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1.
Environ Monit Assess ; 192(11): 682, 2020 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-33030635

RESUMO

Sanitary waste disposal and site selection for establishing landfills are challenging problems for environmental planners. This paper aims to take environmental, socio-economic, geological, geomorphological, hydrological and ecological factors into consideration to provide a decision support framework for landfill siting. Analytical hierarchy process (AHP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) are coupled to develop an efficient multi-criteria decision-making method to be utilized in a Geographic Information System (GIS) environment for evaluating the suitability for landfill siting. As the first attempt to employ DEMATEL effectively in a landfill site selection problem, the proposed method is tested with landfill siting scenarios in New South Wales (NSW), Australia. Regional analysis is also performed to identify the potentially most suitable statistical divisions for landfill siting in NSW. The top two ranked zones covering 0.7% and 22% of the study area, respectively, are considered as the optimal areas for establishing landfills, while the bottom two ranked zones are not recommended for further consideration. Further detailed analysis is also conducted on the existing landfills, which shows that 1.0% and 37.0% of them are ranks 1 and 2, respectively. The scenario-based analysis implies that, among the contributing factors; geological and economic factors are highly important.


Assuntos
Técnicas de Apoio para a Decisão , Resíduos Sólidos , Austrália , Monitoramento Ambiental , New South Wales , Instalações de Eliminação de Resíduos
2.
JAMA ; 324(14): 1406-1418, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33048154

RESUMO

Importance: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. Objective: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. Design, Setting, and Participants: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. Interventions: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). Main Outcome and Measures: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. Results: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2). Conclusions and Relevance: Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01871506.


Assuntos
Aconselhamento/métodos , Neoplasias/diagnóstico , Abandono do Hábito de Fumar/psicologia , Temperança/psicologia , Dispositivos para o Abandono do Uso de Tabaco , Idoso , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Cotinina/análise , Aconselhamento/estatística & dados numéricos , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Entrevista Motivacional , Satisfação do Paciente , Seleção de Pacientes , Saliva/química , Fumar/tratamento farmacológico , Fumar/epidemiologia , Fumar/psicologia , Agentes de Cessação do Hábito de Fumar/efeitos adversos , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Telefone , Dispositivos para o Abandono do Uso de Tabaco/efeitos adversos , Vareniclina/efeitos adversos , Vareniclina/uso terapêutico
3.
Stud Health Technol Inform ; 273: 217-222, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-33087615

RESUMO

The questions 'What constitutes a good health care decision?', and, by extension, 'What constitutes good healthcare decision support?' continue to be asked. The most developed answers focus largely, often exclusively, on the quality of the 'deliberation' component as the determinant of the quality of the decision or decision aid. We argue that these answers and resulting aids reflect the preferences of healthcare professionals and aid developers and that these preferences are closely aligned with their interests. Some interests are material, but many professional, institutional, intellectual, methodological, and ethical. Successful promotion of a particular preference-sensitive, interest-conflicted decision aid does not change its ontological nature. Conflicts of interest are therefore universal and of concern only when this ontology is denied and if aids based on alternative interest-based preferences, such as technologies involving numerical analytic calculation, are subjected to discrimination.


Assuntos
Conflito de Interesses , Técnicas de Apoio para a Decisão , Assistência à Saúde
4.
Medicine (Baltimore) ; 99(38): e22200, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957351

RESUMO

The central lymph nodes of the neck are the most common sites of papillary thyroid carcinoma (PTC) but cannot be easily diagnosed preoperatively. Prophylactic central lymph node dissection (CLND), especially contralateral CLND, is not recommended in various guidelines due to its high risk. The aim of our study was to establish an objective point score based on preoperative and intraoperative data to guide the selection of patients for contralateral CLND.We retrospectively evaluated 1085 consecutive patients with PTC treated by thyroidectomy for inclusion in this study (the training cohort). Variables of contralateral central lymph node macro-metastasis (CLNMM) were investigated using univariate and multivariate analyses; subsequently, nomograms were developed and then validated in an independent cohort of patients (n = 326, the validation cohort).Univariate and multivariate analyses indicated that preoperative fine needle aspiration-proven ipsilateral lateral lymph node metastasis (LNM) (odds ratio [OR] 4.888, 95% confidence interval [CI] 1.587-41.280, P < .001) and cases with frozen-section pretracheal LNM (OR 19.015, 95% CI 2.949-186.040, P < .001) or Delphian LNM (OR 4.494, 95% CI 1.503-54.128, P < .001) were the 3 risk factors for contralateral CLNMM. A receiver operating characteristic curve indicated a cutoff value of 1 for the frozen-section pretracheal LNM number or the Delphian LNM number as a predictor of contralateral central lymph node metastasis (CLNM). The nomogram was then generated according to the 3 risk factors and well validated in the external cohorts, and the intraoperative frozen-section results were highly consistent with the postoperative pathological results.The proposed nomogram based on the 3 factors showed a good prediction of contralateral CLNMM in PTC.


Assuntos
Excisão de Linfonodo , Linfonodos/patologia , Câncer Papilífero da Tireoide/patologia , Neoplasias da Glândula Tireoide/patologia , Adulto , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nomogramas , Curva ROC , Câncer Papilífero da Tireoide/cirurgia , Neoplasias da Glândula Tireoide/cirurgia
5.
Comput Math Methods Med ; 2020: 9391251, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32908584

RESUMO

In this paper, a utility-based multicriteria model is proposed to support the physicians to deal with an important medical decision-the screening decision problem-given the squeeze put on resources due to the COVID-19 pandemic. Since the COVID-19 emerged, the number of patients with an acute respiratory failure has increased in the health units. This chaotic situation has led to a deficiency in health resources. Thus, this study, using the concepts of the multiattribute utility theory (MAUT), puts forward a mathematical model to aid physicians in the screening decision problem. The model is used to generate which of the three alternatives is the best one for where patients with suspected COVID-19 should be treated, namely, an intensive care unit (ICU), a hospital ward, or at home in isolation. Also, a decision information system, called SIDTriagem, is constructed and illustrated to operate the mathematical model proposed.


Assuntos
Betacoronavirus , Técnicas de Laboratório Clínico/estatística & dados numéricos , Infecções por Coronavirus/diagnóstico , Pandemias , Pneumonia Viral/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Cuidados Críticos , Tomada de Decisões Assistida por Computador , Técnicas de Apoio para a Decisão , Serviços de Assistência Domiciliar , Hospitalização , Humanos , Programas de Rastreamento , Conceitos Matemáticos , Método de Monte Carlo , Isolamento de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Triagem/métodos
6.
Value Health ; 23(8): 1040-1048, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828216

RESUMO

The Institute for Clinical and Economic Review (ICER) in the United States recently published a 2020 update to its value assessment framework. We are commenting on the method by which the benefits of health interventions are integrated, relating to contextual considerations and other factors relevant to an intervention's value. We start by discussing the theoretical foundations of decision analysis and its extension to multiple criteria decision analysis (MCDA). Then we provide a detailed, evidence-based response to some of the claims made by ICER with regard to the use of MCDA methods and stakeholder engagement. Finally, we provide a number of recommendations on the use of quantitative decision analysis and decision conferencing that could be of relevance to the ICER methodology. Overall, we agree that some of the proposed changes by ICER are moving in the right direction toward improving transparency in the value assessment process, but these changes are probably inadequate. We advocate that more serious attention should be paid to the use of quantitative decision analysis together with decision conferencing for the construction of value preferences via group processes for the integration of an intervention's various benefit components.


Assuntos
Tomada de Decisões , Avaliação da Tecnologia Biomédica/organização & administração , Algoritmos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Humanos , Projetos de Pesquisa , Estados Unidos
7.
Value Health ; 23(8): 1049-1055, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828217

RESUMO

OBJECTIVES: Using an example of an existing model constructed by the National Institute for Health and Care Excellence (NICE) to inform a real health technology assessment, this study seeks to demonstrate how a discretely integrated condition event (DICE) simulation can improve the implementation of Markov models. METHODS: Using the technical report and spreadsheet, the original model was translated to a standard DICE simulation without making any changes to the design. All original analyses were repeated and the results were compared. Aspects that could have improved the original design were then considered. RESULTS: The original model consisted of 32 copies (8 risk strata × 4 treatments) of the Markov structure, containing more than 6000 Microsoft Excel® formulas (18 MB files). Three aspects (nonadherence, scheduled treatment stop, and end of fracture risk) were handled by incorporating weighted averages into the cycle-specific calculations. The DICE implementation used 3 conditions to represent the states and a single transition event to apply the probabilities; 3 additional events processed the special aspects, and profiles handled the 8 strata (0.12 MB file). One replication took 16 seconds. The original results were reproduced but extensive additional sensitivity analyses, including structural analyses, were enabled. CONCLUSION: Implementing a real Markov model using DICE simulation both preserves the advantages of the approach and expands the available tools, improving transparency and ease of use and review.


Assuntos
Simulação por Computador , Cadeias de Markov , Modelos Estatísticos , Avaliação da Tecnologia Biomédica/organização & administração , Técnicas de Apoio para a Decisão , Humanos , Probabilidade
8.
Value Health ; 23(8): 1087-1095, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828222

RESUMO

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EAC) and the dismal prognosis has stimulated interest in the early detection of EAC. Our objective was to determine individuals' preferences for EAC screening and to assess to what extent procedural characteristics of EAC screening tests predict willingness for screening participation. METHODS: A discrete choice experiment questionnaire was sent by postal mail to 1000 subjects aged 50 to 75 years who were randomly selected from the municipal registry in the Netherlands. Each subject answered 12 discrete choice questions of 2 hypothetical screening tests comprising 5 attributes: EAC-related mortality risk reduction, procedure-related pain and discomfort, screening location, test specificity, and costs. A multinomial logit model was used to estimate individuals' preferences for each attribute level and to calculate expected rates of uptake. RESULTS: In total, 375 individuals (37.5%) completed the questionnaire. Test specificity, pain and discomfort, mortality reduction, and out-of-pocket costs all had a significant impact on respondents' preferences. The average expected uptake of EAC screening was 62.8% (95% confidence interval [CI] 61.1-64.5). Severe pain and discomfort had the largest impact on screening uptake (-22.8%; 95% CI -26.8 to -18.7). Male gender (ß 2.81; P < .001), cancer worries (ß 1.96; P = .01), endoscopy experience (ß 1.46; P = .05), and upper gastrointestinal symptoms (ß 1.50; P = .05) were significantly associated with screening participation. CONCLUSIONS: EAC screening implementation should consider patient preferences to maximize screening attendance uptake. Based on our results, an optimal screening test should have high specificity, cause no or mild to moderate pain or discomfort, and result in a decrease in EAC-related mortality.


Assuntos
Adenocarcinoma/diagnóstico , Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer/psicologia , Neoplasias Esofágicas/diagnóstico , Preferência do Paciente , Comportamento de Escolha , Análise Custo-Benefício , Feminino , Humanos , Modelos Logísticos , Masculino , Países Baixos
9.
Value Health ; 23(8): 979-984, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828225

RESUMO

BACKGROUND: Discrete choice experiments (DCEs) are commonly used to elicit patient preferences as marginal rates of substitution (MRSs) between treatment or health service attributes. Because these studies are increasing in importance, it is vital that uncertainty around MRS estimates is reported. OBJECTIVE: To review recently published DCE studies that elicit patient preferences in relation to MRS reporting and to explore the accuracy of using other reported information to estimate the uncertainty of the MRSs. METHODS: A systematic literature review of DCEs conducted with patients between 2014 and July 2019 was performed. The number of studies reporting coefficients, MRSs, standard errors (SEs), and confidence intervals was recorded. If all information was reported, studies were included in an analysis to determine the impact of estimating the SEs of MRSs using coefficients and assuming zero covariance, to determine the impact of this assumption. RESULTS: Two hundred and thirty-two patient DCEs were identified in the review; 34.1% (n = 79) reported 1 or more MRS and, of these, only 62.0% (n = 49) provided an estimate of the uncertainty. Of these studies, 16 contained enough information for inclusion in the analysis, providing 116 datapoints. Actual SEs were smaller than estimated SEs in 75.0% of cases (n = 87), and estimated SEs were within 25% of the actual SE in 59.5% of cases (n = 69). CONCLUSION: Uncertainty of MRS estimates is unreported in a substantial proportion of recently published DCE studies. Estimating the SE of a MRS by solely using the SEs of the utility coefficients is likely to lead to biased estimates of the precision of patient trade-offs.


Assuntos
Comportamento de Escolha , Análise Custo-Benefício/métodos , Análise Custo-Benefício/normas , Técnicas de Apoio para a Decisão , Preferência do Paciente , Tomada de Decisões , Humanos , Modelos Logísticos , Modelos Econométricos , Incerteza
10.
Value Health ; 23(7): 831-841, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32762984

RESUMO

OBJECTIVE: This study examines European decision makers' consideration and use of quantitative preference data. METHODS: The study reviewed quantitative preference data usage in 31 European countries to support marketing authorization, reimbursement, or pricing decisions. Use was defined as: agency guidance on preference data use, sponsor submission of preference data, or decision-maker collection of preference data. The data could be collected from any stakeholder using any method that generated quantitative estimates of preferences. Data were collected through: (1) documentary evidence identified through a literature and regulatory websites review, and via key opinion leader outreach; and (2) a survey of staff working for agencies that support or make healthcare technology decisions. RESULTS: Preference data utilization was identified in 22 countries and at a European level. The most prevalent use (19 countries) was citizen preferences, collected using time-trade off or standard gamble methods to inform health state utility estimation. Preference data was also used to: (1) value other impact on patients, (2) incorporate non-health factors into reimbursement decisions, and (3) estimate opportunity cost. Pilot projects were identified (6 countries and at a European level), with a focus on multi-criteria decision analysis methods and choice-based methods to elicit patient preferences. CONCLUSION: While quantitative preference data support reimbursement and pricing decisions in most European countries, there was no utilization evidence in European-level marketing authorization decisions. While there are commonalities, a diversity of usage was identified between jurisdictions. Pilots suggest the potential for greater use of preference data, and for alignment between decision makers.


Assuntos
Pesquisa sobre Serviços de Saúde/organização & administração , Preferência do Paciente , Mecanismo de Reembolso , Projetos de Pesquisa , Avaliação da Tecnologia Biomédica/métodos , Tecnologia Biomédica/economia , Comportamento de Escolha , Custos e Análise de Custo , Tomada de Decisões , Técnicas de Apoio para a Decisão , Europa (Continente) , Humanos , Projetos Piloto , Inquéritos e Questionários
11.
PLoS One ; 15(8): e0236410, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32797095

RESUMO

The use and management of single use plastics is a major area of concern for the public, regulatory and business worlds. Focusing on the most commonly occurring consumer plastic items present in European freshwater environments, we identified and evaluated consumer-based actions with respect to their direct or indirect potential to reduce macroplastic pollution in freshwater environments. As the main end users of these items, concerned consumers are faced with a bewildering array of choices to reduce their plastics footprint, notably through recycling or using reusable items. Using a Multi-Criteria Decision Analysis approach, we explored the effectiveness of 27 plastic reduction actions with respect to their feasibility, economic impacts, environmental impacts, unintended social/environmental impacts, potential scale of change and evidence of impact. The top ranked consumer-based actions were identified as: using wooden or reusable cutlery; switching to reusable water bottles; using wooden or reusable stirrers; using plastic free cotton-buds; and using refill detergent/ shampoo bottles. We examined the feasibility of top-ranked actions using a SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) to explore the complexities inherent in their implementation for consumers, businesses, and government to reduce the presence of plastic in the environment.


Assuntos
Monitoramento Ambiental , Plásticos/toxicidade , Rios/química , Poluentes Químicos da Água/toxicidade , Comportamento do Consumidor , Técnicas de Apoio para a Decisão , Poluição Ambiental , Humanos , Plásticos/química , Reciclagem , Resíduos/análise , Poluentes Químicos da Água/química
12.
Public Health Rep ; 135(1_suppl): 50S-56S, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32735197

RESUMO

In 2014, California passed Assembly Bill 966, which required condom access for persons incarcerated in all 35 California state prisons (33 men's and 2 women's prisons). The California Correctional Health Care Services and the Sexually Transmitted Disease Control Branch and the Office of AIDS of the California Department of Public Health collaborated in a prison administration-led multidisciplinary implementation workgroup. Our workgroup, representing public health, correctional health, legal and legislative affairs, labor relations, and prison staff members, participated in 4 planning meetings during May-September 2015. We surveyed prison staff members and incarcerated men to identify and address potential challenges; conceptualized a tamper-resistant condom dispenser; developed educational materials, frequently asked questions for staff members, and fact sheets for the public; and conducted forums for custody and medical staff members at each prison. Key lessons learned included the need for high-level custody support, engagement of labor unions early in the decision-making process, and flexibility within defined parameters for sites to determine best practices given their unique institutional population, culture, and physical layout. Condom access was initiated at 4 prisons in July 2015 and expanded incrementally to the remaining 29 men's prisons through July 2016. A total of 243 563 condoms were accessed in the men's prisons, for an average of 354 condoms per 1000 population per month. The start-up dispenser cost was $69 825 (735 dispensers at $95 each). We estimated an annual condom cost of $0.60 per person. Although staff members and incarcerated men expressed concern that this legislation would condone sex and provide repositories for contraband, no serious adverse incidents involving condoms were reported. California demonstrated that condom access is a safe, low-cost intervention with high uptake for a large correctional system and provided a replicable implementation model for other states. Prison condom programs have the potential to decrease transmission of sexually transmitted infections (STIs) among incarcerated persons and their communities, which are often disproportionately affected by STIs, HIV, and other chronic diseases.


Assuntos
Preservativos/provisão & distribução , Prisões/organização & administração , Saúde Pública , Doenças Sexualmente Transmissíveis/prevenção & controle , California/epidemiologia , Técnicas de Apoio para a Decisão , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Educação em Saúde/organização & administração , Humanos , Capacitação em Serviço/organização & administração , Sindicatos/organização & administração , Masculino , Prisões/economia , Prisões/normas , Desenvolvimento de Programas , Doenças Sexualmente Transmissíveis/epidemiologia
13.
PLoS One ; 15(8): e0237639, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32813717

RESUMO

BACKGROUND: Risk prediction models allow clinicians to forecast which individuals are at a higher risk for developing a particular outcome. We developed and internally validated a delirium prediction model for incident delirium parameterized to patient ICU admission acuity. METHODS: This retrospective, observational, fourteen medical-surgical ICU cohort study evaluated consecutive delirium-free adults surviving hospital stay with ICU length of stay (LOS) greater than or equal to 24 hours with both an admission APACHE II score and an admission type (e.g., elective post-surgery, emergency post-surgery, non-surgical) in whom delirium was assessed using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors included in the model were readily available in electric medical records. Least absolute shrinkage and selection operator logistic (LASSO) regression was used for model development. Discrimination was determined using area under the receiver operating characteristic curve (AUC). Internal validation was performed by cross-validation. Predictive performance was determined using measures of accuracy and clinical utility was assessed by decision-curve analysis. RESULTS: A total of 8,878 patients were included. Delirium incidence was 49.9% (n = 4,431). The delirium prediction model was parameterized to seven patient cohorts, admission type (3 cohorts) or mean quartile APACHE II score (4 cohorts). All parameterized cohort models were well calibrated. The AUC ranged from 0.67 to 0.78 (95% confidence intervals [CI] ranged from 0.63 to 0.79). Model accuracy varied across admission types; sensitivity ranged from 53.2% to 63.9% while specificity ranged from 69.0% to 74.6%. Across mean quartile APACHE II scores, sensitivity ranged from 58.2% to 59.7% while specificity ranged from 70.1% to 73.6%. The clinical utility of the parameterized cohort prediction model to predict and prevent incident delirium was greater than preventing incident delirium by treating all or none of the patients. CONCLUSIONS: Our results support external validation of a prediction model parameterized to patient ICU admission acuity to predict a patients' risk for ICU delirium. Classification of patients' risk for ICU delirium by admission acuity may allow for efficient initiation of prevention measures based on individual risk profiles.


Assuntos
Estado Terminal , Delírio/diagnóstico , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Adulto , Idoso , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Estudos Retrospectivos , Fatores de Risco
14.
Medicine (Baltimore) ; 99(32): e21389, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32769870

RESUMO

BACKGROUND: Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool. RESULTS: Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias. CONCLUSIONS: DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.


Assuntos
Tomada de Decisão Compartilhada , Técnicas de Apoio para a Decisão , Atenção Primária à Saúde , Humanos
15.
South Med J ; 113(8): 368-371, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32747962

RESUMO

Coronavirus disease 2019 (COVID-19) rapidly led to global human devastation, including multiple deaths, sicknesses, and financial reverberations across many individuals and communities. As COVID-19 gained its foothold in the United States, medical school administrators, faculty, and students had to undergo rapid change to mitigate the disease spread, putting all parties in dubious situations. Medical school administrators had to make swift and judicious decisions that would best serve the student body and the diverse patient population at clinical sites. Medical schools with students practicing in rural, remote regions with a dearth of healthcare resources have even more complicated decisions to make in these unprecedented times. We provide an overview of rapid decision-making processes that can be used by curriculum leaders and medical school administrators to continue to meet accreditation requirements while attempting to keep medical students safe and prepared for graduation in response to the COVID-19 health crisis.


Assuntos
Infecções por Coronavirus , Currículo , Técnicas de Apoio para a Decisão , Educação Médica/organização & administração , Pandemias , Pneumonia Viral , Faculdades de Medicina/organização & administração , Acreditação , Betacoronavirus , Educação Médica/normas , Humanos , Saúde da População Rural , Estados Unidos/epidemiologia
16.
PLoS One ; 15(7): e0234071, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32667926

RESUMO

The objective is to study the design method of roadway support and provide technical support for coal mining and other mining methods that need deep roadway excavation. Through literature review, the occurrence, development mechanism and influencing factors of surrounding loose rock zones of roadways are analyzed. A method of detecting is selected according to the characteristics of surrounding rock loosening. Knowledge of elastoplastic mechanics is used to theoretically study the failure mechanism of surrounding rock in deep re-mining roadways. Based on the artificial neural network prediction model (ANN), the surrounding rock is classified and a support network model of the decision system is constructed. After the design of roadway support, a sharp change of vault subsidence normally occurs within about 7 days after excavation, and the total subsidence is 14 mm. In the following month, deformation is slow, subsidence is small, and it is basically stable after one month. The curve of the vault subsidence rate shows that the vault subsidence rate is less than or equal to 1mm/d after 7 days. The convergence rate is also less than 1 mm/d after 7 days. There are two cave mouths AB and CD, and the convergence value of AB is 6.47mm, CD is 10.26mm: CD is slightly larger than AB, and it is close to stable one month later. It is essentially consistent with the time of vault settlement and stability, and the amount of deformation is approximately the same. This shows that, with the advance of the working face, the displacement of the surrounding rock in the section away from the working face will gradually decrease and the surrounding rock will be stable. The stability time of surrounding rock displacement of the portal section is the same as that of vault subsidence under the initial support, and the amount of deformation is approximately the same, indicating that the support parameters and construction methods are reasonable.


Assuntos
Minas de Carvão , Técnicas de Apoio para a Decisão , Aprendizado Profundo , Engenharia/métodos , Fenômenos Geológicos , Deslizamentos de Terra , Elasticidade , Fenômenos Mecânicos , Maleabilidade
17.
Am J Perinatol ; 37(10): 1015-1021, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32604446

RESUMO

OBJECTIVE: Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes. STUDY DESIGN: A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions. RESULTS: In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients. CONCLUSION: Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women. KEY POINTS: · Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..


Assuntos
Corticosteroides/administração & dosagem , Infecções por Coronavirus/prevenção & controle , Morte Materna/estatística & dados numéricos , Trabalho de Parto Prematuro/tratamento farmacológico , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Resultado da Gravidez , Nascimento Prematuro/prevenção & controle , Corticosteroides/efeitos adversos , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Técnicas de Apoio para a Decisão , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva , Masculino , Método de Monte Carlo , Trabalho de Parto Prematuro/prevenção & controle , Pneumonia Viral/epidemiologia , Gravidez , Gravidez de Alto Risco , Cuidado Pré-Natal/métodos , Medição de Risco , Estados Unidos
18.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32694147

RESUMO

OBJECTIVES: We evaluated 4 diagnostic strategies to predict the presence of inflammatory bowel disease (IBD) in children who present with chronic nonbloody diarrhea and abdominal pain. METHODS: We conducted a prospective cohort study including 193 patients aged 6 to 18 years who underwent a standardized diagnostic workup in secondary or tertiary care hospitals. Each patient was assessed for symptoms, C-reactive protein (>10 mg/L), hemoglobin (<-2 SD for age and sex), and fecal calprotectin (≥250 µg/g). Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers. Primary outcome was IBD confirmed by endoscopy or IBD ruled out by endoscopy or uneventful clinical follow-up for 6 months. RESULTS: Twenty-two of 193 (11%) children had IBD. The basic prediction model was based on symptoms only. Adding blood or stool markers increased the AUC from 0.718 (95% confidence interval [CI]: 0.604-0.832) to 0.930 (95% CI: 0.884-0.977) and 0.967 (95% CI: 0.945-0.990). Combining symptoms with blood and stool markers outperformed all other strategies (AUC 0.997 [95% CI: 0.993-1.000]). Triaging with a strategy that involves symptoms, blood markers, and calprotectin will result in 14 of 100 patients being exposed to endoscopy. Three of them will not have IBD, and no IBD-affected child will be missed. CONCLUSIONS: Evaluating symptoms plus blood and stool markers in patients with nonbloody diarrhea is the optimal test strategy that allows pediatricians to reserve a diagnostic endoscopy for children at high risk for IBD.


Assuntos
Diarreia/etiologia , Doenças Inflamatórias Intestinais/diagnóstico , Adolescente , Área Sob a Curva , Biomarcadores , Proteína C-Reativa/análise , Criança , Técnicas de Apoio para a Decisão , Endoscopia Gastrointestinal , Ensaio de Imunoadsorção Enzimática , Fezes/química , Feminino , Hemoglobinas/análise , Humanos , Doenças Inflamatórias Intestinais/complicações , Complexo Antígeno L1 Leucocitário/sangue , Masculino , Estudos Prospectivos , Curva ROC , Proteína S100A12/análise , Sensibilidade e Especificidade
19.
Phlebology ; 35(8): 550-555, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32639862

RESUMO

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.


Assuntos
Infecções por Coronavirus/terapia , Sistemas de Apoio a Decisões Clínicas/normas , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência/normas , Doenças Linfáticas/terapia , Pneumonia Viral/terapia , Triagem/normas , Doenças Vasculares/terapia , Tomada de Decisão Clínica , Consenso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Necessidades e Demandas de Serviços de Saúde/normas , Humanos , Doenças Linfáticas/diagnóstico , Doenças Linfáticas/epidemiologia , Pandemias , Seleção de Pacientes , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Doenças Vasculares/diagnóstico , Doenças Vasculares/epidemiologia
20.
J Allergy Clin Immunol Pract ; 8(8): 2474-2480.e1, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32679348

RESUMO

Shared decision making (SDM) is a management paradigm that empowers patients as partners in their own care in a bidirectional exchange of information and values, and optimize the decision-making process. During the current coronavirus disease 2019 pandemic, there is a greater need to encourage participation in the SDM process. The pandemic has created both challenges and opportunities for delivering care, as system adaptations influence the physician-patient relationship. Although social distancing and health service reallocation can interfere with preference for an in-person visit, these measures also provide an avenue to study and implement virtual SDM processes. Communicating risk at a time of heightened uncertainty may pose a barrier to SDM engagement but provides the opportunity to foster a patient-centered approach within a more personalized context. Social media influence during coronavirus disease 2019 has resulted in an "infodemic" but highlights the importance of patient engagement. The pandemic has changed how we deliver care but allows us to re-evaluate common practices and enhance effectiveness of our management strategies. Navigating the uncertainty of subsequent pandemic waves creates confusion about how to safely reinitiate clinical service. This will require ongoing SDM with our patients and among colleagues through current-and future-challenges. Coronavirus disease 2019 has created many difficulties but has forced us to reexamine how to provide more patient-centered and high-quality care.


Assuntos
Infecções por Coronavirus/epidemiologia , Tomada de Decisão Compartilhada , Participação do Paciente/métodos , Pneumonia Viral/epidemiologia , Betacoronavirus , Técnicas de Apoio para a Decisão , Humanos , Pandemias , Preferência do Paciente , Assistência Centrada no Paciente , Relações Médico-Paciente , Mídias Sociais , Fatores de Tempo
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