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Rev Saude Publica ; 53: 87, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31576946


OBJECTIVE: To analyze the trend of opinion and satisfaction indicators of the Spanish national health system from 2005 to 2017. METHODS: Ecological study of time series analyzing the trend of eight indicators of opinion and satisfaction on the Spanish national health system and its autonomous communities from 2005 to 2017. The data was obtained from the Ministry of Health, Social Services and Equality and from the Health Barometer. The Prais-Winsten regression method was used. RESULTS: A static tendency was observed in the perception of users on how the health system works (APC = 1.898, 95%CI -0.954 - 4.751) and decreasing opinion on the improvement of primary care (APC = -0.283; 95%CI -0.335 - -0.121), specialized (APC = -0.241, 95%CI -0.74 - -0.109) and hospitalization (APC = -0.171, 95%CI -0.307 - -0.036). Satisfaction with knowledge and follow-up by the family doctor and pediatrician showed an increasing trend (APC = 7.939, 95%CI 3.965 - 11.914). Satisfaction with medical and nursing professionals was static. No large differences were observed in the trends of the indicators studied in the autonomous communities. CONCLUSIONS: A negative trend was observed in the opinion of the Spanish national health system users. Financing, human resources, quality management systems and differences in the autonomous communities may be some of the causes.

Programas Nacionais de Saúde/estatística & dados numéricos , Programas Nacionais de Saúde/tendências , Satisfação do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/tendências , Pesquisa sobre Serviços de Saúde , Humanos , Atenção Primária à Saúde/estatística & dados numéricos , Atenção Primária à Saúde/tendências , Valores de Referência , Análise de Regressão , Espanha , Fatores de Tempo
Keio J Med ; 68(3): 68, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31554775


Dementia care currently costs the UK 21 bn pounds a year, and that doesn't include the huge informal costs of family careers and community support networks. Developing services to meet the needs of patients with complex health problems must involve service users. Professor Robinson has addressed what resources are needed to provide a better quality of care, and how these can be successfully delivered to patients and their family. As Newcastle University's Professor of Primary Care and Ageing, and as a working GP in a Newcastle practice, she is keen to ensure that the benefits of the University's excellent research into ageing and the diseases of old age are translated into high quality treatment and care for older people. She leads the Primary Care Group of the Dementia and Neurodegenerative Diseases Research Network (DeNDRoN), a national network of researchers which aims to explore the whole spectrum of dementia care from diagnosis and early detection, through to advanced dementia and end of life care. Another Professor Robinson's ambitions would be to help create a center of excellence at Newcastle University for training GPs, hospital staff, community nurses and others in all aspects of dementia care. In this lecture, Prof Robinson will talk about how her translational research had influenced UK practice over the last 10+ years and at same time bring in her career development in both clinical and academic field.(Presented at the 1982th Meeting, June 25, 2019).

Demência/terapia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Assistência Terminal/organização & administração , Idoso , Idoso de 80 Anos ou mais , Redes Comunitárias/provisão & distribução , Demência/diagnóstico , Demência/psicologia , Humanos , Atenção Primária à Saúde/ética , Qualidade da Assistência à Saúde/tendências , Assistência Terminal/ética , Assistência Terminal/psicologia , Reino Unido
J Orthop Surg Res ; 14(1): 280, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31462273


BACKGROUND: Revision total knee arthroplasty (rTKA) is a demanding procedure, with a high complication and failure rate and a high rate of bone losses and poor bone quality. Different classifications for bone losses have been proposed, but they do not consider bone quality, which may affect implant fixation. The aim of this study is to describe the outcomes of a consecutive series of rTKA. Furthermore, a modified bone loss classification will be proposed based also on bone quality. Finally, the association between radiolucent line (RLL) development and different risk factors will be evaluated. METHODS: All the patients who underwent rTKA between 2008 and 2016 in the same institution were included. rTKAs were performed by the same surgeon according to the three-step technique. Bone losses were classified according to the proposed classification, including bone quality evaluation. The Knee Scoring System (KSS), the Hospital for Special Surgery Knee Score (HSS), and the SF-12 were used for the clinical evaluation. Radiological evaluation was performed according to the Knee Society Roentgenographic Evaluation System. Different possible risk factors (i.e., gender, age, amount of bone losses) associated to RLL development were identified, and this association was evaluated using logistic regression. RESULTS: Fifty-one patients (53 knees) were included (60.8% female, average age 71.5 years). The average follow-up was 56.6 months (range 24-182). The most frequent cause of failure was aseptic loosening (41.5%). 18.9% of the cases demonstrated poor bone quality. Bone losses were treated according to the proposed algorithm. In all the cases, there was a significant improvement in all the scores (P < 0.05). The average post-operative range of motion was 110.5° (SD 10.7). At the radiological evaluation, all the implants resulted well aligned, with 15.1% of non-progressive RLL. There were 2 failures, with a cumulative survivorship of 92.1% at the last follow-up (SD 5.3%). At the logistic regression, none of the evaluated variables resulted associated to RLL development. CONCLUSION: rTKA is a demanding procedure, and adequate treatment of bone losses is mandatory to achieve good results. However, also bone quality should be taken into consideration when approaching bone losses, and the proposed classification may need surgeons after an adequate validation. LEVEL OF EVIDENCE: Level IV.

Artroplastia do Joelho/normas , Doenças Ósseas/cirurgia , Complicações Pós-Operatórias/cirurgia , Qualidade da Assistência à Saúde/normas , Reoperação/normas , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/tendências , Doenças Ósseas/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Prospectivos , Qualidade da Assistência à Saúde/tendências , Reoperação/tendências , Resultado do Tratamento
N Engl J Med ; 381(3): 252-263, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31314969


BACKGROUND: Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). METHODS: Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States. RESULTS: During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets. CONCLUSIONS: During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).

Planos de Seguro Blue Cross Blue Shield , Gastos em Saúde/tendências , Qualidade da Assistência à Saúde , Reembolso de Incentivo/economia , Planos de Seguro Blue Cross Blue Shield/organização & administração , Massachusetts , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/tendências , Encaminhamento e Consulta/tendências , Mecanismo de Reembolso , Estados Unidos
Enferm. glob ; 18(55): 84-98, jul. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-186237


Objetivo: evaluar la calidad de la asistencia en una Unidad de Cuidados Intensivos maternos, ha tenido por base indicadores de estructura proceso y resultados. Material y método: estudio descriptivo, de análisis documental con abordaje cuantitativo. La colecta de datos ocurrió entre enero y febrero de 2017 en la Unidad de Cuidados Intensivos maternos de una maternidad de referencia en Piauí. Fue utilizado un guion observacional con muestra censal de 72 pacientes. Resultados: el eje higiene, confort y seguridad mostró una asistencia global deseable, excepto para los indicadores de nutrición e hidratación que presentaron asistencia tolerable o limíte. El eje que presentó mejores resultados fue las anotaciones de enfermería con asistencia deseable en gran parte de los artículos analizados. Conclusión: el estudio evidenció resultados satisfactorios de forma general, sin embargo, es importante que ocurran mejoras en la asistencia de enfermería a las pacientes ingresadas en la unidad de cuidados intensivos maternosl, sobre todo para los indicadores de nutrición e hidratación

Objetivo: avaliar a qualidade da assistência em uma Unidade de Terapia Intensiva Materna, tendo por base indicadores de estrutura, processo e resultados. Material e método: estudo descritivo, de análise documental com abordagem quantitativa. A coleta de dados ocorreu entre os meses de janeiro e fevereiro de 2017 na Unidade de Terapia Intensiva materna de uma maternidade de referência do Piauí. Utilizou-se roteiro observacional com amostra censitária de 72 pacientes. Resultados: o eixo higiene, conforto e segurança demonstraram uma assistência global desejável, exceto para os indicadores nutrição e hidratação que apresentaram assistência sofrível ou limítrofe. O eixo que apresentou melhores resultados foi anotações de enfermagem com assistência desejável em grande parte dos itens analisados. Conclusão: o estudo evidenciou resultados satisfatórios de forma geral, entretanto, chama-se atenção para melhoras na assistência de enfermagem às pacientes internadas na Unidade de Terapia Intensiva Materna, sobretudo para os indicadores nutrição e hidratação

Objective: to evaluate the quality of care provided in a maternal intensive care unit, based on indicators of structure, process and results. Material and methods: descriptive study of documentary analysis with a quantitative approach. Data collection happened between January and February 2017 at the Maternal Intensive Care Unit of a reference maternity hospital in Piauí. An observational script with a census sample of 72 patients was used. Results: the hygiene, comfort and safety axis showed adequate care. However, the nutrition and hydration indicators presented with risky and undesirable care. The axis that presented the best results was nursing records with adequate care in most of the analyzed items. Conclusion: the study showed satisfactory results in general; however, attention should be given to improvements in nursing care for patients hospitalized in the Maternal Intensive Care Unit, especially for the nutrition and hydration indicators

Humanos , Feminino , Adulto Jovem , Adulto , Enfermagem Materno-Infantil/tendências , Cuidados de Enfermagem/tendências , Cuidados Críticos/métodos , Unidades de Terapia Intensiva/organização & administração , Auditoria de Enfermagem/métodos , Qualidade da Assistência à Saúde/tendências , Melhoria de Qualidade , Segurança do Paciente
Enferm. glob ; 18(55): 510-524, jul. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-186249


Objetivo: describir el perfil demográfico, laboral y evaluar la calidad de vida en el trabajo del equipo de enfermería actuante en la Unidad de Urgencias. Método: estudio transversal, realizado en 2017 con 109 trabajadores. Se utilizó un cuestionario con perfil demográfico y laboral y la calidad de vida en el trabajo fue evaluada por medio de la adaptación del modelo de Walton. Resultados: de los 109 trabajadores, 75,2% eran del sexo femenino, 45,9% casados, 34,9% enfermeros, 53,2% técnicos de enfermería y 11,9% auxiliares de enfermería; El 89,9% tenía una carga horaria semanal de trabajo 30 horas y el 39,4% poseía otro empleo en la enfermería. La escala de la calidad de vida en el trabajo reveló que el 39,5% están insatisfechos y el 60,5% están satisfechos, se destaca que hubo mayor insatisfacción con la calidad de vida en el trabajo entre los profesionales enfermeros. Conclusión: los hallazgos de este estudio podrán guiar a las autoridades del sistema de salud a desarrollar estrategias, para promover mejor calidad de vida en el trabajo a los trabajadores de enfermería insatisfechos y, así, permitirles prestar una asistencia de mejor calidad a sus pacientes

Objetivo: descrever o perfil demográfico, laboral e avaliar a qualidade de vida no trabalho da equipe de enfermagem atuante na Unidade de Pronto Atendimento. Método: estudo transversal, realizado em 2017 com 109 trabalhadores. Foi utilizado um questionário com perfil demográfico e laboral e a qualidade de vida no trabalho foi avaliada por meio da adaptação do modelo de Walton. Resultados: dos 109 trabalhadores, 75,2% eram do sexo feminino, 45,9% casados, 34,9% enfermeiros, 53,2% técnicos de enfermagem e 11,9% auxiliares de enfermagem; 89,9% tinham carga horária semanal de trabalho 30 horas e 39,4% possuíam outro emprego na enfermagem. A escala da qualidade de vida no trabalho revelou que 39,5% estão insatisfeitos e 60,5% estão satisfeitos, destaca-se que houve maior insatisfação com a qualidade de vida no trabalho entre os profissionais enfermeiros. Conclusão: os achados deste estudo poderão nortear as autoridades do sistema de saúde a desenvolverem estratégias, para promover melhor qualidade de vida no trabalho aos trabalhadores de enfermagem insatisfeitos e, assim, permitir a eles prestar uma assistência de melhor qualidade aos seus pacientes

Objective: to describe the demographic and labor profile and evaluate the quality of working life of the nursing team working in an emergency care unit. Method: cross-sectional study, carried out in 2017 with 109 workers. A questionnaire with demographic and labor profile was used and the quality of life at work was evaluated through the adaptation of the Walton model. Results: of the 109 workers, 75.2% were female, 45.9% were married, 34.9% were nurses, 53.2% were nursing technicians and 11.9% were nursing assistants; 89.9% had a weekly workload of 30 hours and 39.4% had another job in nursing. The quality of life at work scale revealed that 39.5% are dissatisfied and 60.5% are satisfied.There was greater dissatisfaction with quality of life at work among nurses. Conclusion: the findings of this study may guide health system authorities to develop strategies to promote better quality of working life for dissatisfied nursing workers and thus enable them to provide better quality care to their patients

Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Socorristas/estatística & dados numéricos , Esgotamento Profissional/psicologia , Esgotamento Profissional/epidemiologia , Satisfação no Emprego , Qualidade de Vida , Enfermagem em Emergência/organização & administração , Condições de Trabalho , Qualidade da Assistência à Saúde/tendências , Equipe de Enfermagem/estatística & dados numéricos
Med Leg J ; 87(2): 85-88, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31179881


The National Health Service in UK is facing grave financial crisis. Recently, 65% of Acute Trusts have reported a collective deficit of £2.5 billion. This financial crunch has had significant impact on patient care and sustenance of essential healthcare services. In order to thrive, the National Health Service has begun significant rationing of treatment which has become increasingly apparent in recent times, exposing the National Health Service to legal challenges. This article reviews the current state of the National Health Service from a legal perspective.

Alocação de Recursos para a Atenção à Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/normas , Medicina Estatal/normas , Alocação de Recursos para a Atenção à Saúde/normas , Acesso aos Serviços de Saúde/economia , Humanos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Medicina Estatal/economia , Medicina Estatal/legislação & jurisprudência
Pharm. pract. (Granada, Internet) ; 17(2): 0-0, abr.-jun. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-184685


Background: Hormonal contraceptive pills have evolved as a common form of contraception worldwide. Pharmacists play a vital role in providing safe and effective access to these medicines. In many developing countries such as the United Arab Emirates (UAE), these medicines are available to the general public without the presentation of a prescription which requires the pharmacist to shoulder responsibility by assessing and educating patients to assure their appropriate use. Objectives: To evaluate community pharmacists' current practice of dispensing and counseling on hormonal contraceptives. Methods: Simulated patient methodology was used in this study. A single simulated patient visited community pharmacies requesting an oral contraceptive as per a preplanned scenario. Information from the visits were recorded on a data collection form including: pharmacist assessing patient eligibility to take hormonal contraceptives, selecting the appropriate oral contraceptive, providing complete counseling on how to use the pill, adherence, missed dose handlings and side effects of the medication. The Pharmacist was prompted by the simulated patient to provide the information if they did not provide spontaneous counseling. The quality of pharmacists' counseling was rated and consequently coded as complete, incomplete or poor. Results: A total of 201 community pharmacies were visited. More than 92% of the pharmacists did not ask the simulated patient any question to assess their eligibility to use contraceptives. Twenty three pharmacists (11.4%) selected the proper product. One hundred seventeen (58.2%) of the pharmacists provided spontaneous counseling on how to use the pill, 17 of them had their counsel rated as complete, but none of the pharmacists provided spontaneous counseling regarding adherence or side effects of the medications. On prompting, 10 pharmacists (12%) provided complete counseling regarding how to use oral contraceptives, 14 pharmacists (7.0%) provided complete counseling on adherence and missing dose handling and five pharmacists (2.5%) provided complete counseling about expected side effects. Conclusions: Pharmacists' practice regarding hormonal contraceptive dispensing and counseling was suboptimal in this study. Areas needing intervention were related to pharmacist assessment of eligibility for oral contraceptive use, choice of optimal oral contraceptive for patient-specific co-morbidities and provision of adequate counseling regarding proper use, adherence and missed dose handlings

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Humanos , Anticoncepcionais/administração & dosagem , Aconselhamento Diretivo/organização & administração , Serviços Comunitários de Farmácia/organização & administração , Anticoncepcionais Orais Hormonais/administração & dosagem , Anticoncepção/métodos , Prática Profissional/tendências , Papel Profissional , Qualidade da Assistência à Saúde/tendências , Emirados Árabes Unidos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle
Medicine (Baltimore) ; 98(20): e15353, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096434


Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases with golden hour. This study aimed to identify and compare factors that affect in-hospital mortality in patients with stroke and AMI who admitted via the emergency department.This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7693 patients who had an ischemic stroke, 2828 patients who had a hemorrhagic stroke, and 4916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged ≥20 years. This study was analyzed by using Cox's proportional hazards frailty model.Five hundred (6.5%) of 7693 patients with ischemic stroke, 569 (20.1%) of 2828 patients with hemorrhagic stroke, and 399 (8.1%) of 4916 patients with AMI were dead. The clinical factors were associated with in-hospital mortality such as age, CCI, hypertension, and diabetes of patient characteristics. In treatment characteristics, performing PCI and weekday admission was associated with in-hospital mortality (aHR, 0.43; 95% CI, 0.27-0.67; aHR, 1.42; 95% CI, 1.14-1.77, respectively). In hospital characteristics, the volume, the proportion of transferred patient to other hospital and ratio of beds per one nurse was associated with in-hospital mortality.Clinical factors of patient characteristics, intervention such as performing PCI and reducing ICP of treatment characteristics, and the volume, transferred rate, and the number of nurse of hospital characteristics were associated with in-hospital mortality.

Isquemia Encefálica/mortalidade , Mortalidade Hospitalar/tendências , Hemorragias Intracranianas/mortalidade , Infarto do Miocárdio/mortalidade , Qualidade da Assistência à Saúde/estatística & dados numéricos , Acidente Vascular Cerebral/mortalidade , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Transferência de Pacientes , Intervenção Coronária Percutânea/métodos , Qualidade da Assistência à Saúde/tendências , República da Coreia/epidemiologia , Acidente Vascular Cerebral/epidemiologia
Obstet Gynecol Clin North Am ; 46(2): 199-214, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31056123


Patient harm continues to be a leading cause of morbidity and mortality in the United States. Among high-risk industries, the health care system has a significantly lower safety profile than that of others. There are many driving forces behind this, including significant resistance within the medical community in the late 1960s to consumer demand of patient-centered and family-centered care. In subsequent decades the voice of the customer has taken center stage. The mounting research linking patient experience and engagement to patient safety and positive clinical outcomes is indisputable.

Família , Segurança do Paciente , Assistência Centrada no Paciente/métodos , Feminino , Ginecologia , Humanos , Masculino , Obstetrícia , Portais do Paciente , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Qualidade da Assistência à Saúde/tendências , Inquéritos e Questionários , Telemedicina , Resultado do Tratamento , Estados Unidos
Isr J Health Policy Res ; 8(1): 35, 2019 04 08.
Artigo em Inglês | MEDLINE | ID: mdl-30961654


Pervasive disparities exist in the treatment of pain and anxiety in pediatric patients presenting to hospitals with emergency conditions. This finding has been demonstrated worldwide, and is especially exacerbated in general emergency departments, which treat both adults and children. Policies to promote appropriate analgesia in the context of pediatric emergency care have been developed by several professional societies and governmental agencies in the United States; however, progress has been uneven, and data regarding these questions is lacking.In their excellent article, Capua and her co-authors address this precise problem through a unique methodology, by surveying nurse directors of both pediatric accredited and non-accredited emergency departments. Survey questions focused on availability of pharmacological and non-pharmacological modalities, and on the prevalence with which providers administered both oral and parenteral medications. The results demonstrated widespread availability of evidence based analgesic and anxiolytic treatment, ranging from medical clowns and specific holding positions, to use of intravenous opiates and conscious sedation. No significant differences were found associated with accreditation.These results are surprising and seem to call into question the value of pediatric accreditation. However, an alternative hypothesis would be that accreditation has succeeded, and the results reflect a large spillover effect, in which providers trained in accredited institutions bring these advanced practices to their local departments. Regionalization has been promoted for emergency care of many acute conditions such as trauma, stroke, and myocardial infarction. These results suggest that for pediatric emergencies, at least in regard to analgesia, the answer likely lies in dissemination of knowledge, rather than super specialization. In other words, bring the expertise to the children, not the children to the experts. Further research in this area could focus on optimal ways to achieve such knowledge translation.

Acreditação/normas , Manejo da Dor/normas , Pediatria/normas , Feminino , Humanos , Masculino , Manejo da Dor/métodos , Pediatria/métodos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Inquéritos e Questionários
J Med Internet Res ; 21(4): e12517, 2019 04 22.
Artigo em Inglês | MEDLINE | ID: mdl-31008706


BACKGROUND: There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored. OBJECTIVE: This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes. METHODS: We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects. RESULTS: Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects. CONCLUSIONS: Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

Qualidade da Assistência à Saúde/tendências , Idoso , Idoso Fragilizado , Humanos , Satisfação do Paciente , Pesquisa Qualitativa
Rev Bras Enferm ; 72(2): 367-374, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31017198


AIM: To evaluate quality of the Family Health Strategy (FHS) in the National Program for Improving Access and Quality of Primary Care in the Federal District (FD) from the perspective of users. METHODS: Evaluative research carried out in 25 basic health units of the Federal District through a validated questionnaire assessing the following dimensions: access, gateway, bond, service range, coordination, family focus, community orientation, and health professionals. RESULTS: Service provision, qualification of professionals, quality of professional-user relationship, and continuity of care were the best evaluated dimensions, while family approach, community approach, and access were the worst. Access to the FHS was found to be compromised, besides failing to establish itself as gateway to the FD health system. CONCLUSION: When they can access the local system, FD users do enjoy several services, but access is still a barrier, mainly because the very system is not prepared to meet users' needs/preferences. The dimensions regarding family focus and community orientation are precarious, which reveals the need for reflection on the care model adopted in the Federal District.

Governo Federal , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Feminino , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/tendências , Atenção Primária à Saúde/tendências , Qualidade da Assistência à Saúde/tendências , Inquéritos e Questionários
Rev Bras Enferm ; 72(suppl 1): 228-234, 2019 Feb.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30942367


OBJECTIVE: verify the perception nurses have of the quality of the Rapid Response Team in the structure, process and outcome dimensions, as well as the influence of time of practice in the institution and the work shift of the professionals on this perception. METHOD: cross-sectional study, conducted between September and October 2016, with questionnaires to 55 nurses working in inpatient care units or members of the Rapid Response Team. The positive index and inferential tests were used in the data analysis. RESULTS: a satisfactory positive index was identified in 25 of the 37 items analyzed, and the main frailties occurred in the process dimension. There was discrepancy in the perception of professionals with different length of time in the institution about medical consumables (p=0.05) and request for the Rapid Response Team (p=0.03), besides the work shift and communication among the members involved (p=0.02). CONCLUSION: the nurses' perception of the quality of the Rapid Response Team is satisfactory, especially in the areas of structure and outcome.

Satisfação no Emprego , Enfermeiras e Enfermeiros/psicologia , Equipe de Assistência ao Paciente/normas , Percepção , Atitude do Pessoal de Saúde , Brasil , Estudos Transversais , Humanos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Inquéritos e Questionários
BMC Geriatr ; 19(1): 103, 2019 04 11.
Artigo em Inglês | MEDLINE | ID: mdl-30975076


BACKGROUND: Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. METHODS: Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996-2016. Outcomes were 1) availability of all nursing home care (1996-2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. RESULTS: From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77-0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51-0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30-0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. CONCLUSION: We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.

Acesso aos Serviços de Saúde/tendências , Instituição de Longa Permanência para Idosos/tendências , Casas de Saúde/tendências , Qualidade da Assistência à Saúde/tendências , Idoso , Idoso de 80 Anos ou mais , /tendências , Feminino , Acesso aos Serviços de Saúde/normas , Instituição de Longa Permanência para Idosos/normas , Humanos , Masculino , Medicaid/normas , Medicaid/tendências , Medicare/normas , Medicare/tendências , Casas de Saúde/normas , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem/normas , Instituições de Cuidados Especializados de Enfermagem/tendências , Estados Unidos/epidemiologia