized controlled trial recommends ELC over delayed laparoscopic cholecystectomy (DLC) management because in addition to reduced hospital stays and costs, ELC also leads to reduced patient morbidity. Therefore, ELC is standard of care for acute cholecystitis. We hypothesize that 1) international guidelines are not presently followed and that 2) a quality improvement (QI) project enforcing ELC for acute cholecystitis will increase rates of ELC management. A retrospective chart review of all surgical consults for cholecystitis from January 2016 to December 2018 was undertaken. A total of 307 patients diagnosed with acute cholecystitis were included. ELC was defined as cholecystectomy within hospital admission. Pre-QI ELC versus DLC rates were 77.4 per cent (233/301) versus 22.6 per cent (68/301). Eight DLC patients (11.8%) returned to the ED after discharge secondary to persistent signs and symptoms of cholecystitis and 62.5 per cent (5/8) received an immediate cholecystectomy before their elective surgery date. After QI initiatives, ELC rates rose to 100 per cent (6/6). These data show there was a lack of consistent ELC management of acute cholecystitis.


Assuntos
Colecistectomia Laparoscópica , Colecistite Aguda/cirurgia , Fidelidade a Diretrizes , Tempo para o Tratamento , Adulto , Idoso , Tratamento Conservador , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Resultado do Tratamento
11.
Am Surg ; 85(8): 883-894, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560308

RESUMO

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.


Assuntos
Protocolos Clínicos , Controle de Custos , Testes Diagnósticos de Rotina/economia , Hepatectomia , Preços Hospitalares/estatística & dados numéricos , Pancreatectomia , Pancreaticoduodenectomia , Cuidados Pós-Operatórios/economia , Medição de Risco/métodos , Algoritmos , Feminino , Humanos , Masculino , Estudos Prospectivos , Melhoria de Qualidade , Estados Unidos
12.
Nephrol Nurs J ; 46(4): 413-445, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31490051

RESUMO

Pediatric patients with chronic kidney disease (CKD) have an increased risk of developing vaccine-preventable diseases due to reduced immunization coverage. Studies have demonstrated that reduced immunization coverage in this population is related to barriers, such as frequent hospitalization, lack of knowledge, and concerns about safety and efficacy. This article examines a nurse practitioner-led quality improvement project (QIP) conducted in an outpatient pediatric nephrology clinic. The QIP focused on educating pediatric providers related to age-appropriate immunizations for children with CKD or nephrotic syndrome, and those who are renal transplant candidates and recipients. A process is now in place to review immunization records upon initial visit and annually, and to notify primary care providers of current recommendations for this population.


Assuntos
Imunização/normas , Transplante de Rim , Síndrome Nefrótica , Insuficiência Renal Crônica , Criança , Humanos , Profissionais de Enfermagem Pediátrica , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Literatura de Revisão como Assunto
14.
Stud Health Technol Inform ; 264: 1880-1881, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438389

RESUMO

In order to reduce the rate of needle re-insertion (hereafter, retaking) during a blood drawing operation, we proposed a method for training blood drawing staff, based on data analysis. The method is composed of three steps: (1) analysis of collected data for selecting staff to be trained intensively, (2) training, and (3) assessment of training results. We obtained the result that the retaking rate was reduced for the trained staff.


Assuntos
Flebotomia , Melhoria de Qualidade , Humanos
15.
Medicine (Baltimore) ; 98(33): e16847, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415411

RESUMO

The aim of the present study was to explore the application and its effect of mobile medical treatment to chronic disease health management in physical examination population, and to provide references for comprehensive intervention and management of chronic diseases.From January to December 2016, 300 medical examiners in a general hospital health management center were randomly divided into health management group (155 cases) and control group (145 cases). The control group completed routine physical examination and health-risk assessment and provided corresponding reports, repeated annual physical examination and health-risks assessment. In addition to the routine physical examination and health-risk assessment, the health management group reminded the examiners to pay attention to their lifestyle and dietary habits by moving online and offline dynamic health interventions and provide targeted guidance for high-risk population such as diabetes, obesity, hypertension, etc. A review was made after 2 years. The clinical indexes and chronic disease behavior of patients before and after management were compared, and the effect was evaluated by statistical analysis.After management, all the clinical indexes were significantly improved, and the patients' dietary structure, bad living habits, psychologic state, and other chronic disease behaviors were obviously improved. The proportion of patients with high risk of hypertension, diabetes, and obesity in health management group was significantly lower than that before intervention and control group (P < .05).Using mobile network online, offline dynamic health intervention model can reduce the risk of common chronic diseases in health management objects, this health management model of chronic disease is worth popularizing.


Assuntos
Comportamentos Relacionados com a Saúde , Promoção da Saúde/métodos , Dieta Saudável/estatística & dados numéricos , Adulto , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Doença Crônica/prevenção & controle , Diabetes Mellitus/epidemiologia , Feminino , Dieta Saudável/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Medição de Risco/métodos , Telemedicina
16.
Stud Health Technol Inform ; 264: 1833-1834, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438366

RESUMO

To prevent healthcare-associated infections, there are a range of clinical practices that should be followed. For example, appropriate administration of prophylactic antibiotics [process] is essential to reduce risks of surgical site infections post-operatively [outcome]. Monitoring adherence to these processes provides insights into potential causes of infection. The Victorian Healthcare Associated Infection Surveillance System (VICNISS) captures process data in the same system as outcome data, thereby providing integrated data to support quality improvement within healthcare and reduce the burden of healthcare-associated infections.


Assuntos
Antibioticoprofilaxia , Infecção Hospitalar , Antibacterianos , Humanos , Melhoria de Qualidade , Infecção da Ferida Cirúrgica
17.
Implement Sci ; 14(1): 78, 2019 08 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399105

RESUMO

BACKGROUND: Advanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning. METHODS: Using an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning. RESULTS: Four of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737). CONCLUSIONS: To our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.


Assuntos
Assistência Ambulatorial/normas , Assistência à Saúde/normas , Ciência da Implementação , Modelos Organizacionais , Neurocirurgia/normas , Ortopedia/normas , Pacientes Ambulatoriais , Técnicas de Planejamento , Melhoria de Qualidade , Grupos Focais , Necessidades e Demandas de Serviços de Saúde , Humanos , Pesquisa Qualitativa , Queensland
20.
Bone Joint J ; 101-B(8): 1015-1023, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31362544

RESUMO

AIMS: Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. MATERIALS AND METHODS: We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. RESULTS: There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. CONCLUSION: This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015-1023.


Assuntos
Fixação de Fratura/economia , Fraturas do Quadril/economia , Melhoria de Qualidade/economia , Reembolso de Incentivo , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Análise de Séries Temporais Interrompida , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Escócia , Tempo para o Tratamento/economia , Resultado do Tratamento
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