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1.
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
3.
Int J Qual Health Care ; 29(6): 810-816, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29025074

RESUMO

Objective: Emphasis on improving healthcare quality has led to centralization of services for patients suspected of ovarian cancer. As centralization of services may induce treatment delays, we aimed to assess compliance with health system interval guidelines in patients suspected of ovarian cancer. Design: Evaluation of health system intervals, comparison between direct and indirect referrals and between 2013 and 2014. Setting: A managed clinical network (MCN) comprising 11 hospitals in the Netherlands. Participants: Patients that were treated for ovarian cancer within the University Medical Center Groningen in 2013 and 2014. Intervention: Introduction of an MCN to centralize services for patients suspected of ovarian cancer. Main Outcome Measure: Compliance with national guidelines regarding health system intervals. Results: Between 2013 and 2014 a clinically relevant improvement in compliance with guidelines was demonstrated. Within this period, median treatment intervals decreased from 34 to 29 days, and the percentage of patients in which treatment interval guidelines were met increased from 63.5 to 72.2%. New regulations and increased awareness of health system intervals inspired changes in local practice leading to improved compliance with guidelines. Compliance was highest in patients that were directly referred to our academic hospital. Conclusion: Evaluation of health system intervals in patients suspected of ovarian cancer was feasible and may be applicable to other MCNs. Though compliance with guidelines improved within the study period, there is potential for improvement. To facilitate real-time evaluation of compliance with national guidelines establishing uniformity of electronic patient files in the MCN is deemed essential.


Assuntos
Serviços Centralizados no Hospital/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Neoplasias Ovarianas/terapia , Tempo para o Tratamento/estatística & dados numéricos , Serviços Centralizados no Hospital/normas , Feminino , Humanos , Programas de Assistência Gerenciada/estatística & dados numéricos , Países Baixos , Garantia da Qualidade dos Cuidados de Saúde
5.
Br J Surg ; 104(10): 1338-1345, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28718940

RESUMO

BACKGROUND: Since 2003, care for patients with oesophageal cancer has been centralized in a few dedicated centres in Denmark. The aim of this study was to assess changes in the treatment and outcome of patients registered in a nationwide database. METHODS: All patients diagnosed with oesophageal cancer or cancer of the gastro-oesophageal junction who underwent oesophagectomy in Denmark between 2004 and 2013, and who were registered in the Danish clinical database of carcinomas in the oesophagus, gastro-oesophageal junction and stomach (DECV database) were included. Quality-of-care indicators, including number of lymph nodes removed, anastomotic leak rate, 30- and 90-day mortality, and 2- and 5-year overall survival, were assessed. To compare quality-of-care indicators over time, the relative risk (RR) was calculated using a multivariable log binomial regression model. RESULTS: Some 6178 patients were included, of whom 1728 underwent oesophagectomy. The overall number of patients with 15 or more lymph nodes in the resection specimen increased from 38·1 per cent in 2004 to 88·7 per cent in 2013. The anastomotic leak rate decreased from 14·8 to 7·6 per cent (RR 0·66, 95 per cent c.i. 0·43 to 1·01). The 30-day mortality rate decreased from 4·5 to 1·7 per cent (RR 0·51, 0·22 to 1·15) and the 90-day mortality rate from 11·0 to 2·9 per cent (RR 0·46, 0·26 to 0·82). There were no statistically significant changes in 2- or 5-year survival rates over time. CONCLUSION: Indicators of quality of care have improved since the centralization of oesophageal cancer treatment in Denmark.


Assuntos
Adenocarcinoma/cirurgia , Carcinoma de Células Escamosas/cirurgia , Serviços Centralizados no Hospital/normas , Neoplasias Esofágicas/cirurgia , Indicadores de Qualidade em Assistência à Saúde , Adenocarcinoma/mortalidade , Idoso , Carcinoma de Células Escamosas/mortalidade , Dinamarca , Neoplasias Esofágicas/mortalidade , Esofagectomia/mortalidade , Junção Esofagogástrica/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/cirurgia , Resultado do Tratamento
8.
Health Policy ; 119(8): 1068-75, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25773506

RESUMO

This study explores important considerations from a patient perspective in decisions regarding centralisation of specialised health care services. The analysis is performed in the framework of the Swedish National Board of Health and Welfare's ongoing work to evaluate and, if appropriate, centralise low volume, highly specialised, health services defined as National Specialised Medical Care. In addition to a literature review, a survey directed to members of patient associations and semi-structured interviews with patient association representatives and health care decision makers were conducted. The results showed that from a patient perspective, quality of care in terms of treatment outcomes is the most important factor in decisions regarding centralisation of low volume, highly specialised health care. The study also indicates that additional factors such as continuity of treatment and a well-functioning care pathway are highly important for patients. However, some of these factors may be dependent on the implementation process and predicting how they will evolve in case of centralisation will be difficult. Patient engagement and patient association involvement in the centralisation process is likely to be a key component in attaining patient focused care and ensuring patient satisfaction with the centralisation decisions.


Assuntos
Serviços Centralizados no Hospital , Preferência do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude Frente a Saúde , Serviços Centralizados no Hospital/normas , Continuidade da Assistência ao Paciente/normas , Procedimentos Clínicos/normas , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Inquéritos e Questionários , Suécia , Adulto Jovem
9.
Health Care Manage Rev ; 40(2): 92-103, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24566250

RESUMO

BACKGROUND: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. PURPOSE: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. METHODOLOGY: Panel data (2006-2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. PRINCIPAL FINDINGS: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital-physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. PRACTICE IMPLICATIONS: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Custos de Cuidados de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/organização & administração , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/normas , Serviços Centralizados no Hospital/economia , Serviços Centralizados no Hospital/organização & administração , Serviços Centralizados no Hospital/normas , Assistência à Saúde/economia , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/normas , Florida/epidemiologia , Custos Hospitalares/normas , Humanos , Modelos Organizacionais , Mortalidade , Alta do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/estatística & dados numéricos
10.
Ned Tijdschr Geneeskd ; 158: A7643, 2014.
Artigo em Holandês | MEDLINE | ID: mdl-25096039

RESUMO

Current debate on complex medical care in the Netherlands includes the treatment of ruptured abdominal aortic aneurysm (RAAA). Topics of interest are hospital volume, patient selection and the use of minimally invasive but more expensive techniques. Based on two recent randomized trials investigating open and endovascular repair for RAAA, we discuss the advantages and disadvantages of techniques, quality of life and age. We conclude that optimal treatment can only be provided in a vascular centre with 24/7 availability of both open and endovascular repair, a top level intensive care unit and a demonstrable low decline rate for surgery. Age should be abandoned as an eligibility criterion for surgery.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Serviços Centralizados no Hospital/normas , Fatores Etários , Humanos , Países Baixos , Seleção de Pacientes , Qualidade de Vida , Resultado do Tratamento
12.
Clin Med (Lond) ; 12(2): 114-8, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22586783

RESUMO

The National Plan for Liver Services in 2009 called for a review of current liver services across the UK to identify areas of good and poor provision. We present the results of a national questionnaire survey of liver services, which focussed on staffing and training, access to key facilities and clinical management of liver disease. Areas of good practice include the increased proportion of consultants who trained at a liver centre, the introduction of specific liver clinics and the widespread use of terlipressin and antibiotics for variceal bleeding. Areas of poor practice include limited access to alcohol psychiatry services and transjugular intrahepatic portosystemic shunts (TIPS) and limited recording of outcome measures or patient databases. Wide variation in the clinical management of serious liver diseases supports the need for managed clinical networks. These results will help to guide the development of standards of care for liver services across the UK.


Assuntos
Serviços Centralizados no Hospital/normas , Gerenciamento Clínico , Unidades Hospitalares , Hospitais Comunitários , Hepatopatias/terapia , Consultores/estatística & dados numéricos , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde/organização & administração , Unidades Hospitalares/normas , Unidades Hospitalares/estatística & dados numéricos , Hospitais Comunitários/normas , Hospitais Comunitários/estatística & dados numéricos , Humanos , Hepatopatias/complicações , Hepatopatias/diagnóstico , Transplante de Fígado/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/normas , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Desenvolvimento de Pessoal/organização & administração , Inquéritos e Questionários , Reino Unido , Recursos Humanos
13.
Ned Tijdschr Geneeskd ; 155(45): A3813, 2011.
Artigo em Holandês | MEDLINE | ID: mdl-22085567

RESUMO

The complexity of diagnosis and treatment for common cancers is rapidly increasing due to multimodality treatment options, advanced imaging, molecular pathology and 'personalized medicine'. To achieve the best chances for cure, treatment centres need to invest in highly trained personnel, including all the necessary diagnostic and therapeutic subspecialists, and in high-tech facilities. In the Netherlands, many patients receive care in community hospitals that lack key members of a treatment team (e.g. the radiotherapist). Such teams may depend on weekly or biweekly cancer conferences with external experts to arrive at patient-management decisions. It is recommended that such hospitals either upgrade their teams and facilities or refer their patients to a hospital that has an established cancer centre.


Assuntos
Serviços Centralizados no Hospital/métodos , Serviços Centralizados no Hospital/normas , Neoplasias/terapia , Administração dos Cuidados ao Paciente , Assistência Centrada no Paciente , Humanos , Prognóstico
14.
Ned Tijdschr Geneeskd ; 155(45): A3854, 2011.
Artigo em Holandês | MEDLINE | ID: mdl-22085569

RESUMO

The Netherlands is strongly leaning towards treating cancer patients at a limited number of hospitals. This approach has been poorly investigated and there is little evidence that the quality of care and the outcome of treatment in the Dutch system are related to the size of the institute. Oncological care is getting more and more complicated and requires a certain scale, but the formation of networks offers more possibilities than centralisation. Technical developments may offer alternatives to centralisation. In addition, care given closer to home to an increasingly older patient population is very valuable. Comorbidity is another reason to provide care at a general hospital in close cooperation with general practitioners. Strong ties with a university clinic is an important requirement for such a network to work well.


Assuntos
Serviços Centralizados no Hospital/métodos , Serviços Centralizados no Hospital/normas , Neoplasias/terapia , Administração dos Cuidados ao Paciente , Assistência Centrada no Paciente , Humanos
17.
Acta Neurochir (Wien) ; 153(6): 1219-29; discussion 1229, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21547495

RESUMO

BACKGROUND: Provider volume is often a central topic in debates about centralization of procedures. In Norway, there is considerable variation in provider volumes of the neurosurgical centers treating children. We sought to explore long-term survival after surgery for central nervous system tumors in children in relation to regional provider volumes. METHOD: Based on data from the Norwegian Cancer Registry we analyzed survival in all reported central nervous system tumors in children under the age of 16 treated over two decades, between March 1988 and April 2008; a total of 816 patients with histologically confirmed disease. RESULTS: There was no overall difference in survival between regions. In the subgroup of PNET/medulloblastomas, both living in the high-provider volume health region and receiving treatment in the high-volume region was significantly associated with inferior survival. CONCLUSIONS: In this population-based study of children operated over a period of two decades, we found no evidence of improved long-term survival in the high-provider volume region. Surprisingly, a subgroup analysis indicated that survival in PNET/medulloblastomas was significantly better if living outside the most populated health region with the highest provider volumes. One should, however, be careful of interpreting this directly as a symptom of quality of care, as there may be unseen confounders. Our study demonstrates that provider case volume may serve as an axiom in debates about centralization of cancer surgery while perhaps much more reliable and valid but less quantifiable factors are important for the final results.


Assuntos
Neoplasias Encefálicas/cirurgia , Serviços Centralizados no Hospital/normas , Competência Clínica/normas , Tamanho das Instituições de Saúde/normas , Complicações Pós-Operatórias/mortalidade , Especialidades Cirúrgicas , Neoplasias Encefálicas/mortalidade , Neoplasias Cerebelares/mortalidade , Neoplasias Cerebelares/cirurgia , Criança , Pré-Escolar , Neoplasias do Plexo Corióideo/patologia , Neoplasias do Plexo Corióideo/cirurgia , Feminino , Humanos , Lactente , Estimativa de Kaplan-Meier , Masculino , Meduloblastoma/mortalidade , Meduloblastoma/cirurgia , Tumores Neuroectodérmicos Primitivos/mortalidade , Tumores Neuroectodérmicos Primitivos/cirurgia , Noruega , Garantia da Qualidade dos Cuidados de Saúde/normas , Sistema de Registros
18.
Med Care ; 48(12): 1041-9, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20966781

RESUMO

BACKGROUND: For more than a decade, health policy groups have recommended concentrating care for certain high-risk oncologic procedures into high-volume centers. The degree to which practice patterns and outcomes have changed over that time period is unclear. OBJECTIVE: To evaluate temporal trends in the mortality and concentration of high-risk oncologic procedures. RESEARCH DESIGN: Retrospective cohort study using data from the Nationwide Inpatient Sample on 93,108 adult patients undergoing pancreatectomy, esophagectomy, gastrectomy, or major lung resection for organ-specific cancers from 1997 to 2006. The main outcome measure was in-hospital mortality. RESULTS: Risk- and volume-adjusted mortality decreased over time for all 4 procedures (P < 0.05). When hospitals were categorized into terciles of case volume, mortality gaps persisted between high- and low-volume centers in all procedures throughout the study period and did not significantly narrow over time. Patient volumes shifted toward high-volume centers over time for all procedures (P <0.001), although at the end of the study period, low-volume centers still cared for one-quarter to one-third of patients undergoing each of the studied procedures. Most of the overall improvements in mortality were attributable to decreasing mortality within volume categories as opposed to the effects of care concentration. CONCLUSIONS: Modest concentration into higher-volume centers has taken place over the past decade, but improvements within volume categories have driven most of the generalized decreases in mortality. Significant outcome gaps between high- and low-volume centers still persist; further centralization may retain the potential to lower overall mortality.


Assuntos
Serviços Centralizados no Hospital/organização & administração , Mortalidade Hospitalar/tendências , Neoplasias/mortalidade , Neoplasias/cirurgia , Serviço Hospitalar de Oncologia/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Adulto , Idoso , Serviços Centralizados no Hospital/normas , Esofagectomia/mortalidade , Feminino , Hepatectomia/mortalidade , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/mortalidade , Pneumonectomia/mortalidade , Estatísticas não Paramétricas , Centro Cirúrgico Hospitalar/normas , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia
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