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1.
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
2.
Am Surg ; 86(8): 1022-1025, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32809851

RESUMO

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t-test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica , Cálculos Biliares/diagnóstico por imagem , Icterícia Obstrutiva/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Procedimentos Desnecessários/estatística & dados numéricos , Colangiografia/métodos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Icterícia Obstrutiva/etiologia , Icterícia Obstrutiva/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade
3.
J Surg Res ; 254: 384-389, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32535257

RESUMO

BACKGROUND: Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm2. We sought to determine the adherence to and effectiveness of this algorithm. METHODS: This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant. RESULTS: Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess. CONCLUSIONS: Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.


Assuntos
Abscesso Abdominal/cirurgia , Apendicectomia/efeitos adversos , Drenagem , Fidelidade a Diretrizes/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Abscesso Abdominal/etiologia , Adolescente , Algoritmos , Criança , Pré-Escolar , Feminino , Humanos , Tempo de Internação , Masculino , Estudos Prospectivos
4.
AJR Am J Roentgenol ; 215(1): 153-158, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32432908

RESUMO

OBJECTIVE. In 2011, the Centers for Medicare & Medicaid Services (CMS) initiated public reporting of outpatient imaging efficiency measures to reduce potentially inappropriate imaging and unnecessary exposure to ionizing radiation performed in hospital outpatient departments. Three CMS quality measures were designed to reduce duplicative CT in the Medicare population: OP-10, which CMS lists as "Abdomen Computed Tomography-Use of Contrast Material"; OP-11, which CMS lists as "Thorax CT-Use of Contrast Material"; and OP-14, which CMS lists as "Simultaneous Use of Brain CT and Sinus CT." We describe trends in hospital performance on these national hospital outpatient imaging efficiency measures since the inception of their public reporting. MATERIALS AND METHODS. This observational analysis used standard Medicare fee-for-service administrative claims to calculate hospital-specific scores for OP-10, OP-11, and OP-14. Consistent with CMS specifications, each measure was calculated as a percentage with appropriate exclusions and minimum case count requirements to ensure measure score validity and reliability. We report national performance as well as distributions of hospital performance scores for each annual public reporting period. Trend analyses were performed to examine changes in annual mean performance over time. Secondary analyses assessed trends and hospital performance by location (rural vs urban) and hospital characteristics. RESULTS. Between 2011 and 2018, the national mean rate of duplicate imaging declined for all three measures (OP-10, 18.9% vs 7.7%; OP-11, 5.6% vs 2.0%; OP-14, 2.5% vs 1.0%). For OP-10 and OP-11, most outlier hospitals were rural, small, and government-owned. For OP-10, rural facilities accounted for 32.2% of all facilities but 46.0% of outliers by the end of the study period. Similarly, for OP-11, rural facilities accounted for 30.1% of all facilities but 47.0% of outliers by the end of the study period. In general, the proportion of outliers located in rural areas decreased over time. CONCLUSION. National performance on CMS quality measures of duplicative CT has improved over time, with reduced variation observed between hospitals since the inception of public reporting. These successes support recent CMS policy initiatives to retire duplicative imaging measures from public reporting. Future work should seek to identify opportunities to use national public reporting initiatives to yield similar improvements across broader indications and settings.


Assuntos
Diagnóstico por Imagem/normas , Eficiência Organizacional , Ambulatório Hospitalar/normas , Indicadores de Qualidade em Assistência à Saúde , Centers for Medicare and Medicaid Services, U.S. , Meios de Contraste , Humanos , Estados Unidos , Procedimentos Desnecessários/estatística & dados numéricos
5.
Am J Emerg Med ; 38(7): 1546.e1-1546.e4, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32340823

RESUMO

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) criteria identify children at low risk of clinically important traumatic brain injury (ciTBI) in whom CT head (CTH) is unnecessary. We assessed compliance with PECARN at outside hospitals (OSH) among children transferred to our pediatric trauma center. METHODS: Patients <18 years transferred between May 2016 and December 2018 undergoing CTH at an OSH were reviewed. A ciTBI was defined as one requiring hospitalization ≥2 midnights, intubation >24 h, neurosurgical intervention, or causing death. RESULTS: 202 children were transferred after CTH. 53 were excluded for incomplete records (16), suspected abuse (33), or penetrating injury (4). Of the 149 included children, PECARN recommended CTH in 39 (26.2%), shared decision making in 79 (53.0%), and no imaging in 31 (20.8%). 26 children (17.4%) had a radiographic traumatic brain injury (rTBI) while only 6 (4.0%) had ciTBIs. Of those with ciTBIs, PECARN recommended CTH in 4 and shared decision making in 2. No child in whom CTH was not recommended had a ciTBI. 45 (30.2%) children had isolated extracranial injuries requiring transfer and 83 (55.7%) were transferred despite normal CTHs and no associated injuries. 2 (1.3%) children underwent non-emergent surgery for ciTBI. CONCLUSIONS: Compliance with PECARN was low among referring facilities with nearly 75% of CTHs being potentially avoidable with proper adherence and parental counseling. Deferring imaging until after transfer appears safe as no child underwent emergent intervention upon arrival. Early transfer and improved compliance with PECARN may reduce the number of CTHs performed.


Assuntos
Lesões Encefálicas/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Centros de Traumatologia
6.
Trop Med Int Health ; 25(7): 824-833, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32324928

RESUMO

OBJECTIVES: Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned. METHODS: We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process. RESULTS: 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely. CONCLUSIONS: Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.


Assuntos
Hospitais de Distrito/estatística & dados numéricos , Encaminhamento e Consulta/normas , Procedimentos Cirúrgicos Operatórios/normas , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Malaui , Masculino , Pessoa de Meia-Idade , Pobreza , Estudos Prospectivos , Melhoria de Qualidade , Encaminhamento e Consulta/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/economia , Adulto Jovem
7.
Medicine (Baltimore) ; 99(17): e19880, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332659

RESUMO

Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it.Data were collected from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification.A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth.Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually.We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.


Assuntos
Cesárea/estatística & dados numéricos , Adolescente , Adulto , Brasil , Cesárea/tendências , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Parto Obstétrico/tendências , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Procedimentos Desnecessários/normas , Procedimentos Desnecessários/estatística & dados numéricos
8.
J Pediatr Surg ; 55(6): 1013-1022, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32169345

RESUMO

BACKGROUND: Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement. METHODS: The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation. RESULTS: We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p < 0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5-36) to 5.5 days (1-19), p = 0.0002) decreased. CONCLUSIONS: A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.


Assuntos
Assistência à Saúde/normas , Intubação Gastrointestinal/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Criança , Procedimentos Clínicos/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Fundoplicatura/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos
10.
J Trauma Acute Care Surg ; 89(1): 222-225, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32118824

RESUMO

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.


Assuntos
Procedimentos Neurocirúrgicos/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Hemorragia Subaracnoídea Traumática/cirurgia , Centros de Traumatologia/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Escala Resumida de Ferimentos , Idoso , Idoso de 80 Anos ou mais , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Hemorragia Subaracnoídea Traumática/mortalidade
11.
Postgrad Med ; 132(6): 506-511, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32133896

RESUMO

Objective: Thyroid nodules are highly prevalent and a common clinical problem worldwide. How to identify the nature of a nodule is a major concern of clinicians. Fine needle aspiration cytology (FNAC) has an established role and is well-utilized in nodule management. However, the unsatisfactory nondiagnostic and indeterminate rates limit its usage and lead to some unnecessary surgery. Hashimoto thyroiditis (HT) is prevalently found concurrent with thyroid nodules. Whether HT can influence the accuracy of cytopathological diagnosis of nodules is still controversial. Methods: We collected medical records of 1,063 patients with thyroid nodules who had done FNAC in our hospital from 2015 to 2016. Thyroid function, anti-thyroid autoantibody levels, thyroid ultrasound records, and cytological and histopathological results of nodules were reviewed to analyze the impact of HT on FNAC outcome. Results: A total of 1,063 patients with an average age of 44 ± 13 years old were retrospectively reviewed for pathological and clinical data. Patients with different cytological diagnoses had comparable positive rates of anti-thyroid autoantibodies. One hundred patients were confirmed to have concurrent HT by histopathology after surgery. The overall nondiagnostic and indeterminate cytology rates were 11.9% and 25% respectively. No statistical difference was found either in the rate of a nondiagnostic cytology results or in the rate of indeterminate cytology results between patients with positive anti-thyroid autoantibodies and patients with negative test for anti-thyroid autoantibodies (P > 0.05). The same was true between patients with histopathologically confirmed HT and HT-negative ones (P > 0.05). Conclusions: The presence of concurrent HT, whether clinically implied with positive anti-thyroid autoantibodies or pathologically confirmed, is unlikely to predispose an FNAC diagnosis of thyroid nodules to be non-diagnostic or indeterminate.


Assuntos
Autoanticorpos/sangue , Biópsia por Agulha Fina/métodos , Doença de Hashimoto , Utilização de Procedimentos e Técnicas/normas , Glândula Tireoide , Nódulo da Glândula Tireoide , Adulto , Confiabilidade dos Dados , Diagnóstico Diferencial , Feminino , Doença de Hashimoto/diagnóstico , Doença de Hashimoto/imunologia , Humanos , Imuno-Histoquímica , Masculino , Registros Médicos Orientados a Problemas , Melhoria de Qualidade , Testes de Função Tireóidea/métodos , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/imunologia , Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/sangue , Nódulo da Glândula Tireoide/patologia , Ultrassonografia/métodos , Procedimentos Desnecessários/estatística & dados numéricos
12.
JAMA Netw Open ; 3(2): e1921202, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32058553

RESUMO

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.


Assuntos
Redução Fechada , Fraturas do Rádio , Procedimentos Desnecessários , Criança , Pré-Escolar , Redução Fechada/economia , Redução Fechada/estatística & dados numéricos , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Hipnóticos e Sedativos , Masculino , Pais , Aceitação pelo Paciente de Cuidados de Saúde , Fraturas do Rádio/economia , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/cirurgia , Estudos Retrospectivos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos
13.
Can J Surg ; 63(2): E100-E109, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32109016

RESUMO

Background: In 2012, the American Society of Clinical Oncology (ASCO) released a Choosing Wisely Top Five list that included a recommendation against ordering advanced imaging tests to screen for metastases among asymptomatic patients with early breast cancer. Our provincial breast cancer staging guideline was subsequently updated. We report on the use of unwarranted bone scanning (BS), computed tomography (CT), nonbreast magnetic resonance imaging (MRI) and positron emission tomography (PET) among women diagnosed with stage 0­II breast cancer in Alberta in 2011­2015. Methods: The cohort was retrospectively ascertained from the Alberta Cancer Registry. We used additional provincial data sources to obtain information about diagnostic imaging tests completed from biopsy to surgical date plus 4 months. The reason for each BS, CT, MRI and PET was abstracted. We calculated the frequency of advanced imaging tests completed for routine metastatic screening. Results: Of 10 142 patients included, 2887 (28.5%) had at least 1 advanced imaging test completed for routine metastatic screening. Of these 2887 patients, 438 (15.2%) had a follow-up BS, CT, MRI or PET, and 28 patients (1.0%) had a nonbreast imageguided biopsy. Use of routine advanced imaging tests did not change clearly over time. Conclusion: Our results demonstrate persistent use of advanced imaging tests for routine metastatic screening among patients with stage 0­II breast cancer despite the release of the ASCO Choosing Wisely recommendations and the update of our provincial breast cancer staging guideline. Investigation of strategies for guideline translation to improve upon value-based care of patients with early breast cancer is warranted.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Diagnóstico por Imagem/estatística & dados numéricos , Metástase Neoplásica/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Osso e Ossos/diagnóstico por imagem , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Sistema de Registros , Estudos Retrospectivos , Adulto Jovem
14.
Acta Med Port ; 33(1): 7-14, 2020 Jan 03.
Artigo em Inglês | MEDLINE | ID: mdl-31928599

RESUMO

INTRODUCTION: Imaging tests are essential for diagnosis in the emergency context and convey clinical information that is essential to assess the appropriateness of the tests and improve their interpretation. Therefore, we aimed to analyze the imaging tests requested by the Emergency Department in a district hospital. MATERIAL AND METHODS: We retrospectively analyzed computed tomography and ultrasound scans requested by the Emergency Department at the Centro Hospitalar Universitário do Algarve and considered the following variables: requested test, clinical information provided (complete/incomplete), appropriateness of the test (appropriate/inappropriate), outcome (presence/absence of relevant findings) and findings related to the clinical information (yes/no). Pearson's chi-squared and odds ratio association tests were used to evaluate the statistical association between the variables. RESULTS: Out of 1427 requests, only 219 (15.3%) were considered to have complete clinical information. Nonetheless, 1075 (75.3%) requests were considered appropriate. Relevant findings were present in about one-third (n = 453; 31.7%) and most of these findings were related to the clinical context (n = 410; 90.5%). There was a significant association between test appropriateness and the presence of relevant findings in the test (p < 0.001). The odds ratio of having a relevant finding was 5.0 times higher in the tests considered appropriate when compared with those classified as inappropriate (CI = 3.4 - 7.3; p < 0.001). DISCUSSION: The fact that appropriate tests potentiate the probability of having a relevant finding emphasizes the importance of defining guidelines so that only the adequate tests are performed. CONCLUSION: Creating guidelines should improve the appropriateness of imaging tests requested in the Emergency Department, yielding their result, with the consequent rationalization of the available resources.


Assuntos
Serviço Hospitalar de Emergência , Prescrições/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Portugal , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Prescrições/normas , Serviço Hospitalar de Radiologia/normas , Serviço Hospitalar de Radiologia/estatística & dados numéricos , Estudos Retrospectivos , Sociedades Médicas/normas , Tomografia Computadorizada por Raios X/normas , Ultrassonografia/normas , Procedimentos Desnecessários/normas
15.
JAMA Intern Med ; 180(2): 274-280, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31904768

RESUMO

Importance: Pelvic examination is no longer recommended for asymptomatic, nonpregnant women and may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination (BPE) is an invasive and controversial examination component. Cervical cancer screening is not recommended for women younger than 21 years. Objectives: To estimate prevalence of potentially unnecessary BPE and Papanicolaou (Pap) tests performed among adolescent girls and women younger than 21 years (hereinafter referred to as young women) in the United States and to identify factors associated with receiving these examinations. Design, Setting, and Participants: A cross-sectional analysis of the National Survey of Family Growth from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years (n = 3410). The analysis used survey weights to estimate prevalence and the number of people represented in the US population. Data were analyzed from December 21, 2018, through September 3, 2019. Main Outcomes and Measures: Receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests. Results: Responses from 3410 young women aged 15 to 20 years were included in the analysis with 6-year sampling weights applied. Among US young women aged 15 to 20 years represented during the 2011-2017 study period, 4.8% (95% CI, 3.9%-5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months (Table 1). Only 2.0% (95% CI, 1.4%-2.9%) reported using an IUD, and 33.5% (95% CI, 30.8%-36.4%) used at least 1 other type of hormonal contraception in the past 12 months. Among US young women aged 15 to 20 years who were surveyed in the years 2011 through 2017, approximately 2.6 million (22.9%; 95% CI, 20.7%-25.3%) reported having received a BPE in the last 12 months. Approximately half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals. Receipt of a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR], 7.12; 95% CI, 5.56-9.12), testing for sexually transmitted infections (aPR, 1.60; 95% CI, 1.34-1.90), and using hormonal contraception other than an intrauterine device (aPR, 1.31; 95% CI, 1.11-1.54). In addition, an estimated 2.2 million young women (19.2%; 95% CI, 17.2%-21.4%) reported having received a Pap test in the past 12 months, and 71.9% (95% CI, 66.0%-77.1%) of these tests were potentially unnecessary. Conclusions and Relevance: This analysis found that more than half of BPEs and almost three-quarters of Pap tests performed among young women aged 15 to 20 years during the years 2011 through 2017 were potentially unnecessary, exposing women to preventable harms. The results suggest that compliance with the current professional guidelines regarding the appropriate use of these examinations and tests may be lacking.


Assuntos
Exame Ginecológico/estatística & dados numéricos , Teste de Papanicolaou/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Esfregaço Vaginal/estatística & dados numéricos , Adolescente , Detecção Precoce de Câncer , Feminino , Contracepção Hormonal , Humanos , Dispositivos Intrauterinos , Guias de Prática Clínica como Assunto , Doenças Sexualmente Transmissíveis/diagnóstico , Estados Unidos , Neoplasias do Colo do Útero/diagnóstico , Adulto Jovem
16.
South Med J ; 113(1): 20-22, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31897494

RESUMO

OBJECTIVES: To determine the clinical utility and adverse consequences of routine admission chest x-ray (CXR) findings in patients with and without respiratory complaints and/or an abnormal chest examination. METHODS: In this prospective cohort study in an internal medicine department, we selected 273 patients and determined outcomes by chart review and physician interviews. The patients were divided into those with and without respiratory tract symptoms and/or findings on chest examination. The outcome variables were appropriate or inappropriate changes in treatment based on CXR findings. RESULTS: Of the 35 patients with respiratory tract symptoms/signs, 7 (20%) had a change in therapy based on CXR findings, which was effective in 5 of them. In the other 238 patients, an unexpected pleural empyema was detected in a hypotensive dialysis patient (0.4%, 95% confidence interval 0-2.3). Besides costs and radiation exposure, major adverse effects included two patients (0.8%, 95% confidence interval 0.1-3.0) with a false-positive test result that resulted in inappropriate hospitalizations and antibiotic therapy. In patients without respiratory tract symptoms or findings on physical examination, the clinical benefits and major adverse consequences were uncommon. CONCLUSIONS: Admission CXRs in patients without respiratory tract symptoms or findings are unwarranted except perhaps in older adult patients with comorbidities and an unclear admitting diagnosis.


Assuntos
Admissão do Paciente/estatística & dados numéricos , Radiografia Torácica/estatística & dados numéricos , Doenças Respiratórias/diagnóstico por imagem , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Procedimentos Desnecessários/estatística & dados numéricos
17.
J Surg Res ; 248: 144-152, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31901641

RESUMO

BACKGROUND: Right iliac fossa (RIF) pain is a common referral to general surgery as acute appendicitis is one of the most common underlying diagnoses. The clinical diagnosis of appendicitis continues to challenge clinicians. Clinical prediction rules (CPRs) are one method used to improve diagnostic accuracy and reduce negative appendicectomy rates. The APPEND score is a novel CPR that was developed at Middlemore Hospital. AIM: To prospectively evaluate the performance of the APPEND CPR within a pathway dedicated to the management of RIF pain. METHODS: A comparative cohort study of the clinical pathway incorporating the APPEND CPR pain was performed from January to July 2016. This was compared to the retrospective cohort used to develop the APPEND CPR. The primary end point was negative appendicectomy rate. RESULTS: The negative appendicectomy rate in the prospective cohort was 9.2% (95% CI: 5.3%, 13.2%) compared to 19.8% (CI 16.2, 23.4%) in the retrospective cohort that did not use the APPEND CPR. After adjusting for multiple variables, the odds ratio of a negative appendicectomy was 2.33 times higher (95% CI; 1.26, 4.3, P value 0.007) in the retrospective cohort compared to the prospective cohort. An APPEND score of ≥5 was 87 % specific for ruling in appendicitis (PPV 94%) and a score of ≥1 was 100% sensitive in ruling out appendicitis (NPV 100%). CONCLUSIONS: In a comparative cohort study of an RIF pain pathway incorporating the APPEND CPR, the rate of negative appendicectomy showed a significant reduction by more than 50%.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico , Regras de Decisão Clínica , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
18.
J Healthc Qual ; 42(1): 12-18, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30649004

RESUMO

The Choosing Wisely (CW) initiative provides recommendations for healthcare providers, aimed at reducing unnecessary or inappropriate tests and procedures. A clinical decision support (CDS) alert in the electronic health record was developed to reflect organizational CW guidelines regarding blood chemistry panel ordering in the primary care setting. An interrupted time series design was used to analyze the weekly proportion of inappropriate blood chemistry panel orders prior to and after implementation of the CDS alert in treatment and control groups. Implementation of the CDS alert significantly decreased the average weekly proportion of inappropriate blood chemistry panels from 28.64% to 15.69% in the treatment group (p < .001). Apart from other efforts implemented simultaneously to reduce inappropriate lab ordering, the CDS alert produced a significant reduction in inappropriate lab ordering. We conclude that CDS alerts can be an effective strategy for healthcare organizations seeking to more closely adhere to CW guidelines.


Assuntos
Análise Química do Sangue/estatística & dados numéricos , Análise Química do Sangue/normas , Sistemas de Apoio a Decisões Clínicas , Testes Diagnósticos de Rotina/estatística & dados numéricos , Testes Diagnósticos de Rotina/normas , Guias como Assunto , Procedimentos Desnecessários/estatística & dados numéricos , Procedimentos Desnecessários/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Idaho , Masculino , Pessoa de Meia-Idade , Utah
19.
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 , Imageamento por Ressonância Magnética Multiparamétrica/estatística & dados numéricos , 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
20.
Appl Health Econ Health Policy ; 18(1): 69-79, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31541361

RESUMO

BACKGROUND: Novel diagnostics are needed to manage antimicrobial resistance (AMR). Patient preferences are important in determining whether diagnostic tests are successful in practice, but there are few data describing the test attributes which matter most to patients. We elicited patients' preferences for attributes of diagnostic tests that could be used to reduce unnecessary antibiotic use in primary care across seven European countries. METHODS: We used an online stated preference survey, including a discrete choice experiment (DCE). The DCE explored how patients make trade-offs between three key attributes of diagnostic tests: the speed that results were available, confidence in the test results, and how convenient it is to take the test. Individuals were eligible to complete the survey if they had taken antibiotics within the last 2 years and were resident in Germany, Italy, Spain, France, Greece, the Netherlands or the United Kingdom (UK). RESULTS: In total, 988 respondents completed the survey. The DCE responses illustrated that speed was the least important attribute in most countries. Responses from Germany and the Netherlands indicated that confidence was most important in these countries. Responses from the UK, France, Spain and Italy showed convenience as the most important attribute in these countries. Two attributes, confidence and convenience, were jointly favoured by respondents in Greece. CONCLUSION: Patients in different European countries do not have the same preferences for the attributes of diagnostic tests to manage AMR in primary care. Failure to account for such differences during test development could reduce test uptake, result in continued overuse of antibiotics, and hamper marketisation.


Assuntos
Antibacterianos , Testes Diagnósticos de Rotina/psicologia , Testes Diagnósticos de Rotina/estatística & dados numéricos , Farmacorresistência Bacteriana , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Procedimentos Desnecessários/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
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