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1.
N Engl J Med ; 382(1): 51-59, 2020 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-31893515

RESUMO

BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).


Assuntos
Instituições Associadas de Saúde , Hospitais , Qualidade da Assistência à Saúde , Idoso , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Medicare , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/tendências , Medidas de Resultados Relatados pelo Paciente , Indicadores de Qualidade em Assistência à Saúde , Estados Unidos
2.
Lancet ; 395(10217): 33-41, 2020 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-31908284

RESUMO

BACKGROUND: Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS: We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS: Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION: Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING: Dutch Adhesion Group and Nordic Pharma.


Assuntos
Laparoscopia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Aderências Teciduais/etiologia , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Complicações Pós-Operatórias/epidemiologia , Reoperação/efeitos adversos , Estudos Retrospectivos , Aderências Teciduais/cirurgia , Adulto Jovem
3.
Anaesthesia ; 75 Suppl 1: e62-e74, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31903563

RESUMO

Critical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri-operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30-day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. A systematic review of MEDLINE, Embase, CINAHL, Web of Science, the Cochrane database and the grey literature identified 44 studies assessing risk factors for unplanned critical care admission in adult populations undergoing non-cardiac, non-thoracic and non-neurological surgery. Comparative, quantitative analysis of the admission criteria was not feasible due to heterogeneity in study design. Age, anaemia, ASA physical status, body mass index, comorbidity burden, emergency surgery, high-risk surgery, male sex, obstructive sleep apnoea, increased blood loss and operative duration were all independent risk factors for unplanned critical care admission. Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.


Assuntos
Cuidados Críticos/métodos , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios , Humanos , Fatores de Risco
4.
Bone Joint J ; 102-B(1): 82-89, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888355

RESUMO

AIMS: The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). METHODS: In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. RESULTS: Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. CONCLUSION: These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82-89.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Artroplastia de Quadril/estatística & dados numéricos , Atividades Cotidianas , Idoso , Estudos de Casos e Controles , Feminino , Fraturas do Quadril/cirurgia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Fraturas Periprotéticas/cirurgia , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Índice de Gravidade de Doença , Inquéritos e Questionários
5.
Ann R Coll Surg Engl ; 102(1): 54-61, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31891669

RESUMO

INTRODUCTION: Studies have attempted to identify prognostic indicators for successful outcomes following bariatric surgery for obesity. The aim of this study was to determine whether the degree of obesity affects outcomes in patients who are morbidly obese (basal metabolic index, BMI, 40-49.9 kg/m2), super-obese (BMI 50-59.9 kg/m2) and super-super-obese (BMI greater than 60 kg/m2) undergoing restrictive or malabsorptive bypass procedures. MATERIAL AND METHODS: Retrospective analysis of a prospectively maintained database was undertaken to include all consecutive laparoscopic adjustable gastric bands (LAGB), laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures since 2010. Patients with at least two years of follow-up were included. At each visit, the patient's weight, BMI, excess weight loss and comorbidity status were recorded. RESULTS: A total of 353 patients (75% women) were included in the analysis; 65 (18.4%) underwent LAGB; 70 (19.8%) LSG and 218 (61.8%) LRYGB. At presentation, the median BMI for the morbidly obese sub-group was 47.2 kg/m2 for LAGB, 46.4 kg/m2 for LSG and 46.6 kg/m2 for LRYGB (P = 0.625); for the super-obese sub-group it was 53.2 kg/m2 for LAGB, 52.9 kg/m2 for LSG and 52.4 kg/m2 for LRYGB (P = 0.481); and for the super-super-obese sub-group 66.9 kg/m2 for (LAGB, 66.7 kg/m2 for LSG and 61.5 kg/m2 for LRYGB (P = 0.169). Percentage of excess weight loss at the end of two years was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB (median 68.5% and 69.5%, respectively; P < 0.001) than in the sub-groups undergoing LAGB and LSG. This was also reflected in the reduction of BMI achieved with bypass in the two sub-groups (P < 0.001). Complete diabetes remission was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB treatment (P < 0.05). Sleep apnoea, asthma and exercise tolerance had significantly improved in the super-morbidly obese undergoing LRYGB (P < 0.05). There was no significant difference between the three treatment groups in remission of hypertension; dyslipidaemia; gastro-oesophageal reflux disease and depression in all three BMI sub-groups. CONCLUSION: The mid-term results for weight loss and resolution of obesity-related comorbidities is best achieved in super-obese patients undergoing LRYGB, without any significant increase in complications with this procedure as compared with LAGB and LSG.


Assuntos
Cirurgia Bariátrica/métodos , Peso Corporal/fisiologia , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Adulto , Cirurgia Bariátrica/estatística & dados numéricos , Feminino , Humanos , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Perda de Peso/fisiologia
8.
N Engl J Med ; 382(5): 405-415, 2020 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-31995686

RESUMO

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).


Assuntos
Tratamento Conservador , Drenagem , Pneumotórax/terapia , Adolescente , Adulto , Tubos Torácicos , Drenagem/métodos , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pneumotórax/diagnóstico por imagem , Complicações Pós-Operatórias , Radiografia Torácica , Recidiva , Resultado do Tratamento , Conduta Expectante , Adulto Jovem
9.
BMJ ; 368: l6831, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31941686

RESUMO

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Assuntos
Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca , Infarto do Miocárdio , Pneumonia , Cuidados Semi-Intensivos , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Revisão da Utilização de Seguros , Masculino , Sobremedicalização/prevenção & controle , Medicare/estatística & dados numéricos , Mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Pneumonia/terapia , Estudos Retrospectivos , Cuidados Semi-Intensivos/métodos , Cuidados Semi-Intensivos/organização & administração , Cuidados Semi-Intensivos/tendências , Estados Unidos/epidemiologia
10.
N Engl J Med ; 382(2): 152-162, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31914242

RESUMO

BACKGROUND: There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services. METHODS: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge. RESULTS: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group. CONCLUSIONS: In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).


Assuntos
Doença Crônica/terapia , Hospitalização/estatística & dados numéricos , Administração dos Cuidados ao Paciente/métodos , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Custos de Cuidados de Saúde , Visita Domiciliar , Humanos , Modelos Lineares , Pessoa de Meia-Idade , New Jersey , Administração dos Cuidados ao Paciente/organização & administração , Sumários de Alta do Paciente Hospitalar , Estudos Prospectivos , Fatores Socioeconômicos , Estados Unidos
11.
J Surg Res ; 246: 457-463, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31706537

RESUMO

BACKGROUND: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.


Assuntos
Colostomia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
12.
Ann Otol Rhinol Laryngol ; 129(2): 110-114, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31526022

RESUMO

OBJECTIVE: To determine the association between intraday timing of outpatient pediatric tonsillectomy and revisit outcomes and complications. STUDY DESIGN: Cross-sectional analysis of New York databases. SETTING: Ambulatory surgery, emergency department and inpatient hospital settings. SUBJECTS AND METHODS: The State Ambulatory Surgery, State Emergency Department and State Inpatient Databases for 2010-2011 were analyzed for revisits. Outcomes assessed were revisits for any reason, bleeding, acute pain or fever, nausea, vomiting and dehydration. The relationships between the hour of admission for surgery, the hour of discharge and the revisit outcomes were analyzed. RESULTS: The study included 33,611 children (mean age, 6.62 years; 45.7% female) and 62.0% were admitted in the early morning. Discharges were most common in the early afternoon (28.3%). Revisit rates were significantly higher for the early evening discharges (6.0%) versus late morning discharges (3.1%) (P < .001). Revisits for bleeding were 1.8% for discharge in the early evening versus 0.6% in the late morning (P < .001). Revisits for fever, nausea, vomiting or dehydration were 1.8% for discharge in the early evening versus 0.9% in the late morning (P = .002). Late afternoon admission was significantly associated with higher revisit rates (10.9%, P < .001). Bleeding revisits were highest for late afternoon admit hour (1.5%, P = .001). Revisits for acute pain were also highest for late afternoon admit hour (2.3%, P = .005). CONCLUSION: Revisit are significantly higher when the patient is discharged late. Late afternoon surgery is also significantly associated with higher revisit rates. Surgeons may wish to consider these findings when a late tonsillectomy or late discharge is anticipated post-tonsillectomy.


Assuntos
Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Tonsilectomia , Procedimentos Cirúrgicos Ambulatórios , Criança , Estudos Transversais , Feminino , Humanos , Masculino , Fatores de Tempo
13.
Anaesthesia ; 75(2): 162-170, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31270799

RESUMO

NHS England recently mandated that the National Early Warning Score of vital signs be used in all acute hospital trusts in the UK despite limited validation in the postoperative setting. We undertook a multicentre UK study of 13,631 patients discharged from intensive care after risk-stratified cardiac surgery in four centres, all of which used VitalPACTM to electronically collect postoperative National Early Warning Score vital signs. We analysed 540,127 sets of vital signs to generate a logistic score, the discrimination of which we compared with the national additive score for the composite outcome of: in-hospital death; cardiac arrest; or unplanned intensive care admission. There were 578 patients (4.2%) with an outcome that followed 4300 sets of observations (0.8%) in the preceding 24 h: 499 out of 578 (86%) patients had unplanned re-admissions to intensive care. Discrimination by the logistic score was significantly better than the additive score. Respective areas (95%CI) under the receiver-operating characteristic curve with 24-h and 6-h vital signs were: 0.779 (0.771-0.786) vs. 0.754 (0.746-0.761), p < 0.001; and 0.841 (0.829-0.853) vs. 0.813 (0.800-0.825), p < 0.001, respectively. Our proposed logistic Early Warning Score was better than the current National Early Warning Score at discriminating patients who had an event after cardiac surgery from those who did not.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Parada Cardíaca/diagnóstico , Unidades de Terapia Intensiva , Readmissão do Paciente/estatística & dados numéricos , Humanos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Reino Unido
14.
J Surg Res ; 245: 544-551, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31470335

RESUMO

BACKGROUND: Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients. METHODS: We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m2, hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed. RESULTS: A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m2. 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (ß = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone. CONCLUSIONS: Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Colectomia/efeitos adversos , Colostomia/efeitos adversos , Doença Diverticular do Colo/cirurgia , Síndrome Metabólica/complicações , Complicações Pós-Operatórias/epidemiologia , Adulto , Índice de Massa Corporal , Colectomia/métodos , Colostomia/métodos , Feminino , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Masculino , Síndrome Metabólica/epidemiologia , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco
15.
J Urol ; 203(1): 57-61, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31600114

RESUMO

PURPOSE: We sought to determine the trend of neoadjuvant chemotherapy use for nonmetastatic muscle invasive urothelial bladder cancer and whether it is associated with adverse perioperative morbidity after robot-assisted radical cystectomy. MATERIALS AND METHODS: We retrospectively reviewed the IRCC (International Robotic Cystectomy Consortium) database between 2006 and 2017. After excluding patients with nonmuscle invasive bladder cancer the patients were divided into 2 groups, including those who did vs did not receive neoadjuvant chemotherapy. Data were reviewed for demographics, preoperative, operative and 90-day perioperative outcomes. We used the Cochran-Armitage trend test to assess trends of neoadjuvant chemotherapy associations with high grade and overall complications with time. Multivariate stepwise regression analyses were done to determine whether neoadjuvant chemotherapy was associated with prolonged operative time, 90-day postoperative complications, readmissions, reoperations and mortality after robot-assisted radical cystectomy. RESULTS: A total of 298 patients (26%) received neoadjuvant chemotherapy. These patients were younger (age 67 vs 69 years, p=0.01) and more frequently had an ASA™ (American Society of Anesthesiologists™) score of 3 or greater (62% vs 55%, p=0.02) and pathological T3 stage or greater disease (28% vs 22%, p=0.04). The use of neoadjuvant chemotherapy increased significantly from 10% in 2006 to 2007 to 42% in 2016 to 2017 (p <0.01). On multivariate analysis neoadjuvant chemotherapy was not significantly associated with prolonged operative time, hospital stay, 90-day postoperative complications, reoperation or mortality. Neoadjuvant chemotherapy was associated with 90-day readmissions after robot-assisted radical cystectomy (OR 5.90, 95% CI 3.30-10.90, p <0.01). CONCLUSIONS: Neoadjuvant chemotherapy utilization has significantly increased in the last decade. It was not associated with perioperative surgical morbidity after robot-assisted radical cystectomy.


Assuntos
Quimioterapia Adjuvante , Cistectomia , Terapia Neoadjuvante , Procedimentos Cirúrgicos Robóticos , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Antineoplásicos/uso terapêutico , Humanos , Masculino , Duração da Cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Taxa de Sobrevida , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/patologia
16.
Anticancer Res ; 39(12): 6877-6880, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810956

RESUMO

BACKGROUND/AIM: This study aimed to analyze associated factors of 30-day hospital readmission after surgery for melanoma. PATIENTS AND METHODS: We conducted a retrospective analysis of postoperative 30-day unplanned readmission in patients with melanoma in the National Cancer Database (NCDB). RESULTS: Higher odds of unplanned readmission were found in non-white patients compared to white, uninsured patients compared to those with private insurance, tumors with invasive behavior compared to in situ, presence of ulceration, American Joint Committee on Cancer stages greater than II, and location in the extremities. Lower odds of unplanned readmission were found in women living in areas where the percentage of adults who did not graduate from high school was below 13.0% with an annual income of $38,000 or more, who were treated in Academic/Research Programs or Integrated Network Cancer Programs. CONCLUSION: Non-white patients and low-income zip-codes were associated with unplanned readmission.


Assuntos
Melanoma/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Disparidades em Assistência à Saúde/etnologia , Humanos , Lactente , Recém-Nascido , Masculino , Melanoma/etnologia , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos/etnologia , Adulto Jovem
17.
JAMA ; 322(23): 2292-2302, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31846016

RESUMO

Importance: Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). Objective: To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. Design, Setting, and Participants: Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. Interventions: Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. Main Outcomes and Measures: The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. Results: Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). Conclusions and Relevance: Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. Trial Registration: ClinicalTrials.gov Identifier: NCT00512759.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Vasodilatadores/administração & dosagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Comorbidade , Esquema de Medicação , Feminino , Insuficiência Cardíaca/mortalidade , Hospitalização , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Vasodilatadores/efeitos adversos
18.
Am Surg ; 85(11): 1253-1261, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31775967

RESUMO

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.


Assuntos
Estomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Comorbidade , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Estomia/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Reoperação/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo
19.
J Surg Oncol ; 120(8): 1327-1334, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31680251

RESUMO

BACKGROUND: Despite the popularity of the U.S. News and World Report (USNWR) hospital rankings among the general public, the relationship between hospital rankings and actual patient outcomes for major cancers remains poorly investigated. METHODS: Medicare Inpatient Standard Analytic Files were queried from 2013-2015 to assess the relationship of postoperative outcomes and Medicare expenditures among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer at hospitals ranked in the top-50 USNWR vs hospitals ranked below 50. RESULTS: Among 94 599 patients, 13 217 vs 81 382 patients underwent surgery at a top-50 hospital versus a non-top 50 ranked hospital. Other than among patients who underwent colorectal surgery, the odds of postoperative complications were lower at top ranked vs non-top ranked hospitals (colorectal: OR, 1.46, 95% CI, 1.28-1.65; lung: OR, 0.73, 95% CI, 0.61-0.87; esophagus: OR, 0.70, 95% CI, 0.52-0.94; pancreas: OR, 0.81, 95% CI, 0.70-0.94; liver: OR, 0.85, 95% CI, 0.69-1.04). Moreover, the odds of 90-day mortality were lower at top ranked hospitals vs non-top ranked hospitals (colorectal: OR, 0.59, 95% CI, 0.48-74; lung: OR, 0.66, 95% CI, 0.53-0.82; esophagus: OR, 0.56, 95% CI, 0.40-0.80; pancreas: OR, 0.51, 95% CI, 0.40-0.65; liver: OR, 0.61, 95% CI, 0.44-0.84). Outcomes were comparable among hospitals within the top-50 rank. CONCLUSION: Mortality rates were lower at hospitals in the top-50 USNWR versus non-top ranked, yet hospitals within the top-50 USNWR rankings had comparable outcomes.


Assuntos
Hospitais/estatística & dados numéricos , Neoplasias/mortalidade , Neoplasias/cirurgia , Idoso , Idoso de 80 Anos ou mais , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Publicações Periódicas como Assunto , Complicações Pós-Operatórias/epidemiologia , Estados Unidos/epidemiologia
20.
BMC Health Serv Res ; 19(1): 776, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31666066

RESUMO

BACKGROUND: In 2002, a voluntary diagnosis-related groups (DRGs) payment system was introduced in South Korea for seven disease groups, and participation in the DRGs was mandated for all hospitals beginning in 2013. The primary aim of this study was to compare results reflective of patient care between voluntary participation hospitals (VPHs) and mandatory participation hospitals (MPHs) governed by either the DRGs or fee-for-service (FFS) payment system. METHODS: We collected DRGs and FFS inpatient records (n=3,038,006) from the Health Insurance Review and Assessment for the period of July 2011 to July 2014 and compared length-of-stay, total medical costs, shifting services to an outpatient setting, and readmission rates according to payment system, time of DRGs implementation, and hospital type. We analyzed the effects of mandatory introduction in DRGs payment system on results for patient care and used generalized estimating equations with difference-in-difference methodology. RESULTS: Most notably, patients at MPHs had significantly shorter LOS and lower readmission rates than VPH patients after mandatory introduction of the DRGs. Shifting services to an outpatient setting was similar between the groups. CONCLUSIONS: Our findings suggest that the DRGs payment policy in Korea has decreased LOS and readmission rates. These findings support the continued implementation and enlargement of the DRGs payment system for other diseases in South Korea, given its potential for curbing unnecessary resource usage encouraged by FFS. If the Korean government deliberates on expansion of the DRGs to include other diseases with higher rates of complications, policymakers need to monitor deterioration of health care quality caused by fixed pricing.


Assuntos
Grupos Diagnósticos Relacionados/economia , Hospitais , Programas Obrigatórios , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Revisão da Utilização de Seguros , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , República da Coreia , Adulto Jovem
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