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2.
BMC Health Serv Res ; 20(1): 103, 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32041670

RESUMO

BACKGROUND: Authors in previous studies demonstrated that centralising acute stroke care is associated with an increased chance of timely Intra-Venous Thrombolysis (IVT) and lower costs compared to care at community hospitals. In this study we estimated the lower bound of the causal impact of centralising IVT on health and cost outcomes within clinical practice in the Northern Netherlands. METHODS: We used observational data from 267 and 780 patients in a centralised and decentralised system, respectively. The original dataset was linked to the hospital information systems. Literature on healthcare costs and Quality of Life (QoL) values up to 3 months post-stroke was searched to complete the input. We used Synthetic Control Methods (SCM) to counter selection bias. Differences in SCM outcomes included 95% Confidence Intervals (CI). To deal with unobserved heterogeneity we focused on recently developed methods to obtain the lower bounds of the causal impact. RESULTS: Using SCM to assess centralising acute stroke 3 months post-stroke revealed healthcare savings of $US 1735 (CI, 505 to 2966) while gaining 0.03 (CI, - 0.01 to 0.73) QoL per patient. The corresponding lower bounds of the causal impact are $US 1581 and 0.01. The dominant effect remained stable in the deterministic sensitivity analyses with $US 1360 (CI, 476 to 2244) as the most conservative estimate. CONCLUSIONS: In this study we showed that a centralised system for acute stroke care appeared both cost-saving and yielded better health outcomes. The results are highly relevant for policy makers, as this is the first study to address the issues of selection and unobserved heterogeneity in the evaluation of centralising acute stroke care, hence presenting causal estimates for budget decisions.


Assuntos
Serviços Centralizados no Hospital/organização & administração , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Serviços Centralizados no Hospital/economia , Custos e Análise de Custo , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Observação , Fatores de Tempo , Resultado do Tratamento
3.
Lakartidningen ; 1162019 Oct 08.
Artigo em Sueco | MEDLINE | ID: mdl-31593285

RESUMO

The recently documented high survival of extremely preterm infants in Sweden is related to a high degree of centralization of pre- and postnatal care and to recently issued national consensus guidelines providing recommendations for perinatal care at 22-24 gestational weeks. The prevalence of major neonatal morbidity remains high and exceeded 60 % in a recent study of extremely preterm infants born at < 27 gestational weeks delivered in Sweden in 2014-2016 and surviving to 1 year of age. Damage to immature organ systems inflicted during the neonatal period causes varying degrees of functional impairment with lasting effects in the growing child. There is an urgent need for evidence-based novel interventions aiming to prevent neonatal morbidity with a subsequent improvement of long-term outcome.


Assuntos
Lactente Extremamente Prematuro , Doenças do Prematuro , Nascimento Prematuro , Displasia Broncopulmonar/epidemiologia , Displasia Broncopulmonar/fisiopatologia , Displasia Broncopulmonar/prevenção & controle , Serviços Centralizados no Hospital , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/fisiopatologia , Hemorragia Cerebral/prevenção & controle , Ventrículos Cerebrais/irrigação sanguínea , Ventrículos Cerebrais/diagnóstico por imagem , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/fisiopatologia , Enterocolite Necrosante/prevenção & controle , Feminino , Humanos , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido , Doenças do Prematuro/epidemiologia , Doenças do Prematuro/fisiopatologia , Doenças do Prematuro/prevenção & controle , Assistência Perinatal/organização & administração , Gravidez , Nascimento Prematuro/mortalidade , Retinopatia da Prematuridade/sangue , Retinopatia da Prematuridade/epidemiologia , Retinopatia da Prematuridade/fisiopatologia , Retinopatia da Prematuridade/prevenção & controle , Taxa de Sobrevida , Suécia/epidemiologia
4.
Cir. Esp. (Ed. impr.) ; 97(8): 470-476, oct. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-187622

RESUMO

El tratamiento quirúrgico de los adenocarcinomas de la unión esofagogástrica se basa en gastrectomías totales o esofaguectomías oncológicas, procedimientos de alta complejidad y considerable morbimortalidad. Los datos obtenidos del análisis de registros quirúrgicos poblacionales muestran una elevada variabilidad en el enfoque terapéutico y los resultados entre diferentes centros hospitalarios y zonas geográficas. Una de las principales medidas destinadas a reducir esta variabilidad, mejorando los resultados globales, es la centralización de la enfermedad en centros de referencia, proceso que debe basarse en el cumplimiento de unos estándares de calidad e ir acompañada de la armonización de protocolos terapéuticos. La cirugía mínimamente invasiva puede disminuir la morbilidad postoperatoria sin comprometer la supervivencia, pero es técnicamente más demandante que la cirugía abierta. Los programas de formación quirúrgica tutelada permiten incorporar la cirugía mínimamente invasiva a la práctica de los equipos quirúrgicos sin que la curva de aprendizaje condicione la morbimortalidad ni la radicalidad oncológica


Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams’ training curves without affecting morbidity, mortality or oncologic radicality


Assuntos
Humanos , Adenocarcinoma/cirurgia , Benchmarking , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgia , Neoplasias Gástricas/cirurgia , Esofagectomia/educação , Esofagectomia/mortalidade , Esofagectomia/normas , Gastrectomia/educação , Gastrectomia/mortalidade , Gastrectomia/normas , Complicações Pós-Operatórias/prevenção & controle , Curva de Aprendizado , Serviços Centralizados no Hospital , Hospitais com Alto Volume de Atendimentos
5.
Semin Thorac Cardiovasc Surg ; 31(4): 664-667, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31283988

RESUMO

There is a lack of evidence on multiple levels for appropriate recognition, management, and outcome results in Type A aortic dissection management in the United Kingdom. A huge amount of retrospective data exists in the literature which provides nonmeaningful prospect to a service that meets the current era. Electronic searches were performed on PubMed and Cochrane databases with no limits placed on dates. Search terms were charted to MeSH terms and combined using Boolean operations, and also used as key words. Papers were selected on the basis of title and abstract. The reference lists of selected papers were reviewed to identify any relevant papers that might be suitable for inclusion in the study. Papers were selected based on providing primary end points of death, rupture, or dissection and/or information regarding aortic aneurysm growth. Papers were not excluded based on patient population age. We demonstrated the lack of evidence for quality outcomes in type A aortic dissection in the United Kingdom. This highlighted the unwarranted variation seen in this entity and the caveats needed to improve structuring of type A aortic dissection from early identification in emergency departments to arrival at destination site for optimum intervention. Emergency services should be restructured to meet the immediate affirmation of diagnosis with gold standard imaging modality available. Management of this dire disease should be instituted at local hospitals prior to transportation and results should be audited regularly to improve quality outcomes. Attempts should be made to create local area networks to improve the efficiencies and outcomes of the service and transfer to centers with concentration of expertise. Recognition of regional networks by the UK Government Care Quality Commission should in part based on cumulative evidence sought after from virtual multidisciplinary teams. Unwarranted variation is an avenue that requires to be addressed to rise with service provision that meets our patients aspiration and be of current evidence in the 21st era.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Serviços Centralizados no Hospital/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Medicina Estatal/organização & administração , Procedimentos Cirúrgicos Vasculares , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Humanos , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
6.
Dan Med J ; 66(7)2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31256776

RESUMO

INTRODUCTION: Ruptured abdominal aortic aneurism (rAAA) is a severe condition with all-cause mortality rates reaching 80%. We speculated whether the 2008 centralisation of the treatment of patients with rAAA in Denmark had improved outcome as suggested in other surgical specialties. Accordingly, our aim was to describe temporal changes in mortality for patients undergoing surgery for rAAA in the Capital Region of Denmark between 2009 and 2015. METHODS: This was a retrospective population-based cohort study of patients in the intensive care unit diagnosed and treated for rAAA at Rigshospitalet from 1 January 2009 to 31 December 2015. Patient characteristics and procedure-related variables were obtained from the medical records. The primary outcome measure was death within 90 days of the primary surgical procedure. RESULTS: A total of 339 patients were diagnosed with rAAA, and 275 patients were included in the final study population; 26.9% of the patients died within 90 days of the primary surgical procedure, whereas the 30-day and one-year mortality was 18.5% and 31.6%, respectively. No consistent reduction in mortality was observed throughout the observation period. CONCLUSIONS: In this population-based cohort study of patients surgically treated for rAAA, we found no consistent reduction in mortality over time following centralisation of treatment. FUNDING: none. TRIAL REGISTRATION: not relevant.


Assuntos
Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/mortalidade , Serviços Centralizados no Hospital , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Dinamarca/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
7.
J Vasc Surg ; 70(3): 921-926, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31147113

RESUMO

OBJECTIVE: The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. METHODS: A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. RESULTS: During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). CONCLUSIONS: In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Serviços Centralizados no Hospital , Educação de Pós-Graduação em Medicina , Procedimentos Endovasculares/educação , Hospitais com Alto Volume de Atendimentos , Regionalização , Cirurgiões/educação , Procedimentos Cirúrgicos Vasculares/educação , Carga de Trabalho , Serviços Centralizados no Hospital/tendências , Competência Clínica , Currículo , Bases de Dados Factuais , Educação de Pós-Graduação em Medicina/tendências , Procedimentos Endovasculares/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Humanos , Ohio , Encaminhamento e Consulta/tendências , Regionalização/tendências , Cirurgiões/tendências , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares/tendências
9.
Cir Esp ; 97(8): 470-476, 2019 Oct.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31014543

RESUMO

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams' training curves without affecting morbidity, mortality or oncologic radicality.


Assuntos
Adenocarcinoma/cirurgia , Benchmarking , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgia , Neoplasias Gástricas/cirurgia , Serviços Centralizados no Hospital/normas , Esofagectomia/educação , Esofagectomia/mortalidade , Esofagectomia/normas , Gastrectomia/educação , Gastrectomia/mortalidade , Gastrectomia/normas , Hospitais com Alto Volume de Atendimentos , Humanos , Curva de Aprendizado , Complicações Pós-Operatórias/prevenção & controle , Sistema de Registros , Resultado do Tratamento
10.
APMIS ; 127(5): 352-360, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30761610

RESUMO

Cystic fibrosis (CF) is a severe, monogenic, autosomal recessive disease caused by mutations in the CFTR (cystic fibrosis transmembrane regulator) gene, where disturbed chloride and bicarbonate transportation in epithelial cells results in a multiorgan disease with primarily pulmonary infections and pancreatic insufficiency. In 1968, the Copenhagen CF Center was established, and centralized care of CF patients with monthly control was introduced. Close monitoring and treatment of Pseudomonas lung infection as well as segregation of patients with different infection status improved the clinical outcome as well as survival. Prophylactic basic treatment as well as infection treatments follow specific algorithms. A variety of comorbidities have all along the pulmonary infection control necessitated personalized care, adjusted to the patients' phenotype. With the introduction of CFTR modulators, the treatment has shifted from prophylactic, symptomatic type toward a new era of precision medicine targeting the basic defect according to the patients' CFTR genotype. Future directions will focus on further improvement of the CFTR modulators and gene therapy, as well as modifier genes and CF phenotype.


Assuntos
Fibrose Cística/terapia , Medicina de Precisão , Serviços Centralizados no Hospital , Comorbidade , Fibrose Cística/microbiologia , Fibrose Cística/mortalidade , Regulador de Condutância Transmembrana em Fibrose Cística/genética , Terapia Genética , Humanos , Pulmão/microbiologia , Pseudomonas aeruginosa/isolamento & purificação
12.
Int J Cancer ; 145(1): 40-48, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30549266

RESUMO

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high-risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high-risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co-ordinating centre ('hub'), for having surgery by the presence of surgical services on-site, and for receiving high dose-rate brachytherapy (HDR-BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91-1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10-1.40), and more likely to receive additional HDR-BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94-12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.


Assuntos
Neoplasias da Próstata/radioterapia , Neoplasias da Próstata/cirurgia , Medicina Estatal/organização & administração , Idoso , Braquiterapia , Serviços Centralizados no Hospital/organização & administração , Serviços Centralizados no Hospital/estatística & dados numéricos , Estudos Transversais , Inglaterra/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Neoplasias da Próstata/epidemiologia , Sistema de Registros , Medicina Estatal/estatística & dados numéricos
13.
Eur J Trauma Emerg Surg ; 45(3): 431-436, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29127439

RESUMO

INTRODUCTION: Centralization of trauma patients has become the standard of care. Unfortunately, overtriage can overcome the capability of Trauma Centres. This study aims to analyse the association of different mechanisms of injury with severe or major trauma defined as Injury Severity Score (ISS) greater than 15 and an estimation of overtriage upon our Trauma Centre. METHODS: A retrospective review of our prospective database was undertaken from March 2014 to August 2016. Univariate and multivariable logistic regression models were used to estimate the association between covariates (gender, age, and mechanisms of injury) and the risk of major trauma. RESULTS: The trauma team (TT) treated 1575 patients: among the 1359 (86%) were triaged only because of dynamics or mechanism of trauma. Overtriage according to an ISS < 15, was 74.6% on all trauma team activation (TTA) and 83.2% among the TTA prompted by the mechanism of injury. Patients aged 56-70 years had an 87% higher risk of having a major trauma than younger patients (OR 1.87, 95% CI 1.29-2.71) while for patients aged more than 71 years OR was 3.45, 95% CI 2.31-5.15. Car head-on collision (OR 2.50, 95% CI 1.27-4.92), intentional falls (OR 5.61, 95% CI 2.43-12.97), motorbike crash (OR 1.67, 95% CI 1.06-2.65) and pedestrian impact (OR 2.68, 95% CI 1.51-4.74) were significantly associated with a higher risk of major trauma in a multivariate analysis. CONCLUSIONS: Significant association with major trauma was demonstrated in the multivariate analysis of different mechanisms of trauma in patients triaged only for dynamics. A revision of our field triage protocol with a prospective validation is needed to improve overtriage that is above the suggested limits.


Assuntos
Acidentes por Quedas , Acidentes de Trânsito , Serviços Centralizados no Hospital , Centros de Traumatologia , Triagem , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Serviços Médicos de Emergência , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Pedestres , Estudos Retrospectivos , Tentativa de Suicídio , Adulto Jovem
14.
PLoS Negl Trop Dis ; 12(12): e0006623, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30571758

RESUMO

Trachoma and Guinea Worm Disease (GWD) are neglected tropical diseases (NTD) slated for elimination as a public health problem and eradication respectively by the World Health Organization. As these programs wind down, uncovering the last cases becomes an urgent priority. In 2010, Ghana Health Services, along with The Carter Center, Sightsavers, and other partners, conducted integrated case searches for both GWD and the last stage of trachoma disease, trachomatous trichiasis (TT), as well as providing surgical treatment for TT to meet elimination (and eradication targets). House to house case searches for both diseases were conducted and two case management strategies were explored: a centralized referral to services method and a Point of Care (POC) delivery method. 835 suspected TT cases were discovered in the centralized method, of which 554 accepted surgery. 482 suspected TT cases were discovered in the POC method and all TT cases accepted surgery. The cost per TT case examined was lower in the POC searches compared to the centralized searches ($19.97 in the POC searches and $20.85 in the centralized searches). Both strategies resulted in high surgical uptake for TT surgery, with average uptakes of 72.4% and 83.9% for the centralized and POC searches respectively. We present here that house to house case searches offering services at POC are feasible and a potential tool for elimination and eradication programs nearing their end.


Assuntos
Dracunculíase/epidemiologia , Doenças Negligenciadas/epidemiologia , Tracoma/epidemiologia , Triquíase/epidemiologia , Administração de Caso , Serviços Centralizados no Hospital , Erradicação de Doenças , Dracunculíase/microbiologia , Dracunculíase/prevenção & controle , Estudos Epidemiológicos , Feminino , Gana/epidemiologia , Inquéritos Epidemiológicos , Humanos , Masculino , Doenças Negligenciadas/microbiologia , Doenças Negligenciadas/prevenção & controle , Sistemas Automatizados de Assistência Junto ao Leito , Prevalência , Saúde Pública , Encaminhamento e Consulta , Tracoma/microbiologia , Tracoma/prevenção & controle , Triquíase/microbiologia , Triquíase/prevenção & controle , Medicina Tropical , Organização Mundial da Saúde
15.
Rev. Hosp. El Cruce ; (23): 1-4, 19/12/2018.
Artigo em Espanhol | LILACS, BINACIS | ID: biblio-967960

RESUMO

El objetivo del estudio es determinar los tratamientos que se generan fruto de la centralización y medir el impacto económico. El proceso de utilización de citostáticos inicia con la confección del protocolo por parte del médico, la validación por el farmacéutico con la confección de la orden de elaboración, y la ejecución por el técnico realizando la preparación en cabina de seguridad biológica. Culmina con la administración por parte de enfermería y seguimiento médico. La centralización disminuye el riesgo de exposición, ofrece protección del producto, paciente, operador, ambiente. Al mismo tiempo disminuye los costos provocando un ahorro significativo si se coordina la programación del protocolo y prescripción médica, la preparación en el servicio de farmacia y la administración en hospital de día agrupando por tratamiento a los pacientes.


The objective of the study is to determine the treatments that are generated by centralization and to measure the economic impact. The process of using cytostatics starts with the preparation of the protocol by the physician, the validation by the pharmacist with the writingof the preparation order, and the execution by the technician carrying out the preparation in the biological safety cabinet. It culminates with nursing administration and medical follow-up. Centralization reduces the risk of exposure, offers protection to the product, the patient, the operator, and the environment. At the same time, it reduces costs, with significant savings if the programming of the protocol and medical prescription, the preparation in the pharmacy service and the administration in the day hospital are coordinated grouping by treatment to the patients.


Assuntos
Serviços Centralizados no Hospital , Serviço Hospitalar de Oncologia , Citostáticos , Acesso a Medicamentos Essenciais e Tecnologias em Saúde
16.
Circ Cardiovasc Qual Outcomes ; 11(9): e004623, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30354548

RESUMO

Background In regional healthcare referral networks, specialty care is provided at a few sites within the network, with patients referred there for management. This model may increase access to specialized care but also increases the distance that patients travel to receive such care, with unknown effects on longitudinal outcomes. The Veterans Administration uses such regional models for percutaneous coronary intervention (PCI). The impact of patient distance from specialty centers on longitudinal outcomes after receipt of specialized care is understudied and may carry implications for care delivery models. Methods and Results We identified 31 483 patients undergoing PCI at 64 Veterans Administration sites between 2008 to 2012, and assessed the relationship between quintile (Qn) of patient distance from PCI center and all-cause death or myocardial infarction within a year of PCI. Secondary analyses investigated interactions between patient distance and PCI presentation, urgency, and Medicare eligibility on the primary outcome. Median distance to PCI site was 48 miles (interquartile range, 17-110). After adjustment, increasing distance from PCI center was not associated with higher risk of 1-year death or myocardial infarction (with Qn1 as reference, Qn2: odds ratio, 1.02 [95% simultaneous CI, 0.84-1.25]; Qn3: 1.06 [95% simultaneous CI, 0.87-1.30]; Qn4: 0.92 [95% simultaneous CI, 0.75-1.14]; Qn5: 0.97 [95% simultaneous CI, 0.78-1.20]). Stratifying the cohort by acute coronary syndrome presentation, urgency of PCI, and by eligibility for Medicare did not find an association between distance and outcome. Conclusions In this cohort of US veterans, 50% traveled 48 miles or longer to undergo PCI, and 25% traveled >110 miles. Despite this wide range of distances traveled, there was no association between patient distance to PCI center and subsequent outcomes of death or myocardial infarction at 1 year. These findings suggest that regional referral networks may represent viable models for PCI care delivery.


Assuntos
Serviços Centralizados no Hospital/organização & administração , Doença da Artéria Coronariana/terapia , Acesso aos Serviços de Saúde/organização & administração , Intervenção Coronária Percutânea , Tempo para o Tratamento/organização & administração , Transporte de Pacientes/organização & administração , Idoso , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
17.
Circ Cardiovasc Qual Outcomes ; 11(9): e003359, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30354551

RESUMO

Background While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers' front door versus Transfer-Ins from another hospital. Methods and Results We analyzed 970 390 AIS cases in the Get With The Guidelines-Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale. Conclusions There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.


Assuntos
Serviços Centralizados no Hospital/tendências , Disparidades em Assistência à Saúde/tendências , Admissão do Paciente/tendências , Transferência de Pacientes/tendências , Acidente Vascular Cerebral/terapia , Tempo para o Tratamento/tendências , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
18.
Ann Surg ; 268(5): 712-724, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30169394

RESUMO

OBJECTIVES: To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations. BACKGROUND/METHODS: Most countries are increasingly forced to maintain quality medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents. RESULTS: Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education. CONCLUSION/RECOMMENDATIONS: There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.


Assuntos
Serviços Centralizados no Hospital/tendências , Política de Saúde/tendências , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios , Consenso , Educação Médica/tendências , Europa (Continente) , Humanos , América do Norte
19.
Ann Surg ; 268(5): 831-837, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30080724

RESUMO

BACKGROUND AND AIMS: The potential benefit of the centralization of Bariatric surgery (BS) remains debated. The aim of this study was to evaluate the impact on 90-day mortality of an innovative organization aiming at centralizing the care of severe postoperative complications of BS. STUDY DESIGN: The centralization of care for postoperative complication after BS was implemented by French Authorities in 2013 in the Nord-Pas-de-Calais Region, France. This unique formalized network (OSEAN), coordinated by 1 tertiary referral center, enrolled all regional institutions performing bariatric surgery. Data were extracted from the medico-administrative database providing information on all patients undergoing BS between 2009 and 2016 in OSEAN (n = 22,928) and in Rest of France (n = 288,942). The primary outcome was the evolution of 90-day mortality before and after the implementation of this policy. Rest of France was used as a control group to adjust the results to improvement with time of BS outcomes. RESULTS: The numbers of primary procedure and reoperations increased similarly before and after 2013 within OSEAN and in Rest of France. The 90-day mortality rate became significantly lower within OSEAN than in the rest of France after 2013 (0.03% vs 0.08%, P < 0.01). This difference was confirmed in multivariate analysis after adjustment to the procedure specific mortality (P < 0.04). The reduction of 90-day mortality was most visible for sleeve gastrectomy. CONCLUSION: The implementation of centralized care for early postoperative complications after BS in OSEAN was associated with reduced 90-day mortality. Our results indicate that this reduction was not due to a lower incidence of complications but to the improvement of their management.


Assuntos
Cirurgia Bariátrica , Serviços Centralizados no Hospital/organização & administração , Complicações Pós-Operatórias/mortalidade , Adulto , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
Neurology ; 91(3): e236-e248, 2018 07 17.
Artigo em Inglês | MEDLINE | ID: mdl-29907609

RESUMO

OBJECTIVE: To investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR). METHODS: The CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective "before-and-after" cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014. RESULTS: Centralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38-0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark. CONCLUSIONS: Centralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.


Assuntos
Serviços Centralizados no Hospital/tendências , Tempo de Internação/tendências , Readmissão do Paciente/tendências , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Serviços Centralizados no Hospital/métodos , Estudos de Coortes , Dinamarca/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico
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