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2.
Medicine (Baltimore) ; 100(4): e24444, 2021 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-33530250

RESUMO

BACKGROUND: This study aimed to access the efficacy and safety of integrated Traditional Chinese and Western medicine treatment for patients with ulcerative colitis (UC) combined diabetes. METHODS: This protocol adheres to the preferred reporting items for systematic reviews and meta-analysis protocol statement. We plan to search 8 electronic databases to identify qualifying studies published from database inception until December 1, 2020. The software of EndNote reference manager (X9) will be used to study selection. A pre-developed standardized data collection form will be used to extract from all eligible studies. For included studies, the quality will be assessed by Cochrane Risk of bias tool. The RevMan 5.3 software (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) developed by the Cochrane Collaboration will be used for all statistical analysis. If possible, meta-analysis will be undertaken for each of the outcomes. For continuous variable data, we will used mean differences with 95% confidence intervals (CIs) as summary statistics. For dichotomous variable data, we will calculate Mantel-Haenszel odds ratio with 95% CIs as summary statistics from the numbers of events in control and intervention groups. We will consider a result to be statistically significant if P < .05. If outcomes cannot be meta-analyzed, we will performer a descriptive analysis. RESULTS: This study will be performed to test the efficacy and safety of integrated Traditional Chinese and Western medicine treatment for patients with UC combined diabetes. CONCLUSION: The results of our study will be published in a peer-reviewed journals, and we will promotion results in domestic and foreign conferences. REGISTRATION NUMBER: INPLASY2020120087. ETHICS AND DISSEMINATION: As a systematic review and meta-analysis which based on previously published literature, ethical approval, and informed consent from patients are not required.


Assuntos
Colite Ulcerativa/terapia , Prestação Integrada de Cuidados de Saúde/métodos , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/terapia , Medicina Tradicional Chinesa/métodos , Adolescente , Adulto , Idoso , Colite Ulcerativa/complicações , Terapia Combinada , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Masculino , Metanálise como Assunto , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Revisões Sistemáticas como Assunto , Resultado do Tratamento , Adulto Jovem
3.
J Am Board Fam Med ; 34(Suppl): S55-S60, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33622819

RESUMO

BACKGROUND: The COVID-19 (C-19) pandemic required swift response from health care organizations to mitigate spread and impact. A large integrated health network rapidly deployed and operationalized multiple access channels to the community, allowing assessment and triage to occur virtually. These channels were characterized by swift implementation of virtual models, including asynchronous e-visits and video visits for C-19 screening. PURPOSE: (1) Evaluate implementation characteristics of C-19 screening e-visits and video visits. (2) Identify volume of C-19 screening and other care provided via e-visits and video visits. (3) Discuss future implications of expanded virtual access models. METHODS: Retrospective analysis of implementation data for C-19 screening e-visits and video visits, including operational characteristics and visit/screening volumes conducted. RESULTS: Virtual channels were implemented and rapidly expanded during the first week C-19 testing was made available. During the study period, primary care clinicians conducted 10,673 e-visits and 31,226 video visits with 9,126 and 26,009 patients, respectively. Within these 2 virtual modalities, 4,267 C-19 tests were ordered (10% of visits). Four hundred forty-eight clinicians supported 24/7 access to these virtual modalities. DISCUSSION: Given ongoing patient interest and opportunity, virtual health care services will continue to be available for an expanded number of symptoms and diagnoses.


Assuntos
Fortalecimento Institucional/organização & administração , Prestação Integrada de Cuidados de Saúde/métodos , Telemedicina/métodos , /epidemiologia , Humanos , Programas de Rastreamento/métodos , Pandemias , Atenção Primária à Saúde/organização & administração , Estudos Retrospectivos
4.
Ann Hematol ; 100(3): 601-606, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33388859

RESUMO

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.


Assuntos
Prestação Integrada de Cuidados de Saúde , Neoplasias Hematológicas/terapia , Oncologia , Cuidados Paliativos , Equipe de Assistência ao Paciente/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Continuidade da Assistência ao Paciente/normas , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/normas , Humanos , Comunicação Interdisciplinar , Oncologia/métodos , Oncologia/organização & administração , Oncologia/normas , Cuidados Paliativos/métodos , Cuidados Paliativos/organização & administração , Cuidados Paliativos/normas , Equipe de Assistência ao Paciente/normas , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/normas
5.
J Am Heart Assoc ; 10(3): e019669, 2021 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-33307964

RESUMO

Background Previous reports suggest that the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin-converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID-19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID-19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID-19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID-19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90-1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91-1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID-19 infection varied in different age groups (P-interaction=0.03). ACEI use was associated with lower odds of COVID-19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12-0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID-19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11-1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID-19 infection. Decreased odds of COVID-19 infection among adults ≥85 years using ACEIs warrants further investigation.


Assuntos
Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Prestação Integrada de Cuidados de Saúde/métodos , Hipertensão/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
6.
BMC Med Inform Decis Mak ; 20(1): 216, 2020 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912224

RESUMO

BACKGROUND: Telehealth (TH) was introduced as a promising tool to support integrated care for the management of chronic obstructive pulmonary disease (COPD). It aims at improving self-management and providing remote support for continuous disease management. However, it is often not clear how TH-supported services fit into existing pathways for COPD management. The objective of this study is to uncover where TH can successfully contribute to providing care for COPD patients exemplified in a Greek care pathway. The secondary objective is to identify what conditions need to be considered for successful implementation of TH services. METHODS: Building on a single case study, we used a two-phase approach to identify areas in a Greek COPD care pathway where care services that are recommended in clinical guidelines are currently not implemented (challenges) and areas that are not explicitly recommended in the guidelines but that would benefit from TH services (opportunities). In phase I, we used the care delivery value chain framework to identify the divergence between the clinical guidelines and the actual practice captured by a survey with COPD healthcare professionals. In phase II, we conducted in-depth interviews with the same healthcare professionals based on the discovered divergences. The responses were analyzed with respect to identified opportunities for TH and care pathway challenges. RESULTS: Our results reveal insights in two areas. First, several areas with challenges were identified: patient education, self-management, medication adherence, physical activity, and comorbidity management. TH opportunities were perceived as offering better bi-directional communication and a tool for reassuring patients. Second, considering the identified challenges and opportunities together with other case context details a set of conditions was extracted that should be fulfilled to implement TH successfully. CONCLUSIONS: The results of this case study provide detailed insights into a care pathway for COPD in Greece. Addressing the identified challenges and opportunities in this pathway is crucial for adopting and implementing service innovations. Therefore, this study contributes to a better understanding of requirements for the successful implementation of integrated TH services in the field of COPD management. Consequently, it may encourage healthcare professionals to implement TH-supported services as part of routine COPD management.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Pessoal de Saúde/psicologia , Doença Pulmonar Obstrutiva Crônica/terapia , Telemedicina/organização & administração , Grécia , Humanos , Entrevistas como Assunto , Equipe de Assistência ao Paciente , Pesquisa Qualitativa , Autogestão
7.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32784225

RESUMO

BACKGROUND: Acute kidney injury (AKI) may lead to short- and long-term consequences in children, but its epidemiology has not been well described at a population level and outside of ICU settings. METHODS: In a large, diverse pediatric population receiving care within an integrated health care delivery system between 2008 and 2016, we calculated age- and sex-adjusted incidences of hospitalized AKI using consensus serum creatinine (SCr)-based diagnostic criteria. We also investigated the proportion of AKI detected in non-ICU settings and the rates of follow-up outpatient SCr testing after AKI hospitalization. RESULTS: Among 1 500 546 children, the mean age was 9.8 years, 49.0% were female, and 33.1% were minorities. Age- and sex-adjusted incidence of hospitalized AKI among the entire pediatric population did not change significantly across the study period, averaging 0.70 (95% confidence interval: 0.68-0.73) cases per 1000 person-years. Among the subset of hospitalized children, the adjusted incidence of AKI increased from 6.0% of hospitalizations in 2008 to 8.8% in 2016. Approximately 66.7% of AKI episodes were not associated with an ICU stay, and 54.3% of confirmed, unresolved Stage 2 or 3 AKI episodes did not have outpatient follow-up SCr testing within 30 days postdischarge. CONCLUSIONS: Community-based pediatric AKI incidence was ∼1 per 1000 per year, with two-thirds of cases not associated with an ICU stay and more than one-half not receiving early outpatient follow-up kidney function testing. Further efforts are needed to increase the systematic recognition of AKI in all inpatient settings with appropriate, targeted postdischarge kidney function monitoring and associated management.


Assuntos
Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/epidemiologia , Prestação Integrada de Cuidados de Saúde/tendências , Hospitalização/tendências , Vida Independente/tendências , Lesão Renal Aguda/terapia , Adolescente , Criança , Pré-Escolar , Prestação Integrada de Cuidados de Saúde/métodos , Feminino , Seguimentos , Humanos , Lactente , Masculino
8.
PLoS One ; 15(8): e0237342, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760163

RESUMO

OBJECTIVES: To explore how to integrate the "best" practice into nursing of venous thromboembolism (VTE) based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS: A mixed-methods design was used. A steering group for clinical evidence implementation (EI) was established to conduct pre-implementation baseline surveys, a thorough analysis of the evidence, and an analysis of the survey results. The hindering and enabling factors associated with the clinical implementation of the evidence were analysed based on the three core elements of i-PARIHS, to formulate the clinical implementation plan for VTE nursing evidence. On-site expert reviews and focus group interviews were used to evaluate the feasibility of the draft plan, make adjustments, and finalize the evidence-based practice plan, which was then put into practice and evaluated. RESULTS: A new nursing process, a health education manual and a nursing quality checklist on VTE has been established and proved to be appropriate through the implementation. Compliance with evidence related to VTE nursing increased significantly in the two units, with better compliance in unit B than unit A. The knowledge, attitude and behaviour scores for VTE nursing increased substantially in both nurses and patients. CONCLUSION: The EI programme of incorporating the "best" evidence on VTE nursing into clinical practice using the i-PARIHS framework demonstrated feasibility, appropriateness and effectiveness and could serve as a reference.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Enfermagem Baseada em Evidências/organização & administração , Implementação de Plano de Saúde/organização & administração , Unidades de Terapia Intensiva/organização & administração , Tromboembolia Venosa/terapia , Adulto , Prestação Integrada de Cuidados de Saúde/métodos , Enfermagem Baseada em Evidências/métodos , Estudos de Viabilidade , Feminino , Grupos Focais , Educação em Saúde/métodos , Educação em Saúde/organização & administração , Pesquisa sobre Serviços de Saúde , Médicos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos
10.
PLoS One ; 15(7): e0235843, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645060

RESUMO

Integration of tuberculosis and HIV services in many resource-limited settings, including Ghana, has been far from optimal despite the existence of policy frameworks for integration. A previous study among programme managers and other stakeholders at the national level has documented tardiness in committing to the integration of services. In this paper, we aimed at unravelling pertinent challenges that confront TB-HIV integrated service delivery. Data were obtained from interviews with 31 individual health care providers operating under different models of TB-HIV service delivery. The study is framed around the Complexity Theory. We applied inductive and deductive techniques to code the data and validations were done through inter-rater mechanisms. The analysis was done with the assistance of QSR NVivo version 12. We found evidence of a convivial working relationship between TB-HIV service providers at the facility level. However, the interactions vary across models of care-the lesser the level of integration, the lesser the complexities for interactions that ensued. This had resulted in operational challenges on account of how the two-disease environment interacts with the other components of the health system. These challenges included; weak/inappropriate infrastructure, frail coordination between the two programmes and hospital administrators, under-staffing in comprehensive TB-HIV management, use of community facility under the Directly-Observed Treatment (DOT) protocols, and financial constraints. To fully appropriate the enormous benefits of TB-HIV service integration, there is a need to address these challenges.


Assuntos
Prestação Integrada de Cuidados de Saúde , Infecções por HIV , Tuberculose , Adulto , Prestação Integrada de Cuidados de Saúde/métodos , Gerenciamento Clínico , Feminino , Gana/epidemiologia , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Pessoal de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Tuberculose/epidemiologia , Tuberculose/terapia , Adulto Jovem
13.
Medicine (Baltimore) ; 99(19): e19994, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384454

RESUMO

INTRODUCTION: Integrated care models aim to provide solutions to fragmentation of care by improving coordination. This study will evaluate the effectiveness of a new integrated care model (Salut + Social), which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) to improve quality of life, adherence to treatment and access to medical services for patients with chronic conditions, and also to reduce caregiver burden. Additionally, we will evaluate the experience of caregivers, health professionals and social workers with the new model implemented. METHODS AND ANALYSIS: A clinical trial using mixed methodology will be carried out. The intervention consists of improving the coordination between the social and healthcare sectors during a 6-month period, by means of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are primary care patients with chronic health and social conditions that can benefit from a collaborative and coordinated approach. A sample size of 141 patients was estimated. Questionnaires that assess quality of life, treatment adherence, medical service and caregiver burden will be used at baseline and at 6, 9, and 12 months after the beginning of the study. The principal variable is quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. A discussion group and semi-structured interviews will be conducted with the aim of improving the care model taking into account the opinions of professionals and caregivers. A thematic content analysis will be carried out. ETHICS AND DISSEMINATION: This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P17/100). Articles will be published in international, peer-reviewed scientific journals. TRIAL REGISTRATION: Clinical-Trials.gov: NCT04164160.


Assuntos
Doença Crônica , Prestação Integrada de Cuidados de Saúde , Modelos Organizacionais , Equipe de Assistência ao Paciente , Qualidade de Vida , Serviço Social , Doença Crônica/epidemiologia , Doença Crônica/psicologia , Doença Crônica/reabilitação , Doença Crônica/terapia , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Humanos , Colaboração Intersetorial , Espanha
14.
J Transl Med ; 18(1): 205, 2020 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-32430070

RESUMO

The COVID-19 pandemic has become the leading societal concern. The pandemic has shown that the public health concern is not only a medical problem, but also affects society as a whole; so, it has also become the leading scientific concern. We discuss in this treatise the importance of bringing the world's scientists together to find effective solutions for controlling the pandemic. By applying novel research frameworks, interdisciplinary collaboration promises to manage the pandemic's consequences and prevent recurrences of similar pandemics.


Assuntos
Pesquisa Biomédica/organização & administração , Infecções por Coronavirus/epidemiologia , Prestação Integrada de Cuidados de Saúde/organização & administração , Emergências , Necessidades e Demandas de Serviços de Saúde , Pandemias , Pneumonia Viral/epidemiologia , Betacoronavirus/patogenicidade , Pesquisa Biomédica/métodos , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Prestação Integrada de Cuidados de Saúde/métodos , História do Século XXI , Humanos , Comunicação Interdisciplinar , Estudos Interdisciplinares , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Saúde Pública/história , Saúde Pública/normas
15.
BMC Public Health ; 20(1): 623, 2020 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-32375741

RESUMO

BACKGROUND: Tuberculosis is among the top-10 causes of mortality in children with more than 1 million children suffering from TB disease annually worldwide. The main challenge in young children is the difficulty in establishing an accurate diagnosis of active TB. The INPUT study is a stepped-wedge cluster-randomized intervention study aiming to assess the effectiveness of integrating TB services into child healthcare services on TB diagnosis capacities in children under 5 years of age. METHODS: Two strategies will be compared: i) The standard of care, offering pediatric TB services based on national standard of care; ii) The intervention, with pediatric TB services integrated into child healthcare services: it consists of a package of training, supportive supervision, job aids, and logistical support to the integration of TB screening and diagnosis activities into pediatric services. The design is a cluster-randomized stepped-wedge of 12 study clusters in Cameroon and Kenya. The sites start enrolling participants under standard-of-care and will transition to the intervention at randomly assigned time points. We enroll children aged less than 5 years with a presumptive diagnosis of TB after obtaining caregiver written informed consent. The participants are followed through TB diagnosis and treatment, with clinical information prospectively abstracted from their medical records. The primary outcome is the proportion of TB cases diagnosed among children < 5 years old attending the child healthcare services. Secondary outcomes include: number of children screened for presumptive active TB; diagnosed; initiated on TB treatment; and completing treatment. We will also assess the cost-effectiveness of the intervention, its acceptability among health care providers and users, and fidelity of implementation. DISCUSSION: Study enrolments started in May 2019, enrolments will be completed in October 2020 and follow up will be completed by June 2021. The study findings will be disseminated to national, regional and international audiences and will inform innovative approaches to integration of TB screening, diagnosis, and treatment initiation into child health care services. TRIAL RESISTRATION: NCT03862261, initial release 12 February 2019.


Assuntos
Serviços de Saúde da Criança , Prestação Integrada de Cuidados de Saúde/métodos , Pessoal de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Tuberculose/terapia , Camarões , Pré-Escolar , Análise por Conglomerados , Análise Custo-Benefício , Feminino , Pessoal de Saúde/psicologia , Humanos , Lactente , Quênia , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
16.
Lancet Neurol ; 19(7): 623-634, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32464101

RESUMO

Chronic neurological diseases are the leading cause of disability globally. Yet, our health-care systems are not designed to meet the needs of many patients with chronic neurological conditions. Care is fragmented with poor interdisciplinary collaboration and lack of timely access to services and therapies. Furthermore, care is typically reactive, and complex problems are managed inadequately because of a scarcity of disease-specific expertise and insufficient use of non-pharmacological interventions. Treatment plans tend to focus on the disease rather than the individual living with it, and patients are often not involved in clinical decision making. By use of Parkinson's disease as a model condition, we show an integrated care concept with a patient-centred perspective that includes evidence-based solutions to improve health-care delivery for people with chronic neurological conditions. We anticipate that this integrated care model will improve the quality of life for patients, create a positive working environment for health-care professionals, and be affordable.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Neurologia/métodos , Doença de Parkinson/terapia , Assistência Centrada no Paciente/métodos , Humanos
17.
Am Heart J ; 224: 35-46, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32302788

RESUMO

BACKGROUND: Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care. METHODS: Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis. RESULTS: No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months. CONCLUSIONS: IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/terapia , Sistemas de Apoio a Decisões Clínicas , Prestação Integrada de Cuidados de Saúde/métodos , Gerenciamento Clínico , Idoso , Feminino , Seguimentos , Humanos , Análise de Intenção de Tratamento , Masculino , Estudos Prospectivos
18.
Int J Med Inform ; 137: 104102, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32179256

RESUMO

BACKGROUND: Health is poorer in rural areas and a major challenge is care coordination for complex chronic conditions. The HITECH and 21st Century Cure Acts emphasize health information exchange which underpins activities required to improve care coordination. OBJECTIVE AND METHODS: Using semi-structured interviews and surveys, we examined how providers experience electronic health information exchange during care coordination since these Acts were implemented, with a focus on rural settings where health disparities exist. We used a purposive sample that included primary care, acute care hospitals, and community health services in the United States. FINDINGS: We identified seven themes related to care coordination and information exchange: 'insufficient trust of data'; 'please respond'; 'just fax it'; 'care plans'; 'needle in the haystack'; 're-documentation'; and 'rural reality'. These gaps were magnified when information exchange was required between unaffiliated electronic health records (EHRs) about shared patients, which was more pronounced in rural settings. CONCLUSION: Policy and incentive modifications are likely needed to overcome the observed health information technology (HIT) shortcomings. Rural settings in the United States accentuate problems that can be addressed through international medical informatics policy makers and the implementation and evaluation of interoperable HIT systems.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Troca de Informação em Saúde/normas , Pessoal de Saúde/normas , Sistemas de Informação Hospitalar/estatística & dados numéricos , Atenção Primária à Saúde/normas , Documentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , População Rural , Estados Unidos
19.
BMC Palliat Care ; 19(1): 31, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164672

RESUMO

BACKGROUND: Palliative care (PC) referral is recommended early in the course of advanced cancer. This study aims to describe, in an integrated onco-palliative care program (IOPC), patient's profile when first referred to this program, timing of this referral and its impact on the trajectory of care at end-of-life. METHODS: The IOPC combined the weekly onco-palliative meeting (OPM) dedicated to patients with incurable cancer, and/or the clinical evaluation by the PC team. Oncologists can refer to the multidisciplinary board of the OPM the patients for whom goals and organization of care need to be discussed. We analyzed all patients first referred at OPM in 2011-2013. We defined the index of precocity (IP), as the ratio of the time from first referral to death by the time from diagnosis of incurability to death, ranging from 0 (late referral) to 1 (early referral). RESULTS: Of the 416 patients included, 57% presented with lung, urothelial cancers, or sarcoma. At first referral to IOPC, 76% were receiving antitumoral treatment, 63% were outpatients, 56% had a performance status ≤2 and 46% had a serum albumin level > 35 g/l. The median [1st-3rd quartile] IP was 0.39 [0.16-0.72], ranging between 0.53 [0.20-0.79] (earliest referral, i.e. close to diagnosis of incurability, for lung cancer) to 0.16 [0.07-0.56] (latest referral, i.e. close to death relatively to length of metastatic disease, for prostate cancer). Among 367 decedents, 42 (13%) received antitumoral treatment within 14 days before death, and 157 (43%) died in PC units. CONCLUSIONS: The IOPC is an effective organization to enable early integration of PC and decrease aggressiveness of care near the end-of life. The IP is a useful tool to model the timing of referral to IOPC, while taking into account each cancer types and therapeutic advances.


Assuntos
Tomada de Decisão Compartilhada , Serviço Hospitalar de Oncologia/normas , Encaminhamento e Consulta/normas , Fatores de Tempo , Idoso , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/normas , Prestação Integrada de Cuidados de Saúde/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/classificação , Neoplasias/terapia , Serviço Hospitalar de Oncologia/organização & administração , Serviço Hospitalar de Oncologia/tendências , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Cuidados Paliativos/tendências , Encaminhamento e Consulta/tendências , Estudos Retrospectivos , Assistência Terminal/organização & administração , Assistência Terminal/normas , Assistência Terminal/tendências
20.
J Am Osteopath Assoc ; 120(3): 144-152, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32091558

RESUMO

Context: Inefficiencies in care coordination-specifically, the lack of an effective method of communication among multiple health care professionals-often leads to an unnecessary increase in length of hospital stay. Objective: To determine whether daily integrated care conferences (ICCs) would significantly reduce the length of stay for patients with chronic obstructive pulmonary disease (COPD) exacerbation. Method: Patients with COPD exacerbation were selected for the study using electronic medical records from 2 osteopathic community hospitals located in northeastern Ohio. One hospital used daily ICCs and the other hospital did not use daily ICCs. The average length of stay for patients at each hospital was retrospectively investigated. Results: A total of 1683 patients with COPD exacerbation were selected. The mean (SD) length of stay in the hospital with daily ICCs was 3.37 (2.89) days compared with 5.55 (3.99) days in the hospital without daily ICCs (P<.0001). At the hospital with daily ICCs, patients aged 40 to 69 years had a 67% shorter hospital stay and patients aged 70 to 99 years or older had a 36% shorter length of stay compared with patients at the hospital without daily ICCs. Conclusion: Daily integrated care conferences significantly reduced the length of stay for patients with COPD exacerbation at an osteopathic community-based hospital. Implementing daily ICCs may make current health care services and coordinated care more efficient, resulting in decreased costs and length of stay for patients with COPD exacerbation.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Tempo de Internação/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/terapia , Visitas com Preceptor/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Estudos Retrospectivos
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