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1.
BMC Cancer ; 21(1): 311, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33761916

RESUMO

BACKGROUND: Breast cancer (BC) presents important physical and psychological challenges that should be appropriately addressed through continuous, integrated and individualized rehabilitation programs after treatment. In this study, we aimed to collect more information on the rehabilitation patterns and utilization of healthcare services by women with BC. METHODS: We retrospectively analyzed data from two archives of the Lazio Regional Health System Database to assess rehabilitation patterns in women diagnosed with BC in the Lazio region (Italy) in 2008. RESULTS: A total of 5538 women diagnosed with BC were considered in the present study. Most patients (81.7%) received outpatient rehabilitative care, consisting mainly of pathology-related interventions and, more rarely, disability-related interventions (mainly motor rehabilitation and rarely cognitive or psychological therapy). Few patients followed an inpatient (1.3%) or an intensive outpatient rehabilitation program (1.0%). CONCLUSION: Most patients do not receive adequate rehabilitation care during the first year after diagnosis. More information and better rehabilitation services should be provided to help patients with BC access rehabilitation programs. The study also suggests the importance of psychosocial and cognitive interventions, which is a major unmet need in women with BC.


Assuntos
Neoplasias da Mama/reabilitação , Procedimentos Clínicos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Itália , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos
2.
J Surg Res ; 257: 529-536, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32919343

RESUMO

BACKGROUND: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization. METHODS: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate. RESULTS: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico por imagem , Procedimentos Clínicos/estatística & dados numéricos , Exposição à Radiação/prevenção & controle , Ultrassonografia , Adolescente , Apendicite/sangue , Apendicite/cirurgia , Criança , Feminino , Humanos , Contagem de Leucócitos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Tempo para o Tratamento , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
3.
BMC Med ; 18(1): 398, 2020 12 16.
Artigo em Inglês | MEDLINE | ID: mdl-33323116

RESUMO

BACKGROUND: Dementia is caused by a variety of neurodegenerative diseases and is associated with a decline in memory and other cognitive abilities, while inflicting an enormous socioeconomic burden. The complexity of dementia and its associated comorbidities presents immense challenges for dementia research and care, particularly in clinical decision-making. MAIN BODY: Despite the lack of disease-modifying therapies, there is an increasing and urgent need to make timely and accurate clinical decisions in dementia diagnosis and prognosis to allow appropriate care and treatment. However, the dementia care pathway is currently suboptimal. We propose that through computational approaches, understanding of dementia aetiology could be improved, and dementia assessments could be more standardised, objective and efficient. In particular, we suggest that these will involve appropriate data infrastructure, the use of data-driven computational neurology approaches and the development of practical clinical decision support systems. We also discuss the technical, structural, economic, political and policy-making challenges that accompany such implementations. CONCLUSION: The data-driven era for dementia research has arrived with the potential to transform the healthcare system, creating a more efficient, transparent and personalised service for dementia.


Assuntos
Biologia Computacional/tendências , Procedimentos Clínicos , Bases de Dados Factuais/provisão & distribução , Demência/terapia , Neurologia/tendências , Big Data/provisão & distribução , Comorbidade , Biologia Computacional/métodos , Biologia Computacional/organização & administração , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Procedimentos Clínicos/estatística & dados numéricos , Ciência de Dados/métodos , Ciência de Dados/organização & administração , Ciência de Dados/tendências , Demência/epidemiologia , Humanos , Neurologia/métodos , Neurologia/organização & administração
4.
Medicine (Baltimore) ; 99(43): e22866, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120826

RESUMO

BACKGROUND: Acute myocardial infarction is a very common disease in the emergency room. Emergency percutaneous coronary intervention (PCI) is the first choice to open infarct-related artery in time to regain the active blood flow of myocardial tissue. Clinical nursing pathway (CNP), namely clinical project, is an original nursing mode with good quality, outstanding efficiency, and low treatment spending, so it has attracted more and more attention. However, few studies have reported the implementation of a CNP in PCIs. The purpose of the protocol is to assess the impact of CNP on the clinical efficacy of transradial emergency PCI. METHODS: This is a randomized controlled, single center trial which will be implemented from January 2021 to June 2021. Hundred samples diagnosed with acute myocardial infarction will be included in this study. It was authorized via the Ethics Committee of Changshan County People's Hospital (CCPH002348). Patients are assigned to the following groups: control group, given normal routine care; CNP group, treated with CNP plan. The time from door to balloon, hospitalization expenses, length of stay, postoperative complications, patients' satisfaction with treatment are compared and analyzed. All data are collected and analyzed by Social Sciences software version 21.0 (SPSS, Inc., Chicago, IL) program. RESULTS: Differences of clinical outcomes between groups (). CONCLUSION: This original evidence-based nursing model can be used as the foundation for further research. TRIAL REGISTRATION NUMBER: researchregistry6030.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/métodos , Artéria Radial/cirurgia , Doença Aguda , Estudos de Casos e Controles , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/economia , Humanos , Tempo de Internação , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/fisiopatologia , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Resultado do Tratamento
6.
Minerva Urol Nefrol ; 72(3): 376-383, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32225135

RESUMO

The public health emergency caused by the Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a significant reallocation of health resources with a consequent reorganization of the clinical activities also in several urological centers. A panel of Italian urologists has agreed on a set of recommendations on pathways of pre-, intra- and post-operative care for urological patients undergoing urgent procedures or non-deferrable oncological interventions during the COVID-19 pandemic. Simplification of the diagnostic and staging pathway has to be prioritized in order to reduce hospital visits and consequently the risk of contagion. In absence of strict uniform regulations that impose the implementation of nasopharyngeal swabs, we recommend that an accurate triage for COVID-19 symptoms be performed both by telephone at home before hospitalization and at the time of hospitalization. We recommend that during hospital stay patients should be provided with as many instructions as possible to facilitate their return to, and stay at, home. Patients should be discharged under stable good conditions in order to minimize the risk of readmission. It is advisable to reduce or reschedule post-discharge controls and implement an adequate system of communication for telemonitoring discharged patients.


Assuntos
Infecções por Coronavirus , Procedimentos Clínicos/estatística & dados numéricos , Pandemias , Pneumonia Viral , Doenças Urológicas/cirurgia , Urologia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Itália , Masculino , Assistência Perioperatória , Saúde Pública , Triagem , Neoplasias Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos , Urologistas
7.
Ann R Coll Surg Engl ; 102(4): 308-311, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32081023

RESUMO

INTRODUCTION: Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services. METHODS: A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports. FINDINGS: There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.


Assuntos
Neoplasias Colorretais/diagnóstico , Procedimentos Clínicos/normas , Detecção Precoce de Câncer/normas , Sangue Oculto , Triagem/normas , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Procedimentos Clínicos/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Detecção Precoce de Câncer/métodos , Humanos , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Prevalência , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Fatores de Tempo , Reino Unido/epidemiologia
8.
Arch Osteoporos ; 15(1): 14, 2020 02 20.
Artigo em Inglês | MEDLINE | ID: mdl-32078057

RESUMO

Management of hospitalised osteoporotic vertebral fracture patients was explored across all major trauma orthopaedic hospitals in Ireland. Findings, based on a survey of orthopaedic doctors and physiotherapists, indicate a lack of standardised clinical care pathways. This study will inform development of clinical audit mechanisms and health service development for this large and growing fracture population in both Ireland and internationally. PURPOSE: To explore the management of hospitalised vertebral fragility fracture (VFF) patients in Ireland. METHODS: A cross-sectional survey of orthopaedic doctors (specialist registrar level) and physiotherapists was conducted across all hospitals with major orthopaedic trauma units in Ireland. Data were analysed using descriptive statistics in SPSS (V24). RESULTS: Responses were achieved from 100% (n = 16) of the hospitals (42 individual physiotherapists and 47 orthopaedic doctors). Conservative management was usual with both orthopaedic doctors (n = 37, 79%) and physiotherapists (n = 40, 96%) reporting prescription of bracing as common practice despite a lack of underpinning evidence. A majority (87%) of the doctors believed osteoporosis medications should commence prior to discharge from the acute setting, but 68% did not agree that responsibility for coordination and delivery of bone health assessment and fracture risk management rested with them. A majority (72%) of physiotherapists reported an absence or were unsure regarding existence of fracture liaison services. 73% of physiotherapists reported prescribing an inpatient or home (78%) exercise programme, including mobility, strength and balance exercise though detail on dose and adherence remain unknown. Wide variance in referral patterns to multi-disciplinary team (MDT) members existed although 79% of orthopaedic doctors supported an MDT approach. CONCLUSION: Clinical care pathways for the hospitalised VFF population lack standardisation in Ireland. Key challenges reported by orthopaedic doctors and physiotherapists relate to pain management, osteoporosis medication prescription, clarity on indications for bracing and a lack of fracture liaison services. Clinical guidelines, defined clinical care pathways and high-quality clinical research trials are required for VFF management.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Cirurgiões Ortopédicos/estatística & dados numéricos , Fraturas por Osteoporose/terapia , Fisioterapeutas/estatística & dados numéricos , Fraturas da Coluna Vertebral/terapia , Idoso , Procedimentos Clínicos/normas , Estudos Transversais , Terapia por Exercício/normas , Terapia por Exercício/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Irlanda , Masculino , Cirurgiões Ortopédicos/normas , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Fisioterapeutas/normas , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos
9.
JAMA Netw Open ; 3(2): e1920622, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32022884

RESUMO

Importance: Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. Objective: To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and Participants: This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. Exposures: One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and Measures: Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. Results: A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and Relevance: Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.


Assuntos
Terapia Comportamental/estatística & dados numéricos , Procedimentos Clínicos/estatística & dados numéricos , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/terapia , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Adolescente , Adulto , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Pesquisa Comparativa da Efetividade , Feminino , Humanos , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Adulto Jovem
10.
Rev Epidemiol Sante Publique ; 68(2): 125-132, 2020 Apr.
Artigo em Francês | MEDLINE | ID: mdl-32035728

RESUMO

BACKGROUND: French Guiana faces singular health challenges: poverty, isolation, structural lag, difficulties in attracting health professionals. Hospital stays exceed the recommended durations. The present study aimed to model the impact of precariousness and geographic isolation on the hospital duration performance indicator and to recalculate the indicator after incrementing severity by 1 unit when patients were socially precarious. METHODS: Cayenne hospital data for 2017 were used to model the hospital duration performance indicator (IP-DMS) using quantile regression to study the impact of geographic and social explanatory variables. This indicator was computed hypothesizing a 1 unit increment of severity for precarious patients and by excluding patients from isolated regions. RESULTS: Most excess hospitalization days were linked to precariousness: the sojourns of precarious patients represented 47% of activity but generated 71% of excess days in hospital. Quantile regression models showed that after adjustment for potential confounders, patients from western French Guiana and Eastern French Guiana, precarious patients and the interactions terms between residence location and precariousness were significantly associated with IP-DMS increases. Recalculating the IP-DMSafter exclusion of patients from the interior and after increasing severity by 1 notch if the patient was precarious led to IP-DMS levels close to 1. CONCLUSION: The results show the nonlinear relationship between the IP-DMS and geographical isolation, poverty, and their interaction. These contextual variables must be taken into account when choosing the target IP-DMS value for French Guiana, which conditions funding and number of hospital beds allowed in a context of rapid demographic growth.


Assuntos
Procedimentos Clínicos , Acesso aos Serviços de Saúde , Tempo de Internação/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Isolamento Social , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Procedimentos Clínicos/estatística & dados numéricos , Feminino , Guiana Francesa/epidemiologia , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Corpo Clínico/organização & administração , Corpo Clínico/normas , Corpo Clínico/estatística & dados numéricos , Corpo Clínico/provisão & distribução , Pessoa de Meia-Idade , Administração em Saúde Pública/normas , Administração em Saúde Pública/estatística & dados numéricos , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Adulto Jovem
11.
Soc Psychiatry Psychiatr Epidemiol ; 55(2): 175-186, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31511926

RESUMO

PURPOSE: To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients by routine Italian mental health services over 5 years since the first service contact. METHODS: Naturalistic study conducted in Veneto, within the context of the Psychosis Incident Cohort Outcome Study (PICOS). A comprehensive set of measures was used, including schedules designed to collect information on referrals to psychiatric services and on psychological and pharmacological treatments at 1, 2, and 5 years since first service contact. RESULTS: Overall, 397 patients were assessed. Most engaged with services with the help of family members (47.4%) and through emergency routes (60.3%). Those referred by clinicians were more likely to access care in a non-emergency way. Mean DUP was 5.62 months (SD 11.8) and longer DUP was associated with poorer functioning at 2 and 5 years. Interventions provided over 5 years were mainly constituted by antipsychotic medications (95.4% at 1 year; 85.8% at 2 years; 80.6% at 5 years), whereas a lower percentage (69.1% at 1 year; 61.5% at 2 years; 44.9% at 5 years) also received some forms of psychological interventions, mainly consisting of unspecific support sessions. Other structured interventions, such as CBT or family interventions, were seldom provided at each time-point. CONCLUSIONS: Mental health services in Veneto seem effective in engaging FEP patients within a short time since illness onset. However, type of care provided does not meet quality standards recommended by treatment guidelines, especially regarding psychological interventions.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Transtornos Psicóticos/terapia , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Incidência , Itália/epidemiologia , Masculino , Avaliação de Resultados em Cuidados de Saúde , Transtornos Psicóticos/epidemiologia , Transtornos Psicóticos/psicologia , Encaminhamento e Consulta/estatística & dados numéricos , Fatores de Tempo , Adulto Jovem
12.
J Plast Reconstr Aesthet Surg ; 73(1): 19-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31628082

RESUMO

INTRODUCTION: Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center. METHODS: We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol. RESULTS: Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/- 0.85 vs. 4.7 +/-1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care. CONCLUSION: A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Mamoplastia/métodos , Adulto , Idoso , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Protocolos Clínicos , Procedimentos Clínicos/economia , Procedimentos Clínicos/estatística & dados numéricos , Feminino , Custos Hospitalares , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Mamoplastia/economia , Mamoplastia/estatística & dados numéricos , Microcirurgia/economia , Microcirurgia/métodos , Microcirurgia/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Retalho Perfurante/economia , Retalho Perfurante/estatística & dados numéricos , Estudos Prospectivos , Reoperação/economia , Reoperação/estatística & dados numéricos
13.
Appl Clin Inform ; 10(5): 935-943, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31860113

RESUMO

BACKGROUND: The Centers for Disease Control and Prevention (CDC) produced a 72-page document titled "U.S. Selective Practice Recommendations for Contraceptive Use" in 2016. This document contains the medical eligibility criteria (MEC) for contraceptive initiation or continuation based on a patient's current health status. Notations such as Business Process Model and Notation (BPMN) and Decision Model and Notation (DMN) might be useful to model such recommendations. OBJECTIVE: Our objective was to use BPMN and DMN to model and standardize the processes and decisions involved in initiating birth control according to the CDC's MEC for birth control initiation. This model could then be incorporated into an electronic health records system or other digital platform. METHODS: Medical terminology, processes, and decisions were modeled in coordination with the CDC to ensure correctness. Challenges in terminology bindings were identified and categorized. RESULTS: A model was successfully produced. Integration of clearly defined data elements proved to be the biggest challenge. CONCLUSION: BPMN and DMN have strengths and weaknesses when modeling medical processes; however, they can be used to successfully create models for clinical pathways.


Assuntos
Anticoncepção/estatística & dados numéricos , Procedimentos Clínicos/estatística & dados numéricos , Modelos Estatísticos , Centers for Disease Control and Prevention, U.S. , Humanos , Estados Unidos
14.
BMC Med ; 17(1): 184, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31570106

RESUMO

BACKGROUND: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS). METHODS: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement. RESULTS: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals. CONCLUSIONS: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Adulto , Brasil/epidemiologia , Cesárea/estatística & dados numéricos , Cidades/epidemiologia , Cidades/estatística & dados numéricos , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Estudos Transversais , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Parto Obstétrico/métodos , Parto Obstétrico/normas , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Serviços de Saúde Materna/organização & administração , Serviços de Saúde Materna/normas , Transferência de Pacientes/organização & administração , Gravidez , Indicadores de Qualidade em Assistência à Saúde , Encaminhamento e Consulta/estatística & dados numéricos , Análise de Sistemas , Transporte de Pacientes/estatística & dados numéricos
15.
J Addict Med ; 13(5): 385-395, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31589181

RESUMO

OBJECTIVES: The medical sequalae of alcohol and other drug (AOD) problems exact a prodigious personal and societal cost, but little is known about the specific prevalence of such medical problems, and their relationship to quality of life and indices of well-being among those recovering from problematic AOD use. To better characterize the lifetime physical disease burden, this study investigated the prevalence of medical conditions commonly caused or exacerbated by excessive and chronic AOD exposure in a nationally representative sample of US adults in AOD problem recovery. Comparisons were made to the general US population. Demographic and clinical correlates of disease prevalence were also investigated along with the relationship between distinct medical conditions and indices of quality of life/well-being. METHODS: Cross-sectional nationally representative survey of the US adult population who report resolving an AOD problem (n = 2002). Weighted lifetime prevalence of common medical conditions were estimated and compared to the US population. Demographic and clinical correlates of medical conditions, and also overall disease burden, were estimated using logistic regression. RESULTS: Relative to the general population, prevalence of hepatitis C, chronic obstructive pulmonary disease, heart disease, and diabetes were elevated. Likelihood of having a lifetime diagnosis of a specific disease was related to primary substance used and sex. Quality of life was lower among those with physical disease histories relative to those without. CONCLUSIONS: Findings highlight the increased medical burden associated with AOD problems, and speak to the need for earlier and more sustained intervention for AOD problems, greater integration of addiction treatment and primary health care, and longitudinal research to explore the complex, dynamic relationships between AOD use and physical disease.


Assuntos
Transtornos Relacionados ao Uso de Álcool/epidemiologia , Transtornos Relacionados ao Uso de Álcool/terapia , Efeitos Psicossociais da Doença , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Adolescente , Adulto , Idoso , Procedimentos Clínicos/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prevalência , Qualidade de Vida , Inquéritos e Questionários , Estados Unidos/epidemiologia , Adulto Jovem
16.
Int J Lang Commun Disord ; 54(6): 914-926, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31364253

RESUMO

BACKGROUND: Primary progressive aphasia (PPA) describes a heterogeneous group of language-led dementias. People with this type of dementia are increasingly being referred to speech and language therapy (SLT) services. Yet, there is a paucity of research evidence focusing on PPA interventions and little is known about SLT practice in terms of assessment and provision of intervention. AIMS: To survey the practices of SLTs in the areas of assessment and intervention for people with PPA. METHODS & PROCEDURES: A 37-item, pilot-tested survey was distributed electronically through the Royal College of Speech and Language Therapists (RCSLT), Clinical Excellence Networks (CENs) and social media networks. Survey items included questions on care pathways, assessment and intervention approaches, and future planning. Analysis was conducted using descriptive statistics and thematic analysis. OUTCOMES & RESULTS: A total of 105 SLTs completed the survey. Respondents reported more frequently using formal assessment tools designed for stroke-related aphasia than for dementia. Informal interviews were reportedly always used during assessment by almost 80% of respondents. Respondents were significantly more likely to use communication partner training than impairment-focused interventions. Goal attainment was the most commonly used outcome measure. Respondents provided 88 goal examples, which fell into six themes: communication aid; conversation; functional communication; impairment focused; specific strategy; and communication partner. Additionally, respondents reported addressing areas such as future deterioration in communication and cognition, decision-making and mental capacity, and driving. Ten (9.4%) respondents reported the existence of a care pathway for people with PPA within their service. CONCLUSIONS & IMPLICATIONS: This survey highlights the range of current PPA assessment and intervention practices in use by the respondents. Communication partner training is commonly used by the surveyed SLTs, despite the lack of research evidence examining its effectiveness for PPA. There is a need to develop evidence-based care pathways for people with PPA in order to advocate for further commissioning of clinical services.


Assuntos
Afasia Primária Progressiva/terapia , Terapia da Linguagem/métodos , Prática Profissional/estatística & dados numéricos , Fonoterapia/métodos , Afasia Primária Progressiva/diagnóstico , Comunicação , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Avaliação de Resultados em Cuidados de Saúde/métodos , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/estatística & dados numéricos , Patologia da Fala e Linguagem/organização & administração , Patologia da Fala e Linguagem/estatística & dados numéricos , Reino Unido
17.
Aliment Pharmacol Ther ; 50(4): 348-372, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31286552

RESUMO

BACKGROUND: National UK data on colorectal cancer (CRC) stage at diagnosis is incomplete. Site-specific fast-track (2-week wait) cancer data are not collected directly by NHS England. Policy making based on these data alone can lead to inaccuracy. AIMS: To review available data on key outcomes (cancer conversion rate and stage at diagnosis) for the UK's lower gastrointestinal 2-week wait pathway. METHODS: A comprehensive literature search was conducted between 2000 and 2017. Primary outcomes were cancer conversion rate and cancer stage at diagnosis. Results were expressed as proportions with 95% CIs. A random effects model was used for meta-analysis; heterogeneity was assessed by I2 . RESULTS: Of 95 papers reviewed, 49 were included in analysis with a total study population of 93,655. Cancer conversion rate was 7.7% (95% CI: 6.9-8.5). The proportion presenting at Dukes A = 11.2% (95% CI 7.4-15.6), B = 36.7% (95% CI 30.8-42.8), C = 35.7% (95% CI: 30.8-40.8) and D = 11.1% (95% CI 7.3-15.5). No colonic pathology was diagnosed in 54.6% (95% CI: 46.2-62.8). CONCLUSIONS: Only 7.7% of patients referred by the 2-week wait pathway were found to have CRC. No beneficial effect on stage at diagnosis was found compared to non-2-week wait referral pathways. Over half of patients had no colonic pathology and detection of adenomas was very low. These results should prompt a reconsideration of the benefits of the 2-week wait pathway in CRC diagnosis and outcomes, with more focus on strategies to improve patient selection.


Assuntos
Neoplasias Colorretais/diagnóstico , Procedimentos Clínicos , Detecção Precoce de Câncer/métodos , Encaminhamento e Consulta , Listas de Espera , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/patologia , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Procedimentos Clínicos/estatística & dados numéricos , Detecção Precoce de Câncer/normas , Detecção Precoce de Câncer/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Estadiamento de Neoplasias , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos
18.
Crit Care Med ; 47(8): e710-e716, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31306259

RESUMO

OBJECTIVES: Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest. DATA SOURCES: PubMed and review of citations in retrieved articles. STUDY SELECTION: Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients. DATA EXTRACTION: Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1-2 at or after hospital discharge. DATA SYNTHESIS: The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46-3.81). CONCLUSIONS: Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Estado Terminal/reabilitação , Procedimentos Clínicos/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/terapia , Instituições de Assistência Ambulatorial , Gerenciamento Clínico , Medicina Baseada em Evidências , Humanos , Prognóstico , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
19.
J Pediatr Urol ; 15(5): 518.e1-518.e7, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31326330

RESUMO

INTRODUCTION: Ultrasound (US) imaging is preferred in the initial evaluation for children with suspected nephrolithiasis; however, computed tomography (CT) continues to be used in this setting with resultant unnecessary ionizing radiation exposure. The study institution implemented a standardized clinical pathway to reduce rates of CT utilization for children with nephrolithiasis. OBJECTIVE: The aim of this study was to evaluate the impact of this pathway on initial imaging strategies for children with suspected nephrolithiasis. STUDY DESIGN: A standardized pathway was designed and implemented using a systematic quality improvement process. A suspected cohort was created using 'reason for study' search terms consistent with a nephrolithiasis diagnosis. A confirmed cohort of children with a final diagnosis of nephrolithiasis was derived from this suspected cohort. The primary outcome was CT use as the initial imaging study in children with suspected or confirmed nephrolithiasis presenting to the emergency department (ED) between October 2013 and February 2018. Comparisons were made before and after pathway implementation (October 2015). Secondary outcomes included rates of CT scan within 30 days, while balancing measures included rates of admission, ED length of stay, and return visits. RESULTS: A total of 534 children with suspected (220 prepathway; 314 postpathway) and 90 children with confirmed (37 prepathway; 53 postpathway) nephrolithiasis were included. For the suspected cohort, CT scans performed as the initial imaging evaluation (9.2% vs 2.5%, P = 0.001) and at any time during the index visit (15.7% vs 5.7%, P = 0.001) decreased after pathway implementation. Within the confirmed cohort, a non-significant decrease in initial CT rates was observed after implementation. No differences were observed in admission rates or ED length of stay after implementation. A trend toward lower return visits to the ED was seen after pathway implementation (5.5% vs 2.2%, P = 0.058). DISCUSSION: Within a tertiary care pediatric ED associated with a strong institutional experience with clinical pathways, initial CT rates were decreased after pathway implementation for children with suspected nephrolithiasis. While retrospective assessment of suspected disease is limited, this is one of the first studies to address imaging patterns for nephrolithiasis beyond the final discharge diagnosis, thus capturing a broader cohort of children. Children with suspected nephrolithiasis can be safely managed with an US-first approach, and postvisit CT scans are rarely necessary for management. CONCLUSIONS: A standardized clinical pathway for suspected nephrolithiasis can reduce rates of initial and overall CT utilization without adversely impacting downstream care.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Nefrolitíase/diagnóstico , Melhoria de Qualidade , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Criança , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos
20.
Pediatr Diabetes ; 20(7): 932-940, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31270908

RESUMO

BACKGROUND: Children and young people (CYP) living with diabetes require integrated child-centered care. We hypothesized that suboptimal uptake to diabetic retinopathy screening in CYP may be partly related to the degree of services integration. We investigated the structure of the current pediatric diabetic eye care pathway and associations between service-level characteristics and screening uptake. METHODS: A quality improvement project between January and May 2017 comprising a survey of practice of all 158 pediatric diabetes services (pediatric diabetes units, PDUs) across England and secondary data analysis of routinely collected service data. Generalized linear models for proportional responses were fitted to investigate associations between reported PDU characteristics and screening uptake. RESULTS: 124 PDUs (78%) responded. In 67% (n = 83), patients could be referred directly to screening programs; the remainder relied on primary care for onward referral. 97% (n = 120) considered eye screening results useful for counseling patients but only 65% (n = 81) reported it was "easy" to obtain them. Factors independently associated with higher screening uptake were a higher proportion of patients referred from primary care (OR = 1.005; 95%CI = 1.004-1.007 per 1% of increase), absence of "out-of-catchment area" patients (OR = 1.13; 95%CI = 1.04-1.22), and easy access to eye screening results (OR = 1.45; 95%CI = 1.34-1.56). CONCLUSIONS: There is limited direct communication between the services involved in diabetic eye care for CYP in England. This risks reducing the effectiveness of diabetic retinopathy screening. Similar vulnerabilities are likely to exist in other countries where retinopathy screening for CYP has been "bolted on" to provision for adults.


Assuntos
Retinopatia Diabética/diagnóstico , Programas de Rastreamento/organização & administração , Programas de Rastreamento/normas , Encaminhamento e Consulta , Adolescente , Fatores Etários , Criança , Pré-Escolar , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Procedimentos Clínicos/estatística & dados numéricos , Diabetes Mellitus/epidemiologia , Retinopatia Diabética/epidemiologia , Inglaterra/epidemiologia , Humanos , Lactente , Recém-Nascido , Programas de Rastreamento/métodos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Adulto Jovem
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