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1.
Invest. educ. enferm ; 38(1): [E04], febrero 15 2020. Tab 1, Tab 2
Artigo em Inglês | LILACS, COLNAL | ID: biblio-1051969

RESUMO

Objective. To evaluate the effect of interactive training conducted during pregnancy on choosing delivery method among primiparous women. Methods. Quasi-experimental study carried out in 2017 in two hospitals in the city of Bushehr (Iran), with the participation of 108 primiparous pregnant women in an educational program consisting of eight 2-hour sessions every two weeks in which interactive training activities were performed (group discussions, classroom sessions, and delivery of printed educational material) on themes related with physiological delivery, painless vaginal delivery methods, and complications of cesarean delivery without indication, among others. Before and after the intervention, the Knowledge and Preferred Method of Delivery Questionnaire by Moradabadi et al., was used to obtain information. Results. The results indicated that the level of knowledge in the group of mothers increased significantly between the pre-intervention and post-intervention assessment (13.2 versus 19.4, of 20 possible maximum points; p <0.001). Additionally, significant difference was observed in the selection of the vaginal delivery method before and after the intervention (74.1% versus 98.1%; p<0.001). Conclusion. Implementation of interactive training increased knowledge of pregnant women on the delivery and induced a positive effect to encourage the primiparous mothers to have a vaginal delivery.


Objetivo. Evaluar el efecto de un entrenamiento interactivo realizado durante el embarazo sobre la elección del método de parto en mujeres primíparas. Métodos. Estudio cuasiexperimental realizado en 2017 en dos hospitales de la ciudad de Bushehr (Irán). 108 mujeres embarazadas primíparas participaron en un programa educativo consistente en ocho sesiones de dos horas de duración cada dos semanas, en las que se realizaron actividades de capacitación interactiva (discusiones grupales, clases magistrales y entrega de material educativo impreso) sobre temas relacionados con el parto fisiológico, los métodos de parto vaginal sin dolor, las complicaciones del parto por cesárea sin indicación, entre otros. Antes y después de la intervención se utilizó, para la toma de información, el Knowledge and Preferred Method of Delivery Questionnaire de Moradabadi et al. Resultados. Los resultados indicaron que el nivel de conocimiento en el grupo de madres aumentó significativamente entre la evaluación preintervención a la posintervención (13.2 versus 19.4, de 20 puntos máximos posibles; p<0.001). Además, se observó una diferencia significativa en la selección del método de parto vaginal antes y después de la intervención (74.1% versus 98.1%; p<0.001). Conclusión. La implementación de la capacitación interactiva aumentó el conocimiento de las embarazadas sobre el parto e indujo un efecto positivo para alentar a las madres primíparas a tener un parto vaginal.


Objetivo. Avaliar o efeito de um treinamento interativo realizado durante a gravidez na escolha do método de parto em mulheres primíparas. Métodos Estudo quase experimental realizado em 2017 em dois hospitais na cidade de Bushehr (Irã). 108 gestantes primíparas participaram de um programa educacional composto por oito sessões de duas horas a cada duas semanas, nas quais foram realizadas atividades de treinamento interativas (discussões em grupo, master classes e entrega de material educacional impresso) sobre questões relacionadas ao parto métodos fisiológicos, parto vaginal sem dor, complicações do parto cesáreo sem indicação, entre outros. Antes e após a intervenção, o Questionário de Conhecimento e Método Preferido de Entrega de Moradabadi et al. Resultados Os resultados indicaram que o nível de conhecimento no grupo de mães aumentou significativamente entre a avaliação pré-intervenção e a pós-intervenção (13.2 versus 19.4, de 20 possíveis pontos máximos; p<0.001). Além disso, foi observada diferença significativa na seleção do método de parto vaginal antes e após a intervenção (74.1% versus 98.1%; p<0.001). Conclusão A implementação do treinamento interativo aumentou o conhecimento das gestantes sobre o parto e induziu um efeito positivo para incentivar as primíparas a terem um parto vaginal.


Assuntos
Humanos , Paridade , Gravidez , Cesárea , Procedimentos Desnecessários , Parto Obstétrico
2.
Can Assoc Radiol J ; 71(1): 110-116, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32063000

RESUMO

AIM: To decrease the number of mobile chest radiograph requests for inpatients in British Columbia who are medically able to tolerate transport to the main department by introducing and implementing request criteria. METHOD: Concerns regarding inappropriate mobile exam requests in patients receiving chest radiography were surveyed at 28 medical imaging sites. In response, a multidisciplinary team composed a set of mobile radiography request guidelines incorporating feedback from all sites. These were successfully implemented along with in-person education to 21 sites. The number of adult annual mobile chest radiographs was tracked from 2014 to 2018, and informal feedback was obtained from participating sites. RESULTS: The percentage of mobile chest radiographs of all chest radiographs performed between 2014 and 2018 decreased by 3.2%, while the total number of all chest radiographs performed during this time, including both departmental and mobile, increased by 1.9%. Sites reported positive engagement with the initiative and expressed need for ongoing education to optimize its effect. CONCLUSION: Implementation of request guidelines with in-person education helped to reduce inappropriate mobile exams in patients receiving chest radiographs in British Columbia between 2014 and 2018. These guidelines promote patient safety through reduced radiation exposure, empower radiographers to mitigate inappropriate requests, and help to optimize use of limited hospital resources by reducing inappropriate mobile exams where routine departmental exams are more suitable.


Assuntos
Unidades Móveis de Saúde/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Radiografia Torácica/estatística & dados numéricos , Adulto , Colúmbia Britânica , Humanos , Procedimentos Desnecessários
3.
Acad Med ; 95(2): 275-282, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31517680

RESUMO

PURPOSE: To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD: In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS: For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS: In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.


Assuntos
Hematologia/educação , Relações Médico-Paciente , Procedimentos Desnecessários/psicologia , Aborto Espontâneo/psicologia , Canadá , Competência Clínica , Humanos , Internato e Residência , Guias de Prática Clínica como Assunto , Trombofilia/diagnóstico
4.
J Urol ; 203(2): 292-298, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31479397

RESUMO

PURPOSE: We sought to develop a triage strategy to reduce negative and indeterminate multiparametric magnetic resonance imaging scans in patients at risk for prostate cancer. MATERIALS AND METHODS: In this retrospective study we evaluated 865 patients with no prior prostate cancer diagnosis who underwent prostate multiparametric magnetic resonance imaging between 2009 and 2017. Age, prostate volume, prostate specific antigen and prostate specific antigen density were assessed as predictors of positive multiparametric magnetic resonance imaging, defined as PI-RADS™ (Prostate Imaging Reporting and Data System) version 2/Likert score 4 or greater. The cohort was split into a training cohort of 605 patients and a validation cohort of 260. The optimal threshold to rule out positive multiparametric magnetic resonance imaging was chosen to achieve a negative predictive value greater than 90%. RESULTS: All clinical variables were significant predictors of positive multiparametric magnetic resonance imaging (p <0.05). Prostate specific antigen density outperformed other parameters in diagnostic accuracy and did not significantly differ compared to a multivariate model (AUC=0.74 vs 0.75). At prostate specific antigen density greater than 0.078 ng/ml2 sensitivity, specificity, positive and negative predictive values were 94%, 29%, 22% and 95%, respectively, resulting in 25% fewer scans (64 of 260). In the multivariate model sensitivity, specificity, positive and negative predictive values were 85%, 32%, 22% and 91%, respectively, resulting in 29% fewer scans (75 of 260). Biopsies in men who would not have undergone multiparametric magnetic resonance imaging according to our proposed strategies revealed 2 clinically significant prostate cancers using prostate specific antigen density and 1 using the multivariate model. CONCLUSIONS: In patients at risk for prostate cancer applying a multivariate prediction model or a prostate specific antigen density cutoff of 0.078 ng/ml2 resulted in 25% to 29% fewer multiparametric magnetic resonance imaging scans performed while missing only a minimal number of clinically significant prostate cancers. Further prospective validation is required.


Assuntos
Calicreínas/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Carga Tumoral
5.
Ann Vasc Surg ; 62: 106-113, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31394233

RESUMO

BACKGROUND: Current algorithms for the management of blunt lower extremity trauma recommend additional imaging in patients presenting with soft signs of vascular injury and an ankle-brachial index (ABI) less than 0.9. The aim of this study is to analyze lower extremity computed tomography angiographies (CTAs) to determine the incidence and characteristics of patients sustaining vascular injury from blunt lower extremity trauma. We hypothesized that a lower ABI threshold can avoid unnecessary imaging without missing clinically significant vascular injury. METHODS: A single-center, retrospective review of all consecutive patients who presented to a level 1 trauma center with blunt lower extremity trauma and underwent a CTA from January 2015 to December 2017 was conducted. Baseline demographics, clinical features, and outcomes were recorded. Patients without documented ABIs were excluded. A receiver operating characteristic curve was used to define the ABI threshold. RESULTS: One hundred twenty-five patients (133 injured limbs) met inclusion criteria. The mean age was 44 years (range 9-96), and 74% of the patients were male. A vascular abnormality was identified on CTA in 65 limbs (48.9%), of which only 8 (12%) required intervention. The ABIs in these 8 injured limbs were between 0 and 0.6. An ABI threshold of 0.6 maximized the balance between sensitivity (100%) and specificity (87%) and missed no injuries requiring revascularization. CONCLUSIONS: The ABI remains useful in evaluating blunt lower extremity trauma. A lower ABI threshold in patients presenting with soft signs of vascular injury after blunt trauma may avoid unnecessary imaging without missing vascular injuries requiring intervention. Further prospective studies are needed to validate the safety and effectiveness of a lower ABI threshold.


Assuntos
Índice Tornozelo-Braço , Artérias/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Extremidade Inferior/irrigação sanguínea , Procedimentos Desnecessários , Lesões do Sistema Vascular/diagnóstico , Ferimentos não Penetrantes/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias/fisiopatologia , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/fisiopatologia , Lesões do Sistema Vascular/terapia , Washington , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/fisiopatologia , Ferimentos não Penetrantes/terapia , Adulto Jovem
6.
Eur Radiol ; 30(1): 452-460, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31338652

RESUMO

OBJECTIVES: Duration of delayed graft function (DGF) and length of hospital stay (LOS) are outcomes of interest in an era that warrants increased efficacy of transplant care whereas renal allografts originate increasingly from marginal donors. While earlier studies investigate the predictive capability of a single renal scintigraphy, this study focuses on the value for both DGF duration and LOS of consecutively performed scintigraphies. METHODS: From 2011 to 2014, renal transplant recipients referred for a Tc-99m MAG3 renal scintigraphy were included in a single-center retrospective study. Primary endpoints were DGF duration and LOS. Both the first (≤ 3 days) and second scintigraphies (3-7 days after transplantation) were analyzed using a 4-grade qualitative scale and quantitative indices (TFS, cTER, MUC10, average upslope). RESULTS: We evaluated 200 first and 108 (54%) consecutively performed scintigraphies. The Kaplan-Meier curves for DGF duration and qualitative grading of the first and second scintigraphy showed significant differences between the grades (p < 0.01). The Kaplan-Meier curve for the delta grades between these procedures (lower, equal, or higher grade) did not show significant differences (p = 0.18). Multivariate analysis showed a significant association between the qualitative grades, from the first and second scintigraphy, and DGF duration, HR 1.8 (1.4-2.2, p < 0.01) and 2.8 (1.8-4.3, p < 0.01), respectively. CONCLUSIONS: Qualitative grades of single renal scintigraphies, performed within 7 days after transplantation, can be used to make a reliable image-guided decision on the need for dialysis and to predict LOS. A consecutive renal scintigraphy, however, did not show an additional value in the assessment of DGF. KEY POINTS: • Post-transplant renal scintigraphy procedures provide information to predict delayed graft function duration and length of hospital stay. • Performing two consecutive renal scintigraphy procedures within 1 week after transplantation does not strengthen the prediction of delayed graft function duration and length of hospital stay. • Single renal scintigraphy procedures can be used to provide clinicians and patients with a reliable indication of the need for dialysis after transplantation and the expected duration of hospitalization.


Assuntos
Função Retardada do Enxerto/diagnóstico por imagem , Transplante de Rim , Cuidados Pós-Operatórios/métodos , Adulto , Idoso , Função Retardada do Enxerto/terapia , Feminino , Humanos , Estimativa de Kaplan-Meier , Rim/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Cintilografia/métodos , Compostos Radiofarmacêuticos , Diálise Renal , Estudos Retrospectivos , Tecnécio Tc 99m Mertiatida , Fatores de Tempo , Doadores de Tecidos , Procedimentos Desnecessários
8.
BMC Health Serv Res ; 19(1): 983, 2019 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-31864352

RESUMO

BACKGROUND: The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder. METHODS: The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS. RESULTS: The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed. CONCLUSIONS: The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.


Assuntos
Clínicos Gerais , Dor Lombar/diagnóstico por imagem , Programas Nacionais de Saúde/economia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Austrália , Análise Custo-Benefício , Humanos , Atenção Primária à Saúde , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/economia , Procedimentos Desnecessários/economia
9.
N Z Med J ; 132(1488): 11-20, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851657

RESUMO

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.


Assuntos
Sobremedicalização/prevenção & controle , Procedimentos Desnecessários/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adulto , Educação em Saúde , Humanos , Sobremedicalização/economia , Sobremedicalização/estatística & dados numéricos , Nova Zelândia , Procedimentos Desnecessários/economia , Urinálise/economia , Urinálise/métodos , Infecções Urinárias/diagnóstico , Infecções Urinárias/microbiologia
10.
N Z Med J ; 132(1488): 21-27, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851658

RESUMO

BACKGROUND: Urinalysis performed by dipstick testing is an aid to diagnosing urinary tract infections (UTI), and a tool in selecting patients who require urine culture and antibiotic treatment. Previous studies have demonstrated that UTI, especially in the elderly, are over-diagnosed and over-treated. We sought to study the pattern and yield of urinalysis and urine culture at our service in a tertiary institution. METHODS: A convenience sampling method was utilised to prospectively collect clinical data, through a pre-designed pro forma, from patients admitted to the General Medicine service at Christchurch Hospital between March and June 2016. RESULTS: The study included 395 patients, with a median age of 76 (range 15-100 years). The presence of urinary tract symptoms was documented in 94 patients (24%) and a non-specific syndrome of elevated temperature, confusion or subjective feverishness in 69 (17%). In symptomatic patients, 121 (74%) had a dipstick performed and 104 (86%) urine samples cultured. In the remaining patients, 181 (78%) had a dipstick performed and 81 (35%) had a urine sample sent for culture. CONCLUSIONS: We found a large number of urine dipsticks is being ordered unnecessarily in asymptomatic patients. A more useful test is urine microscopy and culture that is done on symptomatic patients only following careful clinical evaluation. Performing 'routine' urinalysis in patients presenting a wide variety of symptoms may lead to unnecessary urine cultures and treatment of asymptomatic bacteriuria. Efforts to reduce unnecessary tests and antibiotic treatment are a vital component of diagnostic stewardship programmes.


Assuntos
Medicina Geral/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Prospectivos , Procedimentos Desnecessários/estatística & dados numéricos , Infecções Urinárias/diagnóstico , Infecções Urinárias/epidemiologia , Adulto Jovem
11.
BMC Health Serv Res ; 19(1): 707, 2019 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-31707993

RESUMO

BACKGROUND: It is unknown to what extent Choosing Wisely recommendations about income-generating treatments apply to members of the society generating the recommendations. The primary aim of this study is to determine the proportion of Choosing Wisely recommendations targeting income-generating treatments, and whether recommendations from professional societies on income-generating treatments are more likely to target members or non-members. The secondary aim is to determine the prevalence of qualified statements, and whether qualified statements are more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. METHODS: We performed a content analysis of all Choosing Wisely recommendations, with data extracted from Choosing Wisely websites. Two researchers coded recommendations as test or treatment-based, for or against a procedure, containing qualified statements, income-generating and applying to members. Disagreements were resolved by discussion or consultation with a third researcher. A Chi-squared test evaluated whether society recommendations on income-generating treatments were more likely to target members or non-members; and whether qualified statements were more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. RESULTS: We found 1293 Choosing Wisely recommendations (48.3% tests and 48.6% treatments). Ninety-eight treatment recommendations targeted income-generating treatments (17.8%), and recommendations on income-generating treatments were less likely to target members compared to non-members (15.6% vs. 40.4%, p < 0.001). Nearly half of all recommendations were qualified (41.9%), with a similar proportion of recommendations targeting income-generating and non-income-generating treatments that apply to members containing qualified statements (49.4% vs. 42.0%, p = 0.23). CONCLUSIONS: Many societies provide Choosing Wisely recommendations that minimise impact on their own members. Only 20% of treatment recommendations target income-generating treatments, and of these recommendations mostly target non-members. Many recommendations are also qualified. Increasing the number of recommendations from societies that are unqualified and target member clinicians responsible for de-implementation of low-value and costly treatments should be a priority.


Assuntos
Comportamento de Escolha , Renda , Procedimentos Desnecessários/economia , Saúde Global/economia , Política de Saúde/economia , Humanos , Pobreza , Guias de Prática Clínica como Assunto , Sociedades Médicas/economia
12.
J Am Dent Assoc ; 150(11): 986, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31668175
13.
Ann Saudi Med ; 39(5): 354-358, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31580713

RESUMO

BACKGROUND: Measuring both serum amylase and lipase in the setting of acute pancreatitis is not recommended and monitoring changes in amylase and lipase levels after diagnostic results is of little added value. The extent of the two types of superfluous amylase/lipase testing at our institution is unknown. OBJECTIVE: Explore the extent of superfluous amylase/lipase testing. DESIGN: Medical record review. SETTINGS: Tertiary care, teaching hospital. PATIENTS AND METHODS: We retrospectively reviewed all amylase and lipase tests performed over a recent 12-month period. Amylase tests were considered superfluous if they were ordered with lipase tests at the same time or if they were repeated after diagnostic amylase results. They were considered questionably superfluous if they were repeated alone after non-diagnostic amylase results. Lipase tests were considered superfluous if they were repeated after diagnostic lipase results and questionably superfluous if they were repeated after non-diagnostic lipase results. MAIN OUTCOME MEASURES: Number and percentage of lipase and amylase tests that were superfluous or questionably superfluous. SAMPLE SIZE: 23 950. RESULTS: Superfluous testing was identified in 30.6% of 23 950 amylase/lipase tests and questionably superfluous testing in 12.4%. Of the 7330 superfluous tests, 94.8% were due to simultaneous amylase/lipase testing and 5.2% to repeated lipase testing after diagnostic results. The rate of superfluous and questionably superfluous testing was significantly higher in the inpatient setting compared to emergency department or outpatient settings ( P<.0001). Of the 6483 amylase tests obtained simultaneously with non-diagnostic lipase tests, only 36 (0.6%) showed a diagnostic result. Furthermore, only 0.7% and 3.6% of amylase tests that were repeated after normal and borderline results, respectively, were diagnostic and 1.1% and 9.3% of lipase tests that were repeated after normal and borderline results, respectively, were diagnostic. CONCLUSIONS: About one third of amylase/lipase testing appears to be superfluous, mainly due to simultaneous amylase/lipase testing. Since only 0.6% of simultaneous amylase/lipase tests showed diagnostic amylase with non-diagnostic lipase levels, quality improvement initiatives should be directed at reducing this low-value practice. Repeating amylase/lipase tests following normal results is of little value. LIMITATIONS: Clinical notes and imaging studies were not reviewed. CONFLICT OF INTEREST: None.


Assuntos
Amilases/sangue , Lipase/sangue , Pancreatite/diagnóstico , Procedimentos Desnecessários/estatística & dados numéricos , Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais de Ensino , Humanos , Pancreatite/sangue , Estudos Retrospectivos , Centros de Atenção Terciária
17.
Bone Joint J ; 101-B(10): 1307-1312, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31564143

RESUMO

AIMS: In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries. PATIENTS AND METHODS: Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up. RESULTS: In 100 patients (59 female, 41 male; mean age 57 years), 91 of the fractures (91%) remained stable. In five of nine patients (55%) with secondary displacement, surgery was recommended. Comminution, present in 23 patients (23%), was identified as a predictor of secondary displacement (p < 0.001). Patients' age, sex, fracture configuration, and bone quality were not associated with secondary displacement (p ≥ 0.438). Nonoperative treatment resulted in a mean absolute Constant score (CS) of 80 (49 to 98), relative CS of 101% (63% to 138%), median subjective shoulder value of 95% (interquartile range (IQR) 90% to 100%), and median EuroQol five-dimensional questionnaire score of 0.89 (IQR 0.80 to 1.00) with bone union in all cases at one-year follow-up. CONCLUSION: Radiological re-evaluation was only necessary in patients presenting with comminution and may be redundant for 77% of patients with one-part proximal humerus fractures. Nonoperative treatment of one-part proximal humerus fractures remains the mainstay of treatment with a low rate of secondary surgery, a high union rate, and good clinical results. Cite this article: Bone Joint J 2019;101-B:1307-1312.


Assuntos
Tratamento Conservador/métodos , Consolidação da Fratura/fisiologia , Radiografia/estatística & dados numéricos , Sistema de Registros , Fraturas do Ombro/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Fixação de Fratura/métodos , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Radiografia/métodos , Fraturas do Ombro/terapia , Estatísticas não Paramétricas , Fatores de Tempo
18.
Braz J Infect Dis ; 23(5): 331-335, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31562852

RESUMO

The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.


Assuntos
Doenças Transmissíveis/diagnóstico , Sociedades Médicas , Procedimentos Desnecessários/estatística & dados numéricos , Brasil , Saúde Global , Pesquisa sobre Serviços de Saúde , Humanos
19.
N Z Med J ; 132(1502): 16-24, 2019 09 20.
Artigo em Inglês | MEDLINE | ID: mdl-31563924

RESUMO

AIM: To evaluate the effectiveness of awareness-raising by the Choosing Wisely campaign in a New Zealand public hospital to reduce routine pre-operative testing and to determine what can be done to bring about change in clinician behaviour. METHODS: Short, semi-structured, one on-one interviews were conducted with 15 doctors of varying seniority from general surgery who were exposed to the campaign between August and October 2018. The interviews covered four general topics including background information, asking about awareness and effectiveness of Choosing Wisely campaign, exploring barriers to changing clinician behaviour around pre-operative testing and exploring potential interventions which may be useful to change behaviour. Data were analysed using Braun and Clarke thematic analysis methodology. RESULTS: Four themes and 17 sub-themes emerged from the interviews. The main themes included awareness of Choosing Wisely, thoughts around pre-operative testing, barriers for changing clinician behaviour and strategies for reducing unnecessary pre-operative testing. CONCLUSION: The findings of this study suggest that a strategy that relies on revising guidelines and raising staff awareness alone is likely to be of limited effectiveness in reducing unnecessary pre-operative testing. In addition to increasing clinician awareness of evidence-based recommendations on unnecessary testing, other strategies may be needed to support behaviour change.


Assuntos
Sobremedicalização/prevenção & controle , Padrões de Prática Médica/organização & administração , Cuidados Pré-Operatórios , Procedimentos Desnecessários , Adulto , Atitude do Pessoal de Saúde , Testes Diagnósticos de Rotina/métodos , Testes Diagnósticos de Rotina/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/tendências , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Medição de Risco , Procedimentos Desnecessários/métodos , Procedimentos Desnecessários/estatística & dados numéricos
20.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31511313

RESUMO

BACKGROUND: Although pharyngitis is common, group A Streptococcus is an uncommon etiology, and sequelae are rare in patients <3 years old. Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in this age group. At our urban, tertiary pediatric emergency department (ED), on average, 20 RSTs were performed each month for patients <3 years of age. Our objective was to reduce RSTs in the ED in patients aged <3 years by 50% in 18 months. METHODS: We initiated this project in October 2016 at an urban, tertiary pediatric ED. We surveyed pertinent multidisciplinary stakeholders to identify factors leading to RSTs in children <3 years of age. We conducted multiple interventions and collected weekly data on the number of RSTs in children aged <3 years (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure). We used statistical process control for analysis. RESULTS: The mean number of RSTs ordered per month in patients aged <3 years declined by 52% in 10 months. The majority of tests during the study phase were ordered by nurse practitioners (62%) for patients aged 25 to 36 months (66%). There has been 1 family grievance and no patient complications attributable to the project. CONCLUSIONS: Our interventions led to a successful and sustained reduction of RSTs in patients aged <3 years. A local clinical practice guideline was developed, and the project was expanded to other acute care settings.


Assuntos
Serviço Hospitalar de Emergência , Testes de Sensibilidade Microbiana/estatística & dados numéricos , Faringite/microbiologia , Infecções Estreptocócicas/diagnóstico , Procedimentos Desnecessários , Pré-Escolar , Sistemas de Apoio a Decisões Clínicas , Registros Eletrônicos de Saúde , Feminino , Humanos , Capacitação em Serviço , Masculino , Missouri , Streptococcus pyogenes/isolamento & purificação
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