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1.
Medicine (Baltimore) ; 98(45): e17709, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702622

RESUMO

BACKGROUND: The rising maternal and child healthcare costs and the lack of training and educational resources for healthcare workers have reduced service quality in primary health centers of China. We sought to compare strategies promoting healthcare service utilization in rural western China. METHOD: A randomized community trial was carried out in Zhen'an country between 2007 and 2009. Two cross-sectional surveys were conducted to compare the outcomes of financial subsidy for pregnant women seeking antenatal care and clinical training provided to healthcare workers by difference-in-difference estimation. RESULTS: In all, 1113 women completed the questionnaires. The proportion of postnatal visits increased three times in the training group, reaching 35.7%. The number of women who received advice from their doctors regarding nutrition and warning signs necessitating immediate medical attention also improved significantly (5.8% and 8.2%, respectively). Furthermore, the percentage of women who underwent blood tests increased significantly to 19.5% in the training group. Compared to the financial group, the training group had more women who breastfed for longer than 4 months (15.8%) and provided timely complementary feeding (8.9%). CONCLUSION: The training intervention appeared to have improved prenatal care utilization. Essential obstetric training helped enhance knowledge and self-efficacy among healthcare workers.


Assuntos
Pessoal de Saúde/educação , Serviços de Saúde Materna/economia , Serviços de Saúde Rural/economia , Estudos Transversais , Feminino , Humanos , Aceitação pelo Paciente de Cuidados de Saúde , Gravidez , Autoeficácia , Inquéritos e Questionários
2.
Am J Health Syst Pharm ; 76(2): 108-113, 2019 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31408091

RESUMO

PURPOSE: The stages of development of a health system-wide antimicrobial stewardship program (ASP) using existing personnel and technology are described. SUMMARY: Small hospitals with limited resources may struggle to meet ASP requirements, particularly facilities without onsite infectious disease physicians and/or experienced infectious disease pharmacists. Strategies for ASP development employed by Avera Health, a 33-hospital health system in the Midwest, included identifying relevant drug utilization and resistance patterns, education and pathway development, and implementation of Web-based conferencing to provide pharmacists throughout the system with access to infectious disease expertise on a daily basis. These efforts resulted in an evolving single-system ASP that has leveraged existing resources to overcome some system barriers. Program outcomes to date include a reduction in the use of a targeted agent, improved pathogen susceptibility trends, and rates of hospital-associated Clostridium difficile infection below national benchmarks. CONCLUSION: The Avera Health ASP grew from a collaborative project targeting levofloxacin overuse and resistance among key bacteria to a formal, health system-wide ASP in a rural setting. This program used existing personnel to provide standardized processes, educational campaigns, and antimicrobial expertise through the use of technology. This ASP program may provide helpful examples of ASP strategies for other rural health systems with similar resources.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/organização & administração , Infecções por Clostridium/tratamento farmacológico , Hospitais Rurais/organização & administração , Desenvolvimento de Programas , Antibacterianos/farmacologia , Gestão de Antimicrobianos/economia , Infecções por Clostridium/microbiologia , Clostridium difficile/efeitos dos fármacos , Clostridium difficile/isolamento & purificação , Clostridium difficile/fisiologia , Farmacorresistência Bacteriana/efeitos dos fármacos , Uso de Medicamentos , Hospitais Rurais/economia , Humanos , Levofloxacino/farmacologia , Levofloxacino/uso terapêutico , Testes de Sensibilidade Microbiana , Farmacêuticos/organização & administração , Serviço de Farmácia Hospitalar/economia , Serviço de Farmácia Hospitalar/organização & administração , Papel Profissional , Avaliação de Programas e Projetos de Saúde , Serviços de Saúde Rural/economia , Serviços de Saúde Rural/organização & administração
3.
N Engl J Med ; 381(6): 543-551, 2019 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-31291511

RESUMO

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas. METHODS: We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending. RESULTS: Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending. CONCLUSIONS: With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).


Assuntos
Organizações de Assistência Responsáveis/economia , Gastos em Saúde , Área Carente de Assistência Médica , Medicare/economia , Serviços de Saúde Rural/economia , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Feminino , Custos de Cuidados de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Poupança para Cobertura de Despesas Médicas , Pessoa de Meia-Idade , Estados Unidos
4.
Am J Health Syst Pharm ; 76(7): 453-459, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-31361821

RESUMO

PURPOSE: The barriers and solutions to the current prior-authorization (PA) process at an integrated health system were evaluated. METHODS: Focus groups were conducted with patients at an integrated health system who also had insurance from an affiliated health plan and at least 1 denial for a medication in the past year. Semistructured interviews were conducted with medical staff (physicians, office staff, and PA experts). Both focus groups and interviews were audio-recorded and transcribed. Inductive analysis was used to code transcripts and develop themes. RESULTS: Three focus groups were conducted with 13 patients, and 9 medical staff (3 staff physicians, 2 office staff, and 4 PA staff) who have interactions with the PA process interviewed. Several themes were identified including the complexity of the PA process, consequences experienced, and ineffective communication between key stakeholders. A cross-cutting theme was that stakeholders expressed feelings of frustration, anxiety, and anger throughout the PA process. All stakeholders offered insights on how the process could be improved to better facilitate their preferences, such as access to the list of medications that require PA and the need for a patient advocate. CONCLUSION: Results of this study revealed that the PA process was frustrating, upsetting, and infuriating to patients and medical staff involved in the process. Three main themes identified included the complexity of the PA process, consequences experienced from the PA process, and ineffective communication between stakeholders.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Autorização Prévia , Serviços de Saúde Rural/organização & administração , Participação dos Interessados/psicologia , Atitude do Pessoal de Saúde , Tomada de Decisão Clínica/métodos , Comunicação , Prestação Integrada de Cuidados de Saúde/economia , Feminino , Grupos Focais , Frustração , Pessoal de Saúde/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Serviços de Saúde Rural/economia , Fatores de Tempo
6.
Int J Equity Health ; 18(1): 90, 2019 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200711

RESUMO

BACKGROUND: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China. METHODS: Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS. RESULTS: There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are - 0.043 and - 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS. CONCLUSIONS: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , População Rural/estatística & dados numéricos , Serviços Urbanos de Saúde/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Adulto , China , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Serviços de Saúde Rural/economia , Serviços Urbanos de Saúde/economia
7.
Rural Remote Health ; 19(2): 5113, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31128577

RESUMO

INTRODUCTION: Canada's northern territories are characterized by small, scattered populations separated by long distances. A major challenge to healthcare delivery is the reliance on costly patient transportation, especially emergency air evacuations (medevacs). The purpose of this study was to describe the patterns, costs and providers' perspectives on patient transportation, and identify potential factors associated with utilization and performance. METHODS: Secondary analyses of medical travel databases and an online survey of nurses in the communities and physicians in regional centers were undertaken. RESULTS: The proportion of the population living within 100 km of a hospital was 83% in Yukon, 63% in Northwest Territories (NWT) and 21% in Nunavut. In Nunavut and NWT, road access to a hospital was limited to residents of the cities where the hospitals were located, with the rest relying exclusively on air travel. Medevac rates varied among the three territories: 0.9 trips/1000 residents/year in Yukon, 32/1000 in NWT and 53/1000 in Nunavut. In Yukon, all communities except one are road-accessible whereas in Nunavut no communities are connected by roads. The relative absence of roads is a major reason why the patient transportation costs are high in Nunavut and NWT. The rate of medevacs originating from the remote, air-accessible-only communities varied greatly, which cannot be explained by the air distance from the nearest hospital, population size or frequency of health center visits. Medical travel accounts for 5% of the health expenditures in NWT and 20% in Nunavut. A medevac on average costs $218 per person per year in NWT and $700 in Nunavut. The providers survey detected only 66% or less in support of statements that nurses in the communities received timely access to clinical advice, whereas only 50% of physicians agreed with statements that the clinical information provided by the nurses was clear. CONCLUSION: Patient transportation, especially emergency air evacuations, is an essential but costly component of the healthcare system serving Canada's north. It is the 'glue' that binds an extensive network of facilities staffed by different categories of health professionals. While system design is largely dictated by geography, addressing human factors such as interprofessional communication is important for improving the system's effectiveness. This study is primarily descriptive and it points to additional areas for improved understanding of the performance of the system.


Assuntos
Acesso aos Serviços de Saúde/economia , Serviços de Saúde Rural/economia , Transporte de Pacientes/economia , Canadá , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Territórios do Noroeste , Nunavut , Serviços de Saúde Rural/estatística & dados numéricos , População Rural/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Yukon
8.
BMC Health Serv Res ; 19(1): 315, 2019 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-31096977

RESUMO

BACKGROUND: Rural women experience health disparities in terms of cardiovascular disease (CVD) risk compared to urban women. Cost-effective CVD-prevention programs are needed for this population. The objective of this study was to conduct cost analysis and cost-effectiveness analyses (CEAs) of the Strong Hearts, Healthy Communities (SHHC) program compared to a control program in terms of change in CVD risk factors, including body weight and quality-adjusted life years (QALYs). METHODS: Sixteen medically underserved rural towns in Montana and New York were randomly assigned to SHHC, a six-month twice-weekly experiential learning lifestyle program focused predominantly on diet and physical activity behaviors (n = 101), or a monthly healthy lifestyle education-only control program (n = 93). Females who were sedentary, overweight or obese, and aged 40 years or older were enrolled. The cost analysis calculated the total and per participant resource costs as well as participants' costs for the SHHC and control programs. In the intermediate health outcomes CEAs, the incremental costs were compared to the incremental changes in the outcomes. The QALY CEA compares the incremental costs and effectiveness of a national SHHC intervention for a hypothetical cohort of 2.2 million women compared to the status quo alternative. RESULTS: The resource cost of SHHC was $775 per participant. The incremental cost-effectiveness ratios from the payer's perspective was $360 per kg of weight loss. Over a 10-year time horizon, to avert per QALY lost SHHC is estimated to cost $238,271 from the societal perspective, but only $62,646 from the healthcare sector perspective. Probabilistic sensitivity analyses show considerable uncertainty in the estimated incremental cost-effectiveness ratios. CONCLUSIONS: A national SHHC intervention is likely to be cost-effective at willingness-to-pay thresholds based on guidelines for federal regulatory impact analysis, but may not be at commonly used lower threshold values. However, it is possible that program costs in rural areas are higher than previously studied programs in more urban areas, due to a lack of staff and physical activity resources as well as  availability for partnerships with existing organizations. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02499731 , registered on July 16, 2015.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Análise Custo-Benefício , Serviços Preventivos de Saúde/economia , Serviços de Saúde Rural/economia , Adulto , Idoso , Doenças Cardiovasculares/economia , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Montana , New York , Sobrepeso , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Perda de Peso
9.
Artigo em Inglês | MEDLINE | ID: mdl-31010133

RESUMO

This study aimed to evaluate the effects of the differences between two typical payment methods for the new rural cooperative medical scheme (NRCMS) in China on the utilisation of inpatient services. Interrupted time-series analysis (ITSA) and propensity score matching (PSM) were used to measure the difference between two typical payment methods for the NRCMS with regard to the utilisation of inpatient services. After the reform was formally implemented, the level and slope difference after reform compared with pre-intervention (distribution of inpatients in county hospitals (DIC), distribution of inpatients in township hospitals (DIT) and the actual compensation ratio of inpatients (ARCI)) were not statistically significant. Kernel matching obtained better results in reducing the mean and median of the absolute standardised bias of covariates of appropriateness of admission (AA), appropriateness of disease (AD). The difference in AA and AD of the matched inpatients between two groups was -0.03 (p-value = 0.042, 95% CI: -0.08 to 0.02) and 0.21 (p-value < 0.001, 95% CI: -0.17 to 0.25), respectively. The differences in the utilisation of inpatient services may arise owing to the system designs of different payment methods for NRCMS in China. The causes of these differences can be used to guide inpatients to better use medical services, through the transformation and integration of payment systems.


Assuntos
Assistência à Saúde/economia , Seguro Saúde/economia , Serviços de Saúde Rural/economia , China , Assistência à Saúde/estatística & dados numéricos , Gastos em Saúde , Hospitalização , Hospitais , Hospitais de Condado , Humanos , Pacientes Internados , Seguro Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , População Rural/estatística & dados numéricos
10.
Trials ; 20(1): 152, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30823886

RESUMO

BACKGROUND: Antenatal care (ANC), facility delivery and postnatal care (PNC) are proven to reduce maternal and child mortality and morbidity in high-burden settings. However, few pregnant rural women use these services sufficiently. This study aims to assess the impact, cost-effectiveness and scalability of conditional cash transfers to promote increased contact between pregnant women or women who have recently given birth and the formal healthcare system in Kenya. METHODS: The intervention tested is a conditional cash transfer to women for ANC health visits, a facility birth and PNC visits until their newborn baby reaches 1 year of age. The study is a cluster randomized controlled trial in Siaya County, Kenya. The trial clusters are 48 randomly selected public primary health facilities, 24 of which are in the intervention arm of the study and 24 in the control arm. The unit of randomization is the health facility. A target sample of 7200 study participants comprises pregnant women identified and recruited at their first ANC visit over a 12-month recruitment period and their subsequent newborns. All pregnant women attending one of the selected trial facilities for their first ANC visit during the recruitment period are eligible for the trial and invited to participate. Enrolled mothers are followed up at all health visits during their pregnancy, at facility delivery and for a number of visits after delivery. They are also contacted at three additional time points after enrolling in the study: 5-10days after enrolment, 6 months after the expected delivery date and 12 27 months after birth. If they have not delivered in a facility, there is an additional follow-up 2 wees after the expected due date. The impact of the conditional cash transfers on maternal healthcare services and utilization will be measured by the trial's primary outcomes: the proportion of all eligible ANC visits made during pregnancy, delivery at a health facility, the proportion of all eligible PNC visits attended, the proportion of referrals attended during the pregnancy and the postnatal period, and the proportion of eligible child immunization appointments attended. Secondary outcomes include; health screening and infection control, live birth, maternal and child survival 48 h after delivery, exclusive breastfeeding, post-partum contraceptive use and maternal and newborn morbidity. Data sources for the measurement of outcomes include routine health records, an electronic card-reader system and telephone surveys and focus group discussions. A full economic evaluation will be conducted to assess the cost of delivery and cost effectiveness of the intervention and the benefit incidence and equity impact of trial activities and outcomes. DISCUSSION: This trial will contribute to evidence on the effectiveness and cost-effectiveness of conditional cash transfers in facilitating health visits and promoting maternal and child health in rural Kenya and in other comparable contexts. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03021070 . Registered on 13 January 2017.


Assuntos
Continuidade da Assistência ao Paciente/economia , Apoio Financeiro , Financiamento Pessoal/economia , Custos de Cuidados de Saúde , Cooperação do Paciente , Assistência Perinatal/economia , Serviços de Saúde Rural/economia , Análise Custo-Benefício , Feminino , Humanos , Lactente , Recém-Nascido , Quênia , Motivação , Assistência Perinatal/métodos , Pobreza/economia , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
12.
Health Care Manag (Frederick) ; 38(2): 101-108, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30908289

RESUMO

Securing health services administrators to manage health care organizations in rural areas and small town communities presents unique challenges; however, potential benefits abound for residents in terms of improving population health outcomes from a community-based approach and stimulating the local economy. The influx of community-based approaches to revitalize small towns and rural communities is evident in the literature. Small towns and rural areas lack advanced health care practices, which results in poor health outcomes; economic development as a result of a poorly prepared workforce; and community connection to the vast array of knowledge, activities, and other supports as a result of poor physical and virtual connectivity. An approach that prompts new health management graduates to practice where they have an opportunity to cultivate the residents, the community at large, and themselves is an optimal management method in improving rural areas. This framework places emphasis on students completing a health services administration curriculum training program and beginning their careers in underserved areas to positively impact rural communities by playing a role in revitalizing the local economy and improving population health.


Assuntos
Administração de Serviços de Saúde , Liderança , Saúde da População , Serviços de Saúde Rural/normas , Escolha da Profissão , Serviços de Saúde Comunitária , Análise Custo-Benefício , Humanos , Área Carente de Assistência Médica , Serviços de Saúde Rural/economia
13.
Anesth Analg ; 129(1): 294-300, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30855341

RESUMO

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.


Assuntos
Anestesia , Prestação Integrada de Cuidados de Saúde/organização & administração , Países Desenvolvidos , Acesso aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde/organização & administração , Segurança do Paciente , Serviços de Saúde Rural/organização & administração , Anestesia/efeitos adversos , Anestesia/economia , Anestesiologistas/organização & administração , Prestação Integrada de Cuidados de Saúde/economia , Países Desenvolvidos/economia , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Humanos , Liderança , Equipe de Assistência ao Paciente/organização & administração , Segurança do Paciente/economia , Papel do Médico , Fatores de Risco , Serviços de Saúde Rural/economia
14.
Environ Monit Assess ; 191(3): 175, 2019 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-30788632

RESUMO

Management of healthcare waste in low- and middle-income countries lacks a straightforward solution, especially where rural health services are provided. The purpose of our case study was to explore the knowledge and practices of health surveillance assistants operating at rural village health clinics in Ntcheu District, Malawi, with regard to the collection, segregation, transportion, treatment, and disposal of healthcare waste. Data were collected from 81 clinics. The results indicated that while general gaps in both knowledge and practice were observed, sharps (e.g., needles) management was generally being done well. An opportunity for scale-up was found in one clinic, in which local materials had been used to construct a low-cost innovative sharps disposal receptacle that had been modified from a pit latrine design. This study recommends waste management training suitable for rural settings, the promotion of low-cost sharps disposal receptacles using local materials, further opportunities for low-cost incinerators, central waste collection, and encouraging grassroots innovation in healthcare waste management.


Assuntos
Monitoramento Ambiental/métodos , Eliminação de Resíduos de Serviços de Saúde/métodos , Serviços de Saúde Rural/organização & administração , Países em Desenvolvimento , Monitoramento Ambiental/economia , Humanos , Incineração , Malaui , Eliminação de Resíduos de Serviços de Saúde/economia , Agulhas , Serviços de Saúde Rural/economia , População Rural
15.
J Surg Res ; 239: 8-13, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30782545

RESUMO

BACKGROUND: St. Boniface Hospital (SBH) plays a critical role in providing safe, accessible surgery in rural southern Haiti. We examine the impact of SBH increasing surgical capacity on case volume, patient complexity, and inpatient mortality across three phases. MATERIALS AND METHODS: A retrospective review and geospatial analysis of all surgical cases performed at SBH between 2015 and 2017 were performed. Inpatient mortality was defined by in-hospital deaths divided by the number of procedures performed. RESULTS: Between February 2015 and August 2017, over 2000 procedures were performed. The average number of surgeries per week was 3.1 with visiting surgical teams in phase 1 (P1), 10.4 with a single general surgeon in phase 2 (P2), and 20.1 with two surgeons and a resident in phase 3 (P3). There was a six-fold increase in surgical volume between P1 and P3 and a significant increase in case complexity. The distribution of American Society of Anesthesiologists scores of 1, 2, 3, and 4 during P2 was 81.05%, 14.74%, 3.42%, and 0.79%, respectively, whereas in P3, the distribution was 68.91%, 22.55%, 7.70%, and 0.84%. Surgical mortality was 0%, 1.2%, and 1.67% across phases. CONCLUSIONS: Increasing resources and surgical staff at SBH allowed for greater delivery of safe surgical care. This study highlights that investing in surgery has a significant impact in regions of great surgical need.


Assuntos
Complicações Pós-Operatórias/epidemiologia , Serviços de Saúde Rural/tendências , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Adulto , Criança , Países em Desenvolvimento , Haiti/epidemiologia , Recursos em Saúde/estatística & dados numéricos , Recursos em Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/tendências , Mão de Obra em Saúde/economia , Mão de Obra em Saúde/estatística & dados numéricos , Mão de Obra em Saúde/tendências , Mortalidade Hospitalar/tendências , Humanos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Serviços de Saúde Rural/economia , Serviços de Saúde Rural/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Centros de Atenção Terciária/economia , Centros de Atenção Terciária/tendências
17.
Am J Hosp Palliat Care ; 36(9): 795-800, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30803247

RESUMO

BACKGROUND: In rural communities, providing hospice care can be a challenge. Hospice personnel sometimes travel great distances to reach patients, resulting in difficulty maintaining access, quality, cost-effectiveness, and safety. In 1998, the University of Kansas Medical Center piloted the country's first TeleHospice (TH) service. At that time, challenges with broad adoption due to cost and attitudes regarding technology were noted. A second TH project was launched in early 2017 using newer technology; this article updates that ongoing implementation. METHODS: The Organizational Change Manager was followed for the guided selection of the hospice partner. The University of Kansas Medical Center partnered with Hospice Services, Inc. (HSI), a leader in rural hospice care, providing services to 16 Kansas counties. Along with mobile tablets, a secure cloud-based videoconferencing solution was chosen for ease of use. RESULTS: From August 2017 through January 2018, 218 TH videoconferencing encounters including 917 attendees occurred. Calls were made for direct patient care, family support, and administrative purposes. These TH calls have been shown to save HSI money, and initial reports suggest they may strengthen the communication and relationships between staff, patients, and the patient's family. CONCLUSION: Finding innovative, cost-effective, and community-driven approaches such as TH are needed to continually advance hospice care. TeleHospice's potential to supplement and improve hospice services while reducing costs is significant, but continued research is needed to understand best fit within frontier hospices, to inform future urban applications, and to address reimbursement.


Assuntos
Participação da Comunidade , Computadores de Mão , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Serviços de Saúde Rural/organização & administração , Telemedicina/organização & administração , Atitude do Pessoal de Saúde , Análise Custo-Benefício , Cuidados Paliativos na Terminalidade da Vida/economia , Humanos , Kansas , Equipe de Assistência ao Paciente/organização & administração , Relações Profissional-Paciente , Serviços de Saúde Rural/economia , Telemedicina/economia
18.
J Telemed Telecare ; 25(5): 301-309, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29448879

RESUMO

PURPOSE: Using a mixed-methods formative evaluation, the purpose of this study was to provide a broad overview of the Alabama eHealth programme set-up and initial patient outcomes. The Alabama eHealth programme uses telemedicine to provide medical care to people living with HIV in rural Alabama. It was led by a community-based organisation, Medical Advocacy and Outreach (MAO), and supported by AIDS United and the Corporation for National Community Service's Social Innovation Fund with matching support from non-federal donors. METHODS: We conducted and transcribed in-depth interviews with Alabama eHealth staff and then performed directed content analysis. We also tracked patients' ( n = 240) appointment attendance, CD4 counts, and viral loads. FINDINGS: Staff described the steps taken to establish the programme, associated challenges (e.g., costly, inadequate broadband in rural areas), and technology enabling this programme (electronic medical records, telemedicine equipment). Of all enrolled patients, 76% were retained in care, 88% had antiretroviral therapy and 75% had a suppressed viral load. Among patients without missing data, 96% were retained in care, 97% used antiretroviral therapy and 93% had suppressed viral loads. There were no statistically significant demographic differences between those with and without missing data. CONCLUSIONS: Patients enrolled in a telemedicine programme evaluation successfully moved through the HIV continuum of care.


Assuntos
Infecções por HIV/terapia , Acesso aos Serviços de Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Telemedicina/organização & administração , Adolescente , Adulto , Alabama , Antirretrovirais/uso terapêutico , Registros Eletrônicos de Saúde , Feminino , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Serviços de Saúde Rural/economia , Fatores Socioeconômicos , Carga Viral , Adulto Jovem
19.
Telemed J E Health ; 25(5): 380-390, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30036152

RESUMO

Introduction: Nonavailability of emergency healthcare services in mountainous, isolated, and sparsely populated regions is a universal problem. In a first of its kind initiative, Tele-emergency services (TES) was provided in Keylong and Kaza in Himachal Pradesh in Northern India, at an altitude of 3,353 meters with temperatures of -30°C during winter months. Methods: Existing rooms in regional hospital (Keylong) and community health center (Kaza) were converted into tele-emergency centers by connecting them, to a state-of-the-art emergency department at the Joint Commission International-accredited Apollo Main Hospital at Chennai, 2,925 km away. Training was carried out at both ends. Average turnaround time for an emergency teleconsult was less than 12 minutes. Tele-ECG, Spirometry, and Point-of-Care Diagnostics for blood biochemistry were made available. Results: In the first 35 months, 753 teleconsults were given in the 24/7 TES, out of a total of 10,213 teleconsults constituting 7.4%. Out of a total of 6,442 telelaboratory tests, 431 tests were done in an emergency setting constituting 6.7%. Of the 16 cases of myocardial infarction remotely diagnosed, 4 were thrombolysed through telementoring. Of seven patients with Supra Ventricular Tachycardia, six patients were stabilized through electrical cardioversion and one through chemical cardioversion through telementoring. Ten deaths were documented, of which one occurred at the site. One hundred ninety-six were stabilized and transferred to higher centers. Thirteen required helicopter evacuations. Detailed analysis revealed that the total average cost for a single emergency teleconsult during this period was US$208. Conclusions: Preliminary analysis confirms that delivering TES in inhospitable terrains in a Public Private Partnership mode is doable and is welcomed by the community.


Assuntos
Serviços Médicos de Emergência/organização & administração , Serviços de Saúde Rural/organização & administração , Telemedicina/organização & administração , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Resgate Aéreo/estatística & dados numéricos , Altitude , Criança , Pré-Escolar , Temperatura Baixa , Redes de Comunicação de Computadores/organização & administração , Análise Custo-Benefício , Eletrocardiografia , Serviços Médicos de Emergência/economia , Feminino , Humanos , Índia , Lactente , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos , Serviços de Saúde Rural/economia , Espirometria , Telemedicina/economia , Fatores de Tempo , Adulto Jovem
20.
Ann Vasc Surg ; 54: 40-47.e1, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30217701

RESUMO

BACKGROUND: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations. METHODS: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences. RESULTS: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs. CONCLUSIONS: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.


Assuntos
Demandas Administrativas em Assistência à Saúde/economia , Procedimentos Endovasculares/economia , Custos de Cuidados de Saúde , Preços Hospitalares , Mecanismo de Reembolso/economia , Procedimentos Cirúrgicos Vasculares/economia , Demandas Administrativas em Assistência à Saúde/classificação , Idoso , Idoso de 80 Anos ou mais , Colorado , Análise Custo-Benefício , Current Procedural Terminology , Bases de Dados Factuais , Procedimentos Endovasculares/classificação , Procedimentos Endovasculares/tendências , Feminino , Custos de Cuidados de Saúde/tendências , Preços Hospitalares/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mecanismo de Reembolso/tendências , Serviços de Saúde Rural/economia , Fatores de Tempo , Serviços Urbanos de Saúde/economia , Procedimentos Cirúrgicos Vasculares/classificação , Procedimentos Cirúrgicos Vasculares/tendências
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