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1.
Artigo em Inglês | MEDLINE | ID: mdl-33317088

RESUMO

The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.


Assuntos
Prestação Integrada de Cuidados de Saúde , Hospitais , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Neoplasias/diagnóstico , Neoplasias/terapia , Noruega , Pesquisa Qualitativa
2.
PLoS One ; 15(10): e0230849, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33031399

RESUMO

INTRODUCTION: In South Africa, in 2013-2014, provision of antiretroviral treatment (ART) shifted in some areas from NGOs to public facilities. Tuberculosis (TB) management has also been integrated into public services. We aimed to explore the opinions and experiences of service managers and healthcare providers regarding integration of HIV and TB services into primary healthcare services. METHODS: The study sites included three clinics in one peri-urban/urban administrative region of Johannesburg. From March 2015 to August 2016, trained interviewers conducted semi-structured interviews with purposively selected participants. Participants were eligible if they were city/regional managers, clinic managers, or healthcare providers responsible for HIV, TB, non-communicable diseases, or sexual and reproductive health at the three study sites. We used a grounded theory approach for iterative, qualitative analysis, and produced descriptive statistics for quantitative data. RESULTS: We interviewed 19 individuals (nine city/regional managers, three clinic managers, and seven nurses). Theoretical definitions of integration varied, as did actual practice. Integration of HIV treatment had been anticipated, but only occurred when required due to shifts in funding for ART. The change was rapid, and some clinics felt unprepared. That said, nearly all respondents were in favor of integrated care. Perceived benefits included comprehensive case management, better client-nurse interactions, and reduced stigma. Barriers to integration included staff shortages, insufficient training and experience, and outdated clinic infrastructure. There were also concerns about the impact of integration on staff workloads and waiting times. Finally, there were concerns about TB integration due to infection control issues. DISCUSSION: Integration is multi-faceted and often contingent on local, if not site-specific, factors. In the future in South Africa and in other settings contending with health service reorganization, staff consultations prior to and throughout phase-in of services changes could contribute to improved understanding of operational requirements, including staff needs, and improved patient outcomes.


Assuntos
Antivirais/uso terapêutico , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Infecções por HIV/tratamento farmacológico , Tuberculose/tratamento farmacológico , Atitude do Pessoal de Saúde , Feminino , Humanos , Entrevistas como Assunto , Masculino , Médicos de Atenção Primária , Atenção Primária à Saúde , Pesquisa Qualitativa , Saúde Reprodutiva , África do Sul
3.
Can J Surg ; 63(5): E442-E448, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33026310

RESUMO

BACKGROUND: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. METHODS: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. RESULTS: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. CONCLUSION: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.


Assuntos
Cuidados Críticos/organização & administração , Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Assistentes Médicos/organização & administração , Papel Profissional , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Canadá , Cuidados Críticos/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Salas Cirúrgicas/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Assistentes Médicos/estatística & dados numéricos , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos
4.
PLoS One ; 15(8): e0237772, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32853246

RESUMO

BACKGROUND: Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes. METHODS: We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys. RESULTS: In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively). CONCLUSION: Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Infecções por HIV/terapia , Acesso aos Serviços de Saúde/organização & administração , Centros de Tratamento de Abuso de Substâncias/organização & administração , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Adolescente , Adulto , Fatores Etários , Criança , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Saúde Global , Infecções por HIV/complicações , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Programas de Rastreamento/organização & administração , Programas de Rastreamento/estatística & dados numéricos , Educação de Pacientes como Assunto , Lacunas da Prática Profissional/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/estatística & dados numéricos , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Inquéritos e Questionários/estatística & dados numéricos , Adulto Jovem
5.
BMC Public Health ; 20(1): 1122, 2020 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-32677944

RESUMO

BACKGROUND: Integrated Management of Childhood Illnesses (IMCI) is a strategy developed by the World Health Organization (WHO) and UNICEF in 1992. It was deployed as an integrated approach to improve children's health in the world. This strategy is divided into three components: organizational, clinical, and communitarian. If the Integrated Management of Childhood Illnesses implementation-related factors in low- and middle-income countries are known, the likelihood of decreasing infant morbidity and mortality rates could be increased. This work aimed to identify, from the clinical component of the strategy, the implementation-related factors to Integrated Management of Childhood Illnesses at 18 Colombian cities. METHODS: A quantitative cross-sectional study was performed with a secondary analysis of databases of a study conducted in Colombia by the Public Health group of Universidad de Los Andes in 2016. An Integrated Care Index was calculated as a dependent variable and descriptive bivariate and multivariate analyses to find the relationship between this index and the relevant variables from literature. RESULTS: Information was obtained from 165 medical appointments made by nurses, general practitioners, and pediatricians. Health access is given mainly in the urban area, in the first level care and outpatient context. Essential medicines availability, necessary supplies, second-level care, medical appointment periods longer than 30 min, and care to the child under 30 months are often related to higher rates of Integrated Care Index. CONCLUSION: Health care provided to children under five remains incomplete because it does not present the basic minimums for the adequate IMCI's implementation in the country. It is necessary to provide integrated care that provides medicine availability and essential supplies that reduce access barriers and improve the system's fragmentation.


Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Saúde da Criança/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Implementação de Plano de Saúde/estatística & dados numéricos , Saúde Pública/estatística & dados numéricos , Criança , Serviços de Saúde da Criança/organização & administração , Pré-Escolar , Cidades , Colômbia , Estudos Transversais , Prestação Integrada de Cuidados de Saúde/organização & administração , Feminino , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Humanos , Lactente , Masculino , Nações Unidas , Organização Mundial da Saúde
6.
Medicine (Baltimore) ; 99(24): e20385, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541458

RESUMO

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.


Assuntos
Benchmarking/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Idoso , Algoritmos , Benchmarking/normas , Estudos de Coortes , Grupos Diagnósticos Relacionados/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hispano-Americanos/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/organização & administração
7.
Orthop Surg ; 12(2): 457-462, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32167674

RESUMO

OBJECTIVE: To investigate the clinical efficacy of three different healthcare models (Traditional Model, Geriatric Consultant Model, and Orthogeriatric Unit Model) consecutively applied to a single academic center (University Hospital of Salamanca, Spain) for older hip fracture patients. METHODS: We performed a retrospective study, including 2741 hip fracture patients older than 64 years, admitted between 1 January 2003 and 31 December 2014 to the University Hospital of Salamanca. Patients were divided into three groups according to the healthcare model applied. There were 983 patients on the Traditional Model, 945 patients on the Geriatric Consultant Model, and 813 patients on the Orthogeriatric Unit Model. We recorded age and gender of patients, functional status at admission (Barthel Index, Katz Index, and Physical Red Cross Scale), type of fracture, and intervention, and we analyzed the length of stay, time to surgery, post-surgical stay, and in-hospital mortality according to the healthcare model applied. RESULTS: Hip fractures are much more frequent in women, and an increase in the average age of patients was observed along with the study (P < 0.001). The most common type of fracture in the three models studied was an extracapsular fracture, for which the most common surgical procedure used was osteosynthesis. On the functional status of patients, there were no differences on the ambulatory ability previous to fracture, measured by the Physical Red Cross Scale, and the percentage of patients with a slight dependence determined by the Barthel Index (>60) was similar in both groups, but considering the Katz Index, the percentage of patients with a high degree of independence (A-B) was significantly higher for the group of patients treated on the Orthogeriatric Unit Model period (56%, P = 0.009). The Orthogeriatric Unit Model registered the greatest percentage of patients undergoing surgery (96.1%, P < 0.001) and the greatest number of early surgical procedures (<24 h) (24.8%, P < 0.001). The orthogeriatric unit model showed the shortest duration of stay (9 days median), decreasing by one day in respect of each of the other models studied (P < 0.001). Time to surgery was also significantly reduced with the Orthogeriatric Unit Model (median of 3 days, P < 0.001). With regard to in-hospital follow-up, there was a reduction in in-hospital mortality during the study period. We observed differences among the three healthcare models, but without statistical significance. CONCLUSIONS: The healthcare model based on an Orthogeriatric Unit seems to be the most efficient, because it reaches a reduction in time to surgery, with an increased number of patients surgically treated on in the first 24 h, and the greatest frequency of surgically-treated patients.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde para Idosos/estatística & dados numéricos , Fraturas do Quadril/cirurgia , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
8.
Geriatr Gerontol Int ; 20(4): 366-372, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32072727

RESUMO

AIM: The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS: A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS: Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS: The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Instituições para Cuidados Intermediários/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Hospitalização , Humanos , Pacientes Internados , Tempo de Internação , Estudos Prospectivos , Espanha , Resultado do Tratamento
9.
Pediatrics ; 145(1)2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31888959

RESUMO

CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996-2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0-18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03-0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57-1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.


Assuntos
Serviços de Saúde do Adolescente , Serviços de Saúde da Criança , Prestação Integrada de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Qualidade da Assistência à Saúde , Absenteísmo , Adolescente , Serviços de Saúde do Adolescente/economia , Serviços de Saúde do Adolescente/normas , Serviços de Saúde do Adolescente/estatística & dados numéricos , Asma/terapia , Criança , Saúde da Criança , Serviços de Saúde da Criança/economia , Serviços de Saúde da Criança/normas , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Intervalos de Confiança , Redução de Custos , Análise Custo-Benefício , Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/normas , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/normas , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
Ann Emerg Med ; 75(3): 382-391, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31515180

RESUMO

STUDY OBJECTIVE: The effect of urgent cares on local emergency department (ED) patient volumes is presently unknown. In this paper, we aimed to assess the change in low-acuity ED utilization at 2 academic medical centers in relation to patient proximity to an affiliated urgent care. METHODS: We created a geospatial database of ED visits occurring between April 2016 and March 2018 to 2 academic medical centers in an integrated health care system, geocoded by patient home address. We used logistic regression to characterize the relationship between the likelihood of patients visiting the ED for a low-acuity condition, based on ED discharge diagnosis, and urgent care center proximity, defined as living within 1 mile of an open urgent care center, for each of the academic medical centers in the system, adjusting for spatial, temporal, and patient factors. RESULTS: We identified a statistically significant reduction in the likelihood of ED visits for low-acuity conditions by patients living within 1 mile of an urgent care center at 1 of the 2 academic medical centers, with an adjusted odds ratio of 0.87 (95% confidence interval 0.78 to 0.98). There was, however, no statistically significant reduction at the other affiliated academic medical center. Further analysis showed a statistically significant temporal relationship between time since urgent care center opening and likelihood of a low-acuity ED visit, with approximately a 1% decrease in the odds of a low-acuity visit for every month that the proximal urgent care center was open (odds ratio 0.99; 95% confidence interval 0.985 to 0.997). CONCLUSION: Although further research is needed to assess the factors driving urgent care centers' variable influence on low-acuity ED use, these findings suggest that in similar settings urgent care center development may be an effective strategy for health systems hoping to decrease ED utilization for low-acuity conditions at academic medical centers.


Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Centros Médicos Acadêmicos/organização & administração , Adulto , Idoso , Boston , Prestação Integrada de Cuidados de Saúde/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Feminino , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Espacial
11.
Clin Microbiol Infect ; 26(3): 327-332, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31600582

RESUMO

OBJECTIVES: Antimicrobial stewardship programmes have focused on reducing inappropriate inpatient antimicrobial prescribing, but several small studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. In this study, we describe the prescribing of oral antimicrobials at hospital discharge across an integrated national healthcare system. At the hospital level, we also compare total inpatient antimicrobial use and post-discharge oral antimicrobial use. METHODS: This retrospective cross-sectional study used national administrative data to identify all acute-care admissions during 2014-2016 within the Veterans Health Administration (VHA). We evaluated inpatient days of therapy (DOT) and post-discharge DOT, defined as oral outpatient antimicrobials dispensed at the time of hospital discharge. At the hospital level, inpatient DOT/100 admissions were compared with post-discharge DOT/100 admissions using Spearman's rank-order correlation. RESULTS: There were 1 681 701 acute-care admissions across 122 hospitals, and 335 369 (19.9%) were prescribed an oral antimicrobial at discharge. Fluoroquinolones (38.3%) were the most common post-discharge antimicrobial. At the hospital level, median inpatient antimicrobial use was 331.3 (interquartile range (IQR) 284.9-367.9) DOT/100 admissions and median post-discharge use was 209.5 (IQR 181.5-239.6) DOT/100 admissions. Thirty-nine per cent of the total duration of antimicrobial exposure occurred after discharge. At the hospital-level, the metrics of inpatient DOT/100 admissions and post-discharge DOT/100 admissions were weakly positively correlated with rho=0.44 (p < 0.001). CONCLUSIONS: A large proportion of antimicrobial exposure among hospitalized patients occurred immediately following discharge. Antimicrobial-prescribing at hospital discharge provides an opportunity for antimicrobial stewardship. Hospital-level stewardship metrics need to include both inpatient and post-discharge antimicrobial-prescribing to provide a comprehensive assessment of hospital-associated antimicrobial use.


Assuntos
Antibacterianos , Gestão de Antimicrobianos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/normas , Prescrição Inadequada/estatística & dados numéricos , Sobremedicalização/estatística & dados numéricos , Idoso , Antibacterianos/administração & dosagem , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Vigilância em Saúde Pública
12.
JAMA Netw Open ; 2(12): e1916769, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31800072

RESUMO

Importance: Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care. Objective: To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data. Design, Setting, and Participants: This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources. Exposures: Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives. Main Outcomes and Measures: Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility). Results: In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%]; P < .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays. Conclusions and Relevance: This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , California , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde/normas , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/normas , Adulto Jovem
14.
J Manipulative Physiol Ther ; 42(7): 492-502, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31864434

RESUMO

OBJECTIVES: The purpose of this study was to identify experiences and perception of conventional (Western, allopathic) medical practitioners toward integrative, complementary, and alternative medicine (ICAM). METHODS: There are approximately 1200 conventional medical doctors in Mangalore, India. In February 2017, semistructured self-administered questionnaires were distributed to 200 medical practitioners. The association between categorical variables was analyzed using a χ2 test and those involving continuous variables using unpaired t test, analysis of variance, and Karl Pearson's coefficient of correlation. A P value ≤ .05 was considered statistically significant. RESULTS: Of the surveys, 163 were returned and 129 were satisfactorily completed, giving a response rate of 64.5%. Mean age was 39.9 ± 11.9 years, and most 94 (72.9%) were male. A majority, 96 (74.4%), recommended ICAM to their patients. Nine had some training in ICAM modalities, and 76 (58.9%) participants reported personal usage of ICAM. Regarding perception toward effectiveness of ICAM, 33 (25.6%) felt that it was effective or somewhat effective. However, 82 (63.6%) participants felt that lack of sufficient scientific evidence was a major drawback of ICAM. However, 39 (30.2%) participants felt that ICAM should be part of Bachelor of Medicine and Bachelor of Surgery curricula. Favorable perception toward ICAM (P < .001) and personal usage of ICAM (P < .001) was associated with participants recommending any ICAM for their patients. Elderly practitioners (aged above 65 years) (P = .003) and practitioners with favorable perception regarding effectiveness of ICAM (P = .033) recommended a higher number of types of ICAM to their patients. Favorable perception toward effectiveness of ICAM was associated with favorable perception toward inclusion of ICAM in medical curriculum among participants (P = .002). CONCLUSION: Most participants recommended ICAM to their patients and also reported personal usage of the same.


Assuntos
Atitude do Pessoal de Saúde , Terapias Complementares/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Adulto , Feminino , Humanos , Índia , Medicina Integrativa/normas , Masculino , Pessoa de Meia-Idade , Médicos/estatística & dados numéricos
15.
BMJ Open ; 9(12): e027920, 2019 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-31857296

RESUMO

OBJECTIVE: To assess the reliability and validity of a shortened version of the Rainbow Model of Integrated Care (RMIC) measurement tool (MT). The original version of the measurement tool has been modified (shortened) for the Australian context. DESIGN: Validation of the psychometric properties of the RMIC-MT. SETTING: Healthcare providers providing services to a geographically defined rural area in New South Wales (NSW), Australia. PARTICIPANTS: A sample of 56 healthcare providers providing mental and physical healthcare. MAIN OUTCOME MEASURES: The psychometric properties of the tool were tested using principal component analysis for validity and Cronbach's alpha for reliability. RESULTS: The tool was shown to have good validity and reliability. The 35 items used in the shortened version of the tool were reduced to 29 items grouped into four dimensions: community-governance orientation, normative integration, functional integration and clinical-professional coordination. CONCLUSIONS: The shortened version of the RMIC-MT is a valid and reliable tool that evaluates integrated care from a healthcare provider's perspective in NSW, Australia. In order to assess the tool's appropriateness in an international context, future studies should focus on validating the tool in other healthcare settings.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Pessoal de Saúde/estatística & dados numéricos , Humanos , New South Wales , Psicometria , Reprodutibilidade dos Testes , Inquéritos e Questionários/estatística & dados numéricos
16.
PLoS One ; 14(12): e0225634, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31790448

RESUMO

BACKGROUND: In 2017, the Adamawa State Primary Healthcare Development Agency introduced ALMANACH, an electronic clinical decision support system based on a modified version of IMCI. The target area was the Federal State of Adamawa (Nigeria), a region recovering after the Boko Haram insurgency. The aim of this implementation research was to assess the improvement in terms of quality care offered after one year of utilization of the tool. METHODS: We carried out two cross-sectional studies in six Primary Health Care Centres to assess the improvements in comparison with the baseline carried out before the implementation. One survey was carried out inside the consultation room and was based on the direct observation of 235 consultations of children aged from 2 to 59 months old. The second survey questioned 189 caregivers outside the health facility for their opinion about the consultation carried out through using the tablet, the prescriptions and medications given. RESULTS: In comparison with the baseline, more children were checked for danger signs (60.0% vs. 37.1% at baseline) and in addition, children were actually weighed (61.1% vs. 27.7%) during consultation. Malnutrition screening was performed in 35.1% of children (vs. 12.1%). Through ALMANACH, also performance of preventive measures was significantly improved (p<0.01): vaccination status was checked in 39.8% of cases (vs. 10.6% at baseline), and deworming and vitamin A prescription was increased to 46.5% (vs. 0.7%) and 48.3% (vs. 2.8%) respectively. Furthermore, children received a complete physical examination (58.3% vs. 45.5%, p<0.01) and correct treatment (48.4% vs. 29.5%, p<0.01). Regarding antibiotic prescription, 69.3% patients received at least one antibiotic (baseline 77.7%, p<0.05). CONCLUSIONS: Our findings highlight major improvements in terms of quality of care despite many questions still pending to be answered in relation to a full integration of the tool in the Adamawa health system.


Assuntos
Conflitos Armados , Serviços de Saúde da Criança/organização & administração , Sistemas de Apoio a Decisões Clínicas/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Cuidadores/estatística & dados numéricos , Saúde da Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Feminino , Implementação de Plano de Saúde , Humanos , Lactente , Masculino , Atenção Primária à Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Qualidade da Assistência à Saúde , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/estatística & dados numéricos , Inquéritos e Questionários
17.
Pediatr Emerg Care ; 35(11): 791-798, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31688798

RESUMO

OBJECTIVE: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.


Assuntos
Instituições de Assistência Ambulatorial/normas , Bronquiolite/diagnóstico , Prestação Integrada de Cuidados de Saúde/economia , Serviço Hospitalar de Emergência/normas , Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Bronquiolite/economia , Prestação Integrada de Cuidados de Saúde/normas , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Melhoria de Qualidade , Procedimentos Desnecessários/economia
18.
Asian Pac J Cancer Prev ; 20(11): 3457-3463, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31759372

RESUMO

BACKGROUND: cancer is one of the most common causes of death around the world. The process of this disease and the resulting complications reduce the quality of life of cancer patients. Taking the necessary measures for improving the quality of life of these patients seems to be essential. This study was performed to investigate the effect of integrated educational program on the quality of life of cancer patients. METHOD: in this clinical trial study, 64 patients hospitalized in the specialized cancer hospital affiliated with Ahvaz Jundishapur University of Medical Sciences, Iran, were selected according to the inclusion criteria. Then, through blocked randomization method, they were assigned into intervention and control groups. The intervention group received the necessary trainings over four 60-min sessions (one session per week).  The data collection in this study included demographic questionnaire and quality-of-life questionnaire of cancer patients (QLQ-C30). The quality of life was examined before the training as well as one and two months after the training. The data were analyzed by SPSS 20. Independent t-test was used to compare the means of the life quality dimensions of the studied groups. RESULTS: all of the functional dimensions [physical , role function , emotional , cognitive , social(P≤0.05)] and symptomatic [fatigue , nausea and vomiting, pain , dyspnea , sleep disorders, diminished appetite, constipation, and diarrhea (P≤0.05)] of the quality of life of the intervention group increased significantly one and two months after running the integrated educational program. CONCLUSION: integrated training causes improved symptoms and enhanced quality of life in cancer patients. Thus, it is recommended that integrated training be conducted alongside the routine care of cancer patients. This can improve the therapeutic outcomes, and also highlights the important role of nurses as well as nursing cares.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Educação/estatística & dados numéricos , Neoplasias/fisiopatologia , Adulto , Idoso , Feminino , Humanos , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Inquéritos e Questionários
19.
Health Serv Res ; 54(6): 1203-1213, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31742687

RESUMO

OBJECTIVE: To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs. DATA SOURCES: 2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan. STUDY DESIGN: We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis. PRINCIPAL FINDINGS: After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost. CONCLUSIONS: Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais Pediátricos/economia , Medicaid/economia , Medicaid/estatística & dados numéricos , Serviços de Saúde Mental/economia , Atenção Primária à Saúde/economia , Adolescente , Boston , Criança , Pré-Escolar , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
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