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1.
BMC Geriatr ; 21(1): 43, 2021 01 12.
Artigo em Inglês | MEDLINE | ID: mdl-33435869

RESUMO

BACKGROUND: The economic and public health burden of fragility fractures of the hip in Germany is high. The likelihood of requiring long-term care and the risk of suffering from a secondary fracture increases substantially after sustaining an initial fracture. Neither appropriate confirmatory diagnostics of the suspected underlying osteoporosis nor therapy, which are well-recognised approaches to reduce the burden of fragility fractures, are routinely initiated in the German healthcare system. Therefore, the aim of the study FLS-CARE is to evaluate whether a coordinated care programme can close the prevention gap for patients suffering from a fragility hip fracture through the implementation of systematic diagnostics, a falls prevention programme and guideline-adherent interventions based on the Fracture Liaison Services model. METHODS: The study is set up as a non-blinded, cluster-randomised, controlled trial with unequal cluster sizes. Allocation to intervention group (FLS-CARE) and control group (usual care) follows an allocation ratio of 1:1 using trauma centres as the unit of allocation. Sample size calculations resulted in a total of 1216 patients (608 patients per group distributed over 9 clusters) needed for the analysis. After informed consent, all participants are assessed directly at discharge, after 3 months, 12 months and 24 months. The primary outcome measure of the study is the secondary fracture rate 24 months after initial hip fracture. Secondary outcomes include differences in the number of falls, mortality, quality-adjusted life years, activities of daily living and mobility. DISCUSSION: This study is the first to assess the effectiveness and cost-effectiveness/utility of FLS implementation in Germany. Findings of the process evaluation will also shed light on potential barriers to the implementation of FLS in the context of the German healthcare system. Challenges for the study include the successful integration of the outpatient sector as well as the future course of the coronavirus pandemic in 2020 and its influence on the intervention. TRIAL REGISTRATION: German Clinical Trial Register (DRKS) 00022237 , prospectively registered 2020-07-09.


Assuntos
Prestação Integrada de Cuidados de Saúde , Fraturas por Osteoporose , Atividades Cotidianas , Idoso , Alemanha/epidemiologia , Hospitais , Humanos , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/prevenção & controle , Prevenção Secundária
2.
BMC Musculoskelet Disord ; 22(1): 18, 2021 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-33402136

RESUMO

BACKGROUND: Like with all cancers, multidisciplinary team (MDT) meetings are the norm in bone and soft tissue tumour (BST) management too. Problem in attendance of specialists due to geographical location is the one of the key barriers to effective functioning of MDTs. To overcome this problem, virtual MDTs involving videoconferencing or telemedicine have been proposed, but however this has been seldom used and tested. The COVID-19 pandemic forced the implementation of virtual MDTs in the Oxford sarcoma service in order to maintain normal service provision. We conducted a survey among the participants to evaluate its efficacy. METHODS: An online questionnaire comprising of 24 questions organised into 4 sections was circulated among all participants of the MDT after completion of 8 virtual MDTs. Opinions were sought comparing virtual MDTs to the conventional face-to-face MDTs on various aspects. A total of 36 responses were received and were evaluated. RESULTS: 72.8% were satisfied with the depth of discussion in virtual MDTs and 83.3% felt that the decision-making in diagnosis had not changed following the switch from face-to-face MDTs. About 86% reported to have all essential patient data was available to make decisions and 88.9% were satisfied with the time for discussion of patient issues over virtual platform. Three-fourths of the participants were satisfied (36.1% - highly satisfied; 38.9% - moderately satisfied) with virtual MDTs and 55.6% of them were happy to attend MDTs only by the virtual platform in the future. Regarding future, 77.8% of the participants opined that virtual MDTs would be the future of cancer care and an overwhelming majority (91.7%) felt that the present exercise would serve as a precursor to global MDTs involving specialists from abroad in the future. CONCLUSION: Our study shows that the forced switch to virtual MDTs in sarcoma care following the unprecedented COVID-19 pandemic to be a viable and effective alternative to conventional face-to-face MDTs. With effective and efficient software in place, virtual MDTs would also facilitate in forming extended MDTs in seeking opinions on complex cases from specialists abroad and can expand cancer care globally.


Assuntos
Neoplasias Ósseas/terapia , Comunicação Interdisciplinar , Oncologia/organização & administração , Neoplasias Musculares/terapia , Equipe de Assistência ao Paciente/organização & administração , Sarcoma/terapia , Telemedicina/organização & administração , Comunicação por Videoconferência/organização & administração , Atitude do Pessoal de Saúde , Atitude Frente aos Computadores , Neoplasias Ósseas/diagnóstico , Tomada de Decisão Clínica , Prestação Integrada de Cuidados de Saúde/organização & administração , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Neoplasias Musculares/diagnóstico , Sarcoma/diagnóstico , Centros de Atenção Terciária
3.
J Ethnopharmacol ; 267: 113477, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33098971

RESUMO

ETHNOPHARMACOLOGICAL RELEVANCE: Traditional pharmacopeias have been developed by multiple cultures and evaluated for efficacy and safety through both historical/empirical iteration and more recently through controlled studies using Western scientific paradigms and an increasing emphasis on data science methodologies for network pharmacology. Traditional medicines represent likely sources of relatively inexpensive drugs for symptomatic management as well as potential libraries of new therapeutic approaches. Leveraging this potential requires hard evidence for efficacy that separates science from pseudoscience. MATERIALS AND METHODS: We performed a review of non-Western medical systems and developed case studies that illustrate the epistemological and practical translative barriers that hamper their transition to integration with Western approaches. We developed a new data analytics approach, in silico convergence analysis, to deconvolve modes of action, and potentially predict desirable components of TM-derived formulations based on computational consensus analysis across cultures and medical systems. RESULTS: Abstraction, simplification and altered dose and delivery modalities were identified as factors that influence actual and perceived efficacy once a medicine is moved from a non-Western to Western setting. Case studies on these factors highlighted issues with translation between non-Western and Western epistemologies, including those where epistemological and medicinal systems drive markets that can be epicenters for zoonoses such as the novel Coronavirus. The proposed novel data science approach demonstrated the ability to identify and predict desirable medicinal components for a test indication, pain. CONCLUSIONS: Relegation of traditional therapies to the relatively unregulated nutraceutical industry may lead healthcare providers and patients to underestimate the therapeutic potential of these medicines. We suggest three areas of emphasis for this field: First, vertical integration and embedding of traditional medicines into healthcare systems would subject them to appropriate regulation and evidence-based practice, as viable integrative implementation mode. Second, we offer a new Bradford-Hill-like framework for setting research priorities and evaluating efficacy, with the goal of rescuing potentially valuable therapies from the nutraceutical market and discrediting those that are pseudoscience. Third, data analytics pipelines offer new capacity to generate new types of TMS-inspired medicines that are rationally-designed based on integrated knowledge across cultures, and also provide an evaluative framework against which to test claims of fidelity and efficacy to TMS made for nutraceuticals.


Assuntos
Ciência de Dados , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/tendências , Medicina Tradicional/tendências , /terapia , Interpretação Estatística de Dados , Humanos , Medicina , Fitoterapia
4.
J Stroke Cerebrovasc Dis ; 30(1): 105418, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33152594

RESUMO

INTRODUCTION: Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care. METHODS: We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke. RESULTS: Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization. CONCLUSION: We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.


Assuntos
Afro-Americanos , Prestação Integrada de Cuidados de Saúde , Grupo com Ancestrais do Continente Europeu , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos , Telemedicina , Idoso , Feminino , Humanos , /etnologia , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes , Fatores Raciais , Sistema de Registros , Estudos Retrospectivos , Fatores Sexuais , Texas/epidemiologia , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento
5.
J Stroke Cerebrovasc Dis ; 30(1): 105433, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33160124

RESUMO

BACKGROUND AND PURPOSE: Delays in recognition and assessment of in-hospital strokes (IHS) can lead to poor outcomes. The aim was to examine whether reorganized IHS code protocol can reduce treatment time. METHODS: IHS code protocol was developed, educational workshops were held for medical personnel. In the protocol, any medical personnel should directly consult a stroke neurologist before any diagnostic studies. Time intervals were compared between the pre- and post-implementation periods and between direct consultation with a stroke neurologist (DC group) and non-DC group in the post-implementation period. RESULTS: A total of 145 patients were included (pre, 42; post, 103). Time from recognition to stroke neurologist assessment (91 vs. 35 min, p = 0.002) and time from recognition to neuroimaging (123 vs. 74, p = 0.013) were significantly lower in the post-implementation period. Time from stroke neurologist assessment to groin puncture was significantly lower (135 vs. 81, p = 0.037). In the post-implementation period, DC group showed significant time savings from last known well (LKW) to recognition (93 vs. 260, p = 0.001), LKW to stroke neurologist assessment (145 vs. 378, p = 0.001), and recognition to stroke neurologist assessment (16 vs. 76, p < 0.001) compared with non-DC group. CONCLUSIONS: Reorganization of IHS code protocol reduced time from stroke recognition to assessment and treatment time. Reorganized IHS code and direct consultation with a stroke neurologist improved the initial response time.


Assuntos
Protocolos Clínicos , Prestação Integrada de Cuidados de Saúde , Procedimentos Endovasculares , Neuroimagem , Encaminhamento e Consulta , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pacientes Internados , Masculino , Valor Preditivo dos Testes , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
7.
BMJ Glob Health ; 5(12)2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33303514

RESUMO

Today's global health challenges in underserved communities include the growing burden of cancer and other non-communicable diseases (NCDs); infectious diseases (IDs) with epidemic and pandemic potential such as COVID-19; and health effects from catastrophic 'all hazards' disasters including natural, industrial or terrorist incidents. Healthcare disparities in low-income and middle-income countries and in some rural areas in developed countries make it a challenge to mitigate these health, socioeconomic and political consequences on our globalised society. As with IDs, cancer requires rapid intervention and its effective medical management and prevention encompasses the other major NCDs. Furthermore, the technology and clinical capability for cancer care enables management of NCDs and IDs. Global health initiatives that call for action to address IDs and cancer often focus on each problem separately, or consider cancer care only a downstream investment to primary care, missing opportunities to leverage investments that could support broader capacity-building. From our experience in health disparities, disaster preparedness, government policy and healthcare systems we have initiated an approach we call flex-competence which emphasises a systems approach from the outset of program building that integrates investment among IDs, cancer, NCDs and disaster preparedness to improve overall healthcare for the local community. This approach builds on trusted partnerships, multi-level strategies and a healthcare infrastructure providing surge capacities to more rapidly respond to and manage a wide range of changing public health threats.


Assuntos
Doenças Transmissíveis/epidemiologia , Doenças Transmissíveis/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Saúde Global , Disparidades em Assistência à Saúde , Neoplasias/epidemiologia , Neoplasias/terapia , /epidemiologia , Humanos , Pandemias
8.
J Gastrointestin Liver Dis ; 29(4): 549-553, 2020 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-33331349

RESUMO

BACKGROUND AND AIMS: Inflammatory bowel diseases (IBD) patients management has been challenging during the ongoing coronavirus disease 2019 (COVID-19) pandemic, due to lockdowns, limitation of access to medical facilities and new recommendations regarding patient management. The implications of the COVID-19 pandemic on IBD patients' management were assessed in our Tertiary Gastroenterology Center in Bucharest, Romania. METHODS: Medical records of IBD patients admitted between 15th of March and 15th of August 2020 were retrospectively reviewed and compared to a control cohort of consecutive IBD patients admitted to our unit during the corresponding period of 2019. RESULTS: There was a highly significant shift towards one-day hospitalization during the referral period in 2020 for IBD cases (91% in 2020 vs 82.2% in 2019, p=0.0001). There was no statistically significant difference between the distribution of patient's gender, IBD phenotype or newly diagnosed IBD cases. A significantly lower proportion of admitted patients received 5-aminosalicylic acid (29% vs 41.2%, p=0.0001), whereas a substantially higher number of patients were prescribed biological therapy in 2020 in comparison to the corresponding 2019-time frame (79.5% vs 57.9%, p<0.0001). The distribution of the biological agent used was significantly different in 2019 in comparison to the 2020 period mainly due to the increase in vedolizumab prescription in 2020 (p<0.0001). During the study period in 2020, seven IBD patients (1.7%) were diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection, all of them with mild symptoms without impact on the IBD course. CONCLUSIONS: The COVID-19 pandemic led to reorganizing medical care, limiting the hospital admissions in favor of severe IBD cases, favoring telemedicine for mild disease and optimization of treatment for moderate to severe IBD with an increased use of biologicals aimed to maximize the risk/benefit ratio. Incidence of SARS-Cov2 infection during the first wave of COVID-19 infection in our study group was 1.7% and did not adversely impact the IBD disease course.


Assuntos
Anti-Inflamatórios/uso terapêutico , Produtos Biológicos/uso terapêutico , Prestação Integrada de Cuidados de Saúde/tendências , Hospitalização/tendências , Doenças Inflamatórias Intestinais/tratamento farmacológico , Telemedicina/tendências , Anti-Inflamatórios/efeitos adversos , Produtos Biológicos/efeitos adversos , Humanos , Incidência , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/epidemiologia , Segurança do Paciente , Estudos Retrospectivos , Romênia/epidemiologia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento
10.
Pan Afr Med J ; 35(Suppl 2): 122, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33282077

RESUMO

COVID-19 is a new disease of pandemic proportions. Since the announcement of the first confirmed case of COVID-19 in Cameroon early this year, there has been an increasing number of circulating videos and messages from families about the poor management of their loved ones in clinical care settings. This correspondence highlights the challenges posed by COVID-19 and its impact on clinical care of patients in Cameroon.


Assuntos
/terapia , Prestação Integrada de Cuidados de Saúde/normas , Camarões , Humanos , Área Carente de Assistência Médica , Qualidade da Assistência à Saúde
11.
Mayo Clin Proc ; 95(11): 2395-2407, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33153630

RESUMO

OBJECTIVE: To quantify the impact of the severe acute respiratory syndrome coronavirus 2 pandemic on emergency department volumes and patient presentations and evaluate changes in community mortality for the purpose of characterizing new patterns of emergency care use. PATIENTS AND METHODS: This is an observational cross-sectional study using electronic health records for emergency department visits in an integrated multihospital system with academic and community practices across 4 states for visits between March 17 and April 21, 2019, and February 9 and April 21, 2020. We compared numbers and proportions of common and critical chief symptoms and diagnoses, triage assessments, throughput, disposition, and selected hospital lengths of stay and out-of-hospital deaths. RESULTS: In the period of interest, emergency department visits decreased by nearly 50% (35037 to 18646). Total numbers of patients with myocardial infarctions, stroke, appendicitis, and cholecystitis diagnosed decreased. The percentage of visits for mental health symptoms increased. There was an increase in deaths, driven by out-of-hospital mortality. CONCLUSION: Fewer patients presenting with acute and time-sensitive diagnoses suggests that patients are deferring care. This may be further supported by an increase in out-of-hospital mortality. Understanding which patients are deferring care and why will allow us to develop outreach strategies and ensure that those in need of rapid assessment and treatment will do so, preventing downstream morbidity and mortality.


Assuntos
Infecções por Coronavirus , Prestação Integrada de Cuidados de Saúde/tendências , Serviço Hospitalar de Emergência/tendências , Utilização de Instalações e Serviços/tendências , Pandemias , Pneumonia Viral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Estados Unidos , Adulto Jovem
12.
J Med Internet Res ; 22(11): e20549, 2020 11 30.
Artigo em Inglês | MEDLINE | ID: mdl-33170799

RESUMO

BACKGROUND: Pressure on the US health care system has been increasing due to a combination of aging populations, rising health care expenditures, and most recently, the COVID-19 pandemic. Responses to this pressure are hindered in part by reliance on a limited supply of highly trained health care professionals, creating a need for scalable technological solutions. Digital symptom checkers are artificial intelligence-supported software tools that use a conversational "chatbot" format to support rapid diagnosis and consistent triage. The COVID-19 pandemic has brought new attention to these tools due to the need to avoid face-to-face contact and preserve urgent care capacity. However, evidence-based deployment of these chatbots requires an understanding of user demographics and associated triage recommendations generated by a large general population. OBJECTIVE: In this study, we evaluate the user demographics and levels of triage acuity provided by a symptom checker chatbot deployed in partnership with a large integrated health system in the United States. METHODS: This population-based descriptive study included all web-based symptom assessments completed on the website and patient portal of the Sutter Health system (24 hospitals in Northern California) from April 24, 2019, to February 1, 2020. User demographics were compared to relevant US Census population data. RESULTS: A total of 26,646 symptom assessments were completed during the study period. Most assessments (17,816/26,646, 66.9%) were completed by female users. The mean user age was 34.3 years (SD 14.4 years), compared to a median age of 37.3 years of the general population. The most common initial symptom was abdominal pain (2060/26,646, 7.7%). A substantial number of assessments (12,357/26,646, 46.4%) were completed outside of typical physician office hours. Most users were advised to seek medical care on the same day (7299/26,646, 27.4%) or within 2-3 days (6301/26,646, 23.6%). Over a quarter of the assessments indicated a high degree of urgency (7723/26,646, 29.0%). CONCLUSIONS: Users of the symptom checker chatbot were broadly representative of our patient population, although they skewed toward younger and female users. The triage recommendations were comparable to those of nurse-staffed telephone triage lines. Although the emergence of COVID-19 has increased the interest in remote medical assessment tools, it is important to take an evidence-based approach to their deployment.


Assuntos
/diagnóstico , Prestação Integrada de Cuidados de Saúde/métodos , Triagem/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Avaliação de Sintomas/métodos , Avaliação de Sintomas/normas , Triagem/normas , Adulto Jovem
13.
Healthc Q ; 23(3): 15-23, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33243361

RESUMO

The East Toronto Health Partners (ETHP) include more than 50 organizations working collaboratively to create an integrated system of care in the east end of Toronto. This existing partnership proved invaluable as a platform for a rapid, coordinated local response to the COVID-19 pandemic. Months after the first wave of the pandemic began, with the daily numbers of COVID-19 cases finally starting to decline, leaders from ETHP provided preliminary reflections on two critical questions: (1) How were existing integration efforts leveraged to mobilize a response during the COVID-19 crisis? and (2) How can the response to the initial wave of COVID-19 be leveraged to further accelerate integration and better address subsequent waves and system improvements once the pandemic abates?


Assuntos
/terapia , Participação da Comunidade , Prestação Integrada de Cuidados de Saúde/organização & administração , Assistência à Saúde/organização & administração , Política de Saúde , /epidemiologia , Participação da Comunidade/métodos , Tomada de Decisões Gerenciais , Assistência à Saúde/métodos , Prestação Integrada de Cuidados de Saúde/métodos , Saúde Global , Humanos , Ontário , Inovação Organizacional , Atenção Primária à Saúde/organização & administração , Administração em Saúde Pública/métodos , Alocação de Recursos/métodos , Alocação de Recursos/organização & administração
14.
PLoS One ; 15(11): e0242440, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33211744

RESUMO

BACKGROUND: The misdiagnosis of non-malarial fever in sub-Saharan Africa has contributed to the significant burden of pediatric pneumonia and the inappropriate use of antibiotics in this region. This study aims to assess the impact of 1) portable pulse oximeters and 2) Integrated Management of Childhood Illness (IMCI) continued education training on the diagnosis and treatment of non-malarial fever amongst pediatric patients being treated by the Global AIDS Interfaith Alliance (GAIA) in rural Malawi. METHODS: This study involved a logbook review to compare treatment patterns between five GAIA mobile clinics in Mulanje, Malawi during April-June 2019. An intervention study design was employed with four study groups: 1) 2016 control, 2) 2019 control, 3) IMCI-only, and 4) IMCI and pulse oximeter. A total of 3,504 patient logbook records were included based on these inclusion criteria: age under five years, febrile, malaria-negative, and treated during the dry season. A qualitative questionnaire was distributed to the participating GAIA providers. Fisher's Exact Testing and odds ratios were calculated to compare the prescriptive practices between each study group and reported with 95% confidence intervals. RESULTS: The pre- and post-exam scores for the providers who participated in the IMCI training showed an increase in content knowledge and understanding (p<0.001). The antibiotic prescription rates in each study group were 75% (2016 control), 85% (2019 control), 84% (IMCI only), and 42% (IMCI + pulse oximeter) (p<0.001). An increase in pneumonia diagnoses was detected for patients who received pulse oximeter evaluation with an oxygen saturation <95% (p<0.001). No significant changes in antibiotic prescribing practices were detected in the IMCI-only group (p>0.001). However, provider responses to the qualitative questionnaires indicated alternative benefits of the training including improved illness classification and increased provider confidence. CONCLUSION: Clinics that implemented both the IMCI course and pulse oximeters exhibited a significant decrease in antibiotic prescription rates, thus highlighting the potential of this tool in combatting antibiotic overconsumption in low-resource settings. Enhanced detection of hypoxia in pediatric patients was regarded by clinicians as helpful for identifying pneumonia cases. GAIA staff appreciated the IMCI continued education training, however it did not appear to significantly impact antibiotic prescription rates and/or pneumonia diagnosis.


Assuntos
Antibacterianos/uso terapêutico , Prestação Integrada de Cuidados de Saúde , Educação Médica Continuada , Educação Continuada em Enfermagem , Oximetria , Pneumonia/diagnóstico , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Pré-Escolar , Diagnóstico Tardio , Prestação Integrada de Cuidados de Saúde/organização & administração , Erros de Diagnóstico , Uso de Medicamentos , Feminino , Febre/etiologia , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Lactente , Recém-Nascido , Malaui , Masculino , Unidades Móveis de Saúde/estatística & dados numéricos , Enfermeiras Pediátricas/educação , Oxigênio/sangue , Pediatras/educação , Pneumonia/sangue , Pneumonia/tratamento farmacológico , População Rural , Inquéritos e Questionários , Instituições Filantrópicas de Saúde
15.
Lancet Oncol ; 21(12): e555-e563, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33212045

RESUMO

Oncology nurses are at the heart of tackling the increasing global burden of cancer. Their contribution is unique because of the scale and the diversity of care roles and responsibilities in cancer care. In this Series paper, to celebrate the International Year of the Nurse and Midwife, we highlight the contribution and impact of oncology nurses along the cancer care continuum. Delivering people-centred integrated care and optimal communication are essential components of oncology nursing care, which are often played down. More oncology nurses using, doing, and leading research will further show the key nursing impact on care as part of a team. The oncology nurse influence in saving lives through prevention and early detection of cancer is noteworthy. Supportive care, the central pillar of oncology nursing, enables and empowers people to self-manage where possible. Globally, oncology nurses make a great positive difference to cancer care worldwide; their crucial contribution throughout the continuum of care warrants the inclusion and promotion of nursing in every country's cancer strategy. 2020 is the year of the nurse: let us take this learning to the future.


Assuntos
Continuidade da Assistência ao Paciente , Prestação Integrada de Cuidados de Saúde , Neoplasias/enfermagem , Papel do Profissional de Enfermagem , Enfermagem Oncológica , Equipe de Assistência ao Paciente , Assistência Centrada no Paciente , Humanos , Relações Enfermeiro-Paciente , Padrões de Prática em Enfermagem
16.
Methodist Debakey Cardiovasc J ; 16(3): 212-219, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33133357

RESUMO

The learning health system is a conceptual model for continuous learning and knowledge generation rooted in the daily practice of medicine. While companies such as Google and Amazon use dynamic learning systems that learn iteratively through every customer interaction, this efficiency has not materialized on a comparable scale in health systems. An ideal learning health system would learn from every patient interaction to benefit the care for the next patient. Notable advances include the greater use of data generated in the course of clinical care, Common Data Models, and advanced analytics. However, many remaining barriers limit the most effective use of large and growing health care data assets. In this review, we explore the accomplishments, opportunities, and barriers to realizing the learning health system.


Assuntos
Big Data , Cardiologistas/educação , Cardiologia/educação , Prestação Integrada de Cuidados de Saúde , Educação Médica Continuada , Educação de Pós-Graduação em Medicina , Sistema de Aprendizagem em Saúde , Acesso à Informação , Confidencialidade , Humanos , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde
17.
BMC Health Serv Res ; 20(1): 995, 2020 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-33129332

RESUMO

BACKGROUND: Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promote integrated care. The critical realist study reported here is part of the longitudinal development and evaluation of complex integrated health and social care interventions in Sydney, Australia. METHODS: We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Qualitative interviews were undertaken with HHAN clients (n = 12), staff and other stakeholders (n = 21). Interviews and coding used a context (C), mechanism (M) and outcome (O) framework. Inductive, deductive, retroductive and abductive modes of reasoning were used with the CMO heuristic tool to inform the developing programme theory. RESULTS: The mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. CONCLUSIONS: Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.


Assuntos
Prestação Integrada de Cuidados de Saúde , Austrália , Família , Feminino , Promoção da Saúde , Humanos
18.
PLoS One ; 15(11): e0241194, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33147265

RESUMO

BACKGROUND: This article explores mental health services in Norway and their availability for women subjected to female genital mutilation/cutting (FGM/C). The article focus on the system of communication and referrals from the perspective of health workers, and aims to identify bottlenecks in the system, what and where they are to be found, and analyze how different mental health services deal with Sub Saharan African (SSA) women in general, but in particular with respect to FGM/C. METHOD: The study was conducted in Oslo, Norway, using a qualitative fieldwork research design, with the use of purposeful sampling, and a semi-structural guideline. One hundred interviews were done with general practitioners (GPs), gynecologists, psychologists, psychiatrists, midwives and nurses. ANALYSIS: A system analysis is applied using socio-cybernetics as a tool to identify the flow of communication and referrals of patients. FINDINGS: The study shows that borders of subsystems, silencing mechanisms, regulations and "attitudes" of the system can lead to women with SSA background having difficulty getting access to the specialist services. High standards for referral letters, waiting lists, out pushing to the lower levels, insecurities around treatment and deference rules silencing mental health issues during consultancies, have a negative impact on the accessibility of services. Consequences are that mental health problems due to FGM/C are under-investigated, under-referred, and under-treated and a silenced problem within the mental health services for women. CONCLUSION: A better integration of subsystems at the specialist level with the GP scheme is necessary, as well as providing competence on FGM/C to the different levels. It is also important to strengthen and integrating the services at the Municipal level and provide information to SSA women about the low threshold services.


Assuntos
Circuncisão Feminina/reabilitação , Prestação Integrada de Cuidados de Saúde/organização & administração , Emigrantes e Imigrantes/psicologia , Acesso aos Serviços de Saúde/organização & administração , Serviços de Saúde Mental/organização & administração , Circuncisão Feminina/psicologia , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Humanos , Noruega , Pesquisa Qualitativa , Encaminhamento e Consulta/organização & administração , Análise de Sistemas
19.
Open Heart ; 7(2)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33106441

RESUMO

OBJECTIVES: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. METHODS: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. CONCLUSION: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.


Assuntos
Infecções por Coronavirus , Procedimentos Clínicos/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Pandemias , Intervenção Coronária Percutânea , Pneumonia Viral , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Ambulâncias/organização & administração , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Infecções por Coronavirus/transmissão , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Londres/epidemiologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Segurança do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Pneumonia Viral/transmissão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Trombose/mortalidade , Trombose/terapia , Fatores de Tempo , Tempo para o Tratamento/organização & administração , Resultado do Tratamento
20.
PLoS Med ; 17(10): e1003367, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33007052

RESUMO

BACKGROUND: Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings. METHODS AND FINDINGS: The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias. CONCLUSIONS: ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Adulto , Estudos de Coortes , Feminino , Hong Kong/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Autocuidado/métodos , Resultado do Tratamento
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