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1.
J Surg Res ; 246: 224-230, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31606512

RESUMO

BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.


Assuntos
Cuidados de Suporte Avançado de Vida no Trauma/estatística & dados numéricos , Lesões Encefálicas Traumáticas/terapia , Cuidados Paliativos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Cuidados de Suporte Avançado de Vida no Trauma/organização & administração , Cuidados de Suporte Avançado de Vida no Trauma/tendências , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/mortalidade , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/tendências , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/normas , Cuidados Paliativos/tendências , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/estatística & dados numéricos , Melhoria de Qualidade/tendências , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/tendências , Estados Unidos
3.
BMJ Sex Reprod Health ; 45(3): 190-199, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31289100

RESUMO

BACKGROUND: Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception. METHODS: Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data. RESULTS: Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion. CONCLUSION: The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.


Assuntos
Aborto Induzido/psicologia , Comportamento Contraceptivo/estatística & dados numéricos , Aconselhamento/métodos , Contracepção Reversível de Longo Prazo/normas , Adulto , Aconselhamento/normas , Aconselhamento/estatística & dados numéricos , Serviços de Planejamento Familiar/métodos , Serviços de Planejamento Familiar/tendências , Feminino , Humanos , Contracepção Reversível de Longo Prazo/psicologia , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Gravidez , Pesquisa Qualitativa , Melhoria de Qualidade/tendências , Inquéritos e Questionários , Suécia
4.
Nurs Adm Q ; 43(3): 280-288, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31162348

RESUMO

Traditional quality assurance processes provide significant opportunities for positive disruption. Doctor of Nursing Practice (DNP) students are well positioned to apply program learning to large-scale change in complex organizations. This article presents an innovative approach for creating a point-of-care interdisciplinary approach to address high fall risk frequencies in ambulatory oncology clinics using complexity leadership principles. Processes for nurse executives to consider for replication of this approach for other challenging clinical situations are suggested using the emerging competence of DNP educated nurses. Adults with cancer who are older than 65 years are at a higher risk for falls than older adults without cancer. Oncology providers and nurses are not routinely screening, documenting, and preventing falls. A fall injury in an older adult with cancer may not only delay or impact cancer treatment but also result in hospitalization, loss of function, and/or death. Increasing awareness of the impact of falls and implementing change within a large ambulatory health care organization requires an interdisciplinary team approach. Complexity theory supports nonlinear change initiated at the grassroots level to create a dynamic movement to bring forth emergence and adaptation. The use of the Centers for Disease Control and Prevention STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative will enable oncology professionals to screen, assess, and intervene by collaborating, communicating, and coordinating with other health care specialists to introduce a fall prevention quality improvement system process. Nurse executives need to know about STEADI.


Assuntos
Acidentes por Quedas/prevenção & controle , Indicadores de Qualidade em Assistência à Saúde/normas , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Geriatria/métodos , Geriatria/normas , Humanos , Masculino , Serviço Hospitalar de Oncologia/organização & administração , Serviço Hospitalar de Oncologia/normas , Serviço Hospitalar de Oncologia/estatística & dados numéricos , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos
5.
Emerg Med J ; 36(7): 423-430, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31230040

RESUMO

OBJECTIVES: Reducing the treatment time while increasing the proportion of eligible stroke patients who receive intravenous tissue plasminogen activator (tPA) has been a priority for many quality improvement efforts. Recent studies have primarily focused on identifying interventions that reduce door-to-needle (DTN) time, while comparatively little has been done to determine whether these interventions also improve tPA rates. METHODS: In order to investigate interventions related to process improvements, an electronic dashboard serving as a stroke performance tool was implemented to store and retrieve patient outcome data. These data were used to study the efficacy of interventions designed to facilitate triage of stroke patients in the ED, and determine the individual interventions associated with the most significant improvements in the fraction of patients receiving tPA and in reducing the DTN time. Stroke performance data from the dashboard collected over a 2-year period (2015-2017) from 89 US hospitals were analysed with respect to interventions implemented by individual facilities, as verified by a hospital survey. RESULTS: A statistically significant association was found between increases in the fraction of patients receiving tPA and reductions in DTN time over the study period. These improvements in outcomes were most strongly associated with process interventions that allocate stroke-specific physical and human resources in the ED, most notably a designated emergency room space for stroke, and with workflows that decrease the time to key checkpoints for determining a patient's eligibility for tPA. CONCLUSIONS: Data from the stroke performance tool was leveraged to identify the programmes and process interventions that lead to improved patient outcomes and allow EDs to better prioritise process interventions and resources.


Assuntos
Melhoria de Qualidade/tendências , Acidente Vascular Cerebral/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Terapia Trombolítica/métodos , Terapia Trombolítica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
6.
Ann Biol Clin (Paris) ; 77(3): 331-338, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31219423

RESUMO

The monitoring of quality indicators, combined with a detailed risk analysis, validates the process of automated blood culture. Here we report the methodology of 5 years monitoring for 5 indicators at the Biology Department of Foch Hospital: volume sampled, proportion of contaminants, proportion of positive blood cultures in each instrument and drawer, epidemiological indicator and proportion of false-positive instrument signals. The results obtained were outside the expected target for the volume sampled and were acceptable for the other indicators. The analysis of these results leads us to discuss the evolution of quality indicators and more particularly the implementation of corrective measures, their periodicity, their relevance as well as the need to refine their results to carry out targeted actions.


Assuntos
Hemocultura/normas , Hemocultura/tendências , Controle de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Acreditação , Automação Laboratorial/normas , Hemocultura/métodos , Contaminação de Equipamentos , Reações Falso-Positivas , Humanos , Fase Pré-Analítica/normas , Fase Pré-Analítica/tendências , Valor Preditivo dos Testes , Melhoria de Qualidade/normas , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Sepse/sangue , Sepse/diagnóstico , Estudos Soroepidemiológicos , Esterilização/métodos , Esterilização/normas
10.
Nurs Womens Health ; 23(3): 253-264, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31059674

RESUMO

Choosing Wisely is a national health care improvement campaign promoting conversations between women and their health care professionals about selecting high-value health care practices. It disseminates lists of recommendations and downloadable educational materials from professional societies on its website. In November 2018, we searched for and categorized Choosing Wisely recommendations pertinent to women's health care. Of 78 recommendations, 28 (36%) were related to perinatal care, 22 (28%) were related to gynecologic care, and 28 (36%) were related to women's health and general care. Twelve recommendations (17.6%) were related to antenatal care, 10 (14.7%) to intrapartum and postpartum care, and 10 (14.7%) to cervical cancer screening. These free resources can help frame the shared decision-making process in clinical practice.


Assuntos
Tomada de Decisões , Melhoria de Qualidade/tendências , Serviços de Saúde da Mulher/normas , Feminino , Humanos , Gravidez , Desenvolvimento de Programas/métodos , Qualidade da Assistência à Saúde/normas , Serviços de Saúde da Mulher/tendências
11.
S Afr Med J ; 109(4): 241-245, 2019 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-31084689

RESUMO

BACKGROUND: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies. OBJECTIVES: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme. METHODS: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and a before-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures. RESULTS: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts. CONCLUSIONS: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths.


Assuntos
Parto Obstétrico/métodos , Educação Médica Continuada/métodos , Educação Continuada em Enfermagem/métodos , Serviços Médicos de Emergência/métodos , Morte Materna/prevenção & controle , Complicações do Trabalho de Parto/terapia , Treinamento por Simulação , Competência Clínica , Parto Obstétrico/mortalidade , Emergências , Feminino , Humanos , Morte Materna/tendências , Complicações do Trabalho de Parto/mortalidade , Gravidez , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , África do Sul
12.
Rev Med Inst Mex Seguro Soc ; 57(1): 30-35, 2019 Apr 01.
Artigo em Espanhol | MEDLINE | ID: mdl-31071252

RESUMO

The residual risk of transfusion-related infections has decreased dramatically in countries that have routinely implemented serological screening. Most of the donation in Mexico is from replacement practice, a risk factor for positive serology. In Mexico, the altruistic donation is only 2.7%. The heterogeneity of technical factors, regional factors and internal policies of each center influences the variability of data on the prevalence of positive screening, as well as the prevalence of confirmed cases. The main advantage of nucleic acid technology is the detection of donors in the period of serological window or occult infections, being occult hepatitis reports in Mexican donors from 1 to 3.4%. The limitation of available technology, the scope of the clinic and perspectives, invites us to improve technology and health policies in the interest of transfusion safety.


Assuntos
Segurança do Sangue/métodos , Transfusão de Sangue/normas , Reação Transfusional/prevenção & controle , Segurança do Sangue/tendências , Transfusão de Sangue/tendências , Humanos , México/epidemiologia , Melhoria de Qualidade/tendências , Reação Transfusional/epidemiologia
13.
Matern Child Health J ; 23(8): 989-995, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31055701

RESUMO

Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.


Assuntos
Serviços de Saúde Materna/normas , Morbidade/tendências , Melhoria de Qualidade/tendências , Ciência de Dados , Feminino , Humanos , Massachusetts , Serviços de Saúde Materna/estatística & dados numéricos , Ohio , Gravidez , Fatores de Risco
14.
BMC Med ; 17(1): 88, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064388

RESUMO

BACKGROUND: Despite increasing interest in research on how to translate knowledge into practice and improve healthcare, the accumulation of scientific knowledge in this field is slow. Few substantial new insights have become available in the last decade. MAIN BODY: Various problems hinder development in this field. There is a frequent misfit between problems and approaches to implementation, resulting in the use of implementation strategies that do not match with the targeted problems. The proliferation of concepts, theories and frameworks for knowledge transfer - many of which are untested - has not advanced the field. Stakeholder involvement is regarded as crucial for successful knowledge implementation, but many approaches are poorly specified and unvalidated. Despite the apparent decreased appreciation of rigorous designs for effect evaluation, such as randomized trials, these should remain within the portfolio of implementation research. Outcome measures for knowledge implementation tend to be crude, but it is important to integrate patient preferences and the increased precision of knowledge. CONCLUSIONS: We suggest that the research enterprise be redesigned in several ways to address these problems and enhance scientific progress in the interests of patients and populations. It is crucially important to establish substantial programmes of research on implementation and improvement in healthcare, and better recognize the societal and practical benefits of research.


Assuntos
Ciência da Implementação , Melhoria de Qualidade , Pesquisa Médica Translacional , Política de Saúde/tendências , Humanos , Conhecimento , Melhoria de Qualidade/normas , Melhoria de Qualidade/tendências , Projetos de Pesquisa , Pesquisa Médica Translacional/organização & administração , Pesquisa Médica Translacional/normas
15.
Pediatrics ; 143(5)2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31028159

RESUMO

OBJECTIVES: Unintended extubations (UEs) lead to significant morbidity in neonates. A quality improvement project was initiated in response to high rates in our level IV NICU. We targeted creating and sustaining UE rates below the published standard of 1 per 100 ventilator days. METHODS: This project spanned 4 time periods: baseline, epoch 1 (December 2010-May 2012), sustain, and epoch 2 (May 2015-December 2017) by using standard quality improvement methodology. Epoch 1 interventions included real-time analysis of UE events, standardization of taping, patient positioning and movement, accurate event reporting, and change in nomenclature. Epoch 2 interventions included reduction in daily chest radiographs (CXRs) and development of a high-risk tool. Patient and event characteristics were statistically compared across time points. RESULTS: Of the 612 UE events recorded over 10 years, 249 UEs occurred from May 2011 to 2017 involving 184 unique patients. UE rates decreased by 43% (from 1.75 to 0.99 per 100 ventilator days; epoch 1) and were sustained until a notable spike. Epoch 2 interventions led to a further 31% rate reduction. Single CXR use decreased by half. Median corrected gestational age at the time of an event was 35 weeks (interquartile range: 29-41). Seventy percent of infants experiencing an UE required reintubation, 29% had a previous event, and 9% had a code event. CONCLUSIONS: A decrease in UE below benchmarks can be achieved and sustained by standardization and mitigation interventions. This decline was also accompanied by a reduction in use of CXRs without increasing UE events.


Assuntos
Centros Médicos Acadêmicos/tendências , Extubação/tendências , Unidades de Terapia Intensiva Neonatal/tendências , Intubação Intratraqueal/tendências , Melhoria de Qualidade/tendências , Centros Médicos Acadêmicos/normas , Extubação/normas , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Intubação Intratraqueal/normas , Masculino , Melhoria de Qualidade/normas
17.
Enferm. glob ; 18(54): 285-293, abr. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-183484

RESUMO

La tuberculosis pulmonar (TB pulmonar) es una enfermedad infecciosa común en el mundo, incluso en Indonesia. Se transmite muy fácilmente a través de las salpicaduras de esputo. Fomenta el desarrollo de intervenciones para controlar la transmisión de la TB, como la educación sanitaria estructurada. El objetivo de este estudio fueron determinar el efecto de la intervención de educación sanitaria estructurada sobre el comportamiento preventivo de la tuberculosis pulmonar en la regencia de Bogor, Indonesia. Este estudio utilizó un diseño cuasiexperimental con diseño previo y posterior a la prueba, que involucró a 82 miembros adultos de la comunidad de edad que se dividieron en grupos de intervención y control. El muestreo aleatorio en varias etapas se utilizó para determinar el área de investigación, mientras que el sujeto de investigación se seleccionó mediante muestreo aleatorio simple. Los resultados mostraron que la educación estructurada afecta significativamente el conocimiento (valor de p = 0,000), la actitud (valor de p = 0,000) y la prevención de habilidades de transmisión de TB pulmonar (valor de p = 0,000). La salud estructurada podría aplicarse como una alternativa de intervención de enfermería comunitaria que se puede administrar a las personas en riesgo de TB pulmonar


Pulmonary Tuberculosis (pulmonary TB) is a common infectious disease in the world, including in Indonesia. It is very easily transmitted through sputum splashes. It encourages development of interventions in order to control the transmission of TB, such as structured health education. The aims of this study were to determine the effect of structured health education intervention on the prevention behavior of pulmonary TB in Bogor regency, Indonesia. This study used quasi-experimental design with pre- and post-test design, involving 82 adults age community member who were devided into intervention and control group. The study was conducted in districts with high TB prevalence selected by purposive sampling, while the research subject was selected using simple random sampling. The results showed that structured education significantly affects knowledge (p value = 0,000), attitude (p value = 0,000), and skill prevention of pulmonary TB transmission (p value = 0,000). Structured health could applied as an alternative choice of community nursing interventions that can be given to people at risk of pulmonary TB


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Tuberculose Pulmonar/prevenção & controle , Qualidade da Assistência à Saúde/organização & administração , Educação em Saúde/organização & administração , Cuidados de Enfermagem/métodos , Indonésia/epidemiologia , Avaliação de Resultado de Ações Preventivas , Melhoria de Qualidade/tendências , Estudos de Casos e Controles
18.
Med Decis Making ; 39(3): 228-238, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30834808

RESUMO

BACKGROUND: Gain in mean survival time from new cancer treatments is a core component of cost-effectiveness analyses frequently used by payers for reimbursement decisions. Due to limited follow-up time, clinical trials rarely report this measure, whereas they often report hazard ratios comparing treatment groups. AIM: We aimed to explore the empirical relationship between gain in mean survival time and the hazard ratio for cancer patients. METHODS: We included all patients in Norway diagnosed from 1965 through 2004 with late-stage cancer at the point of diagnosis and with one of the following cancers: stomach, colon, rectal, pancreas, lung and trachea, kidney excluding renal pelvis, and metastasized breast and prostate. Patients were followed until emigration, death, or June 30, 2016, whichever came first. Observed mean survival times and hazard ratios were obtained in subcohorts defined by patients' sex, age, cancer type, and time period of diagnosis, which had nearly complete follow-up. Based on theoretical considerations, we fitted a linear relationship between observed differences in mean survival and logarithmic hazard ratios. For validation, we estimated differences in mean survival from hazard ratios of bootstrap samples with artificially induced censoring and compared with fitting a Weibull distribution. RESULTS: The relationship between differences in mean survival time and corresponding logarithmic hazard ratios was linear for each of the included cancers. The predicted differences in mean survival of the empirical approach generally had smaller bias than the Weibull approach. CONCLUSION: For cancer diagnoses with poor prognosis, differences in mean survival times could be predicted from corresponding hazard ratios. This hazard ratio-based approach outperforms or is similar to fitting Weibull models to data with incomplete follow-up, while making fewer assumptions.


Assuntos
Neoplasias/mortalidade , Melhoria de Qualidade/normas , Taxa de Sobrevida , Fatores de Tempo , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/fisiopatologia , Noruega , Prognóstico , Modelos de Riscos Proporcionais , Melhoria de Qualidade/tendências , Análise de Sobrevida
19.
Int J Cardiovasc Imaging ; 35(7): 1259-1263, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30850907

RESUMO

Previous studies have demonstrated the impact of appropriate use criteria (AUC) education and feedback interventions in reducing unnecessary ordering of transthoracic echocardiography (TTE) by trainees. To our knowledge, no study has evaluated the impact of the addition of price transparency to this education and feedback model on TTE utilization by resident physicians. We performed an education and feedback quality improvement initiative combining charge transparency data with information on AUC. We hypothesized that the initiative would reduce the number of complete TTE ordered and increase the number of limited TTE ordered, anticipating there would be substitution of limited for complete studies. Residents rotating on inpatient teaching cardiology ward teams received education on AUC for TTE, indications for limited TTE, and hospital charges for TTE. Feedback was provided on the quantity and charges for complete and limited TTE ordered by each team. We analyzed the effects of the intervention using a linear mixed effects regression model to adjust for potential confounders. The post-intervention weeks showed a reduction of 4.6 complete TTE orders per 100 patients from previous weekly baseline of 31.3 complete TTE orders per 100 patients (p value = 0.012). Charges for complete TTE decreased $122 from baseline of $980 per patient (p value = 0.040) on a per-week basis. Secondarily, there was no statistically significant change in limited TTE ordering during the intervention period. This initiative shows the feasibility of a house staff-driven charge transparency and education/feedback initiative that decreased medical residents' ordering of inpatient TTE.


Assuntos
Ecocardiografia/tendências , Educação Médica Continuada/tendências , Feedback Formativo , Custos Hospitalares/tendências , Pacientes Internados , Internato e Residência/tendências , Padrões de Prática Médica/tendências , Procedimentos Desnecessários/tendências , Atitude do Pessoal de Saúde , Redução de Custos , Análise Custo-Benefício , Ecocardiografia/economia , Educação Médica Continuada/economia , Estudos de Viabilidade , Custos de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internato e Residência/economia , Padrões de Prática Médica/economia , Valor Preditivo dos Testes , Estudos Prospectivos , Melhoria de Qualidade/economia , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/economia , Indicadores de Qualidade em Assistência à Saúde/tendências , Procedimentos Desnecessários/economia
20.
Semin Thorac Cardiovasc Surg ; 31(3): 434-441, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30849464

RESUMO

Between 2000 and 2008, the mitral valve (MV) repair rate in patients with severe mitral regurgitation at our low-volume Veterans Affairs hospital was 21%. After instituting a multidisciplinary valve team in 2009, we determined whether this rate increased and characterized the outcomes of patients with degenerative disease. We retrospectively reviewed data from 103 MV operations performed at our hospital between 1/2009 and 8/2016. MV pathology was categorized as degenerative, rheumatic, endocarditis, ischemic, hypertrophic cardiomyopathy, or failed prior MV repair. The surgical techniques used for MV repair were reviewed. For the patients with degenerative disease who underwent MV repair, we assessed leaflet involvement and postoperative valve function. For the full cohort, the MV repair rate was 67% and the 30-day mortality rate was 0.97%. Of the 74 patients with degenerative disease, 64 (86.5%) underwent MV repair (none required reoperation). For these patients, the MV repair rate was significantly higher when the surgical approach was sternotomy rather than minimally invasive right minithoracotomy (92.5% vs 71.4%, P = 0.03). After MV repair, 95.3% of the degenerative disease patients had mild or less mitral regurgitation; median echocardiography follow-up time was 555 days. Anatomic features associated with a reduced MV repair rate in patients with degenerative disease were dystrophic leaflet calcification and severe mitral annular calcification. In an institution with a low volume of MV operations, preoperative surgical planning with a multidisciplinary valve team was associated with improved MV repair rates and excellent repair quality in patients with degenerative valve disease.


Assuntos
Implante de Prótese de Valva Cardíaca/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Hospitais de Veteranos/tendências , Anuloplastia da Valva Mitral/tendências , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Equipe de Assistência ao Paciente/tendências , Padrões de Prática Médica/tendências , Idoso , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Recuperação de Função Fisiológica , Estudos Retrospectivos , Índice de Gravidade de Doença , Esternotomia/tendências , Toracotomia/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
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