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1.
Methods Mol Biol ; 2194: 45-59, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32926361

RESUMO

Clinical practice guidelines in oncology provide an evidence-based roadmap for most cancer care delivery but often lack directions for specific patient factors and disease conditions. Clinical pathways serve as a real-time clinical decision support system to translate guidelines to clinical practice. Pathways allow for the creation of a standardized, multidimensional roadmap for the continuum of care that can support clinical decision-making, maintain optimal outcomes, and limit unnecessary variation in cancer care. Here we describe the process to develop and implement clinical pathways in the electronic health record. This process includes building the appropriate foundation for a clinical pathways team with supports in the institutional ecosystem, creating visual representations of care paths, formalizing the pathway approval process, and translating clinical pathways into an electronic health record-integrated clinical decision support tool.

2.
Artigo em Inglês | MEDLINE | ID: mdl-33025639

RESUMO

The US Government has embarked on the largest initiative to date to encourage widespread use of electronic health records (EHRs). Up to now, it is not yet clear that what the actual effectiveness of EHR promotion is like since the Health Information Technology for Economic and Clinical Health (HITECH) Act. As a response, this study analyzes the EHR conversion at the primary stage (sign-up EHR→go-live EHR) and the advanced stage (go-live EHR→meaningful use of EHR) for different types of healthcare providers in the United States. With the data from the Office of National Coordinator for Health Information Technology-Regional Extension Centers Program, this study finds that healthcare providers have achieved progress in the EHR conversion at both the primary and advanced stage. However, the levels of progress made at different stages of EHR conversion vary for different providers. For rural and underserved healthcare settings, the progress made at the advanced stage is smaller than that at the primary stage, contrary to the case for other kinds of providers. Moreover, although the greater progress has been made at the advanced stage for some kinds of providers, the overall level of EHR conversion for various healthcare providers is far greater at the primary stage than at the advanced stage.

3.
J Gynecol Obstet Hum Reprod ; : 101936, 2020 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-33039600

RESUMO

INTRODUCTION: Hysterectomy remains a commonly performed procedure with widely variable costs. As gynecologists divert from invasive to minimally invasive approaches, many factors come into play in determining hysterectomy cost and efforts should be sought to minimize it. Our objective was to identify the predictors of hysterectomy cost. MATERIAL AND METHODS: This was a retrospective cohort study where women who underwent hysterectomy for benign conditions at [Name removed to maintain the integrity of the review process] from 2009 to 2016 were identified. We obtained and analyzed demographic, operative, and financial data from electronic medical records and the hospital finance department. RESULTS: We identified 1,847 women. Open hysterectomy was the most frequently practiced (35.8%), followed by vaginal (23.7%), laparoscopic (23.6%), and robotic (16.9%) approaches. Multivariate regression demonstrated that hysterectomy charges can be significantly predicted from surgical route, patient's age, operating room (OR) time, length of stay (LOS), estimated blood loss, insurance type, fiscal year, and concomitant procedures. Charges increased by $3723.57 for each day increase in LOS (P < 0.001), by $76.02 for each minute increase in OR time (P < 0.001), and by $48.21 for each one-year increase in age (P 0.037). Adjusting for LOS and OR time remarkably decreased the cost of open and robotic hysterectomy, respectively when compared with the vaginal approach. CONCLUSION: Multiple demographic and operative factors can predict the cost of hysterectomy. Healthcare providers, including gynecologists, are required to pursue additional roles in proper resource management and be acquainted with the cost drivers of therapeutic interventions. Future efforts and policies should target modifiable factors to minimize cost and promote value-based practices.

4.
Artigo em Inglês | MEDLINE | ID: mdl-33043368

RESUMO

OBJECTIVE: To determine the content priorities and design preferences for a longitudinal care plan (LCP) among caregivers and healthcare providers who care for children with medical complexity (CMC) in acute care settings. MATERIALS AND METHODS: We conducted iterative one-on-one design sessions with CMC caregivers (ie, parents/legal guardians) and providers from 5 groups: complex care, primary care, subspecialists, emergency care, and care coordinators. Audio-recorded sessions included content categorization activities, drawing exercises, and scenario-based testing of an electronic LCP prototype. We applied inductive content analysis of session materials to elicit content priorities and design preferences between sessions. Analysis informed iterative prototype revisions. RESULTS: We conducted 30 design sessions (10 with caregivers, 20 with providers). Caregivers expressed high within-group variability in their content priorities compared to provider groups. Emergency providers had the most unique content priorities among clinicians. We identified 6 key design preferences: a familiar yet customizable layout, a problem-based organization schema, linked content between sections, a table layout for most sections, a balance between unstructured and structured data fields, and use of family-centered terminology. DISCUSSION: Findings from this study will inform enhancements of electronic health record-embedded LCPs and the development of new LCP tools and applications. The design preferences we identified provide a framework for optimizing integration of family and provider content priorities while maintaining a user-tailored experience. CONCLUSION: Health information platforms that incorporate these design preferences into electronic LCPs will help meet the information needs of caregivers and providers caring for CMC in acute care settings.

5.
JAMA Intern Med ; 2020 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-33044494

RESUMO

Importance: There are concerns with translating results from the Systolic Blood Pressure Intervention Trial (SPRINT) into clinical practice because the standardized protocol used to measure blood pressure (BP) may not be consistently applied in routine clinical practice. Objectives: To evaluate the concordance between BPs obtained in routine clinical practice and those obtained using the SPRINT protocol and whether concordance varied by target trial BP. Design, Setting, and Participants: This observational prognostic study linking outpatient vital sign information from electronic health records (EHRs) with data from 49 of the 102 SPRINT sites was conducted from November 8, 2010, to August 20, 2015, among 3074 adults 50 years or older with hypertension without diabetes or a history of stroke. Statistical analysis was performed from May 21, 2019, to March 20, 2020. Main Outcomes and Measures: Blood pressures measured in routine clinical practice and SPRINT. Results: Participant-level EHR data was obtained for 3074 participants (2482 men [80.7%]; mean [SD] age, 68.5 [9.1] years) with 3 or more outpatient and trial BP measurements. In the period from the 6-month study visit to the end of the study intervention, the mean systolic BP (SBP) in the intensive treatment group from outpatient BP recorded in the EHR was 7.3 mm Hg higher (95% CI, 7.0-7.6 mm Hg) than BP measured at trial visits; the mean difference between BP recorded in the outpatient EHR and trial SBP was smaller for participants in the standard treatment group (4.6 mm Hg [95% CI, 4.4-4.9 mm Hg]). Bland-Altman analyses demonstrated low agreement between outpatient BP recorded in the EHR and trial BP, with wide agreement intervals ranging from approximately -30 mm Hg to 45 mm Hg in both treatment groups. In addition, the difference between BP recorded in the EHR and trial BP varied widely by site. Conclusions and Relevance: Outpatient BPs measured in routine clinical practice were generally higher than BP measurements taken in SPRINT, with greater mean SBP differences apparent in the intensive treatment group. There was a consistent high degree of heterogeneity between the BPs recorded in the EHR and trial BPs, with significant variability over time, between and within the participants, and across clinic sites. These results highlight the importance of proper BP measurement technique and an inability to apply 1 common correction factor (ie, approximately 10 mm Hg) to approximate research-quality BP estimates when BP is not measured appropriately in routine clinical practice. Trial Registration: SPRINT ClinicalTrials.gov Identifier: NCT01206062.

6.
J Neurosurg Spine ; : 1-7, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33007753

RESUMO

OBJECTIVE: In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity and/or use a proxy for actual cost. The purpose of this study was to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions after elective lumbar spine surgery. METHODS: A prospective, multisurgeon, single-center electronic medical record was queried for elective lumbar spine fusion surgeries from 2013 to 2017. Predictive models were created for 90-day ER visits and readmissions. RESULTS: Of 5444 patients, 729 (13%) returned to the ER, most often for pain (n = 213, 29%). Predictors of an ER visit were prior ER visit (OR 2.5), underserved zip code (OR 1.4), and number of chronic medical conditions (OR 1.4). In total, 421 (8%) patients were readmitted, most frequently for wound infection (n = 123, 2%), exacerbation of chronic obstructive pulmonary disease (n = 24, 0.4%), and sepsis (n = 23, 0.4%). Predictors for readmission were prior ER visit (OR 1.96), multiple chronic conditions (OR 1.69), obesity (nonobese, OR 0.49), race (African American, OR 1.43), admission status (ER admission, OR 2.29), and elevated hemoglobin A1c (OR 1.80). The mean direct hospital cost for an ER visit was $1971, with 75% of visits costing less than $1890, and the average readmission cost was $7347, with 75% of readmissions costing less than $8820. Over the 5-year study period, the cost to the institution for 90-day return ER visits was $5.1 million. CONCLUSIONS: Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient counseling, appropriate postoperative pain management, and optimization of modifiable risk factors prior to surgery are areas to focus future efforts to lower 90-day ER visits and readmissions and reduce healthcare costs.

7.
J Clin Med ; 9(10)2020 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-33007932

RESUMO

Diagnostic and treatment strategies for acute coronary syndrome have improved dramatically over the past few decades, but mortality and recurrent myocardial infarction rates remain high. An aging population with increasing co-morbidities heralds new clinical challenges. Therefore, in order to evaluate and improve current treatment strategies, detailed information on clinical presentation, treatment and follow-up in real-world patients is needed. The Future Optimal Research and Care Evaluation in patients with Acute Coronary Syndrome (FORCE-ACS) registry (ClinicalTrials.gov Identifier: NCT03823547) is a multi-center, prospective real-world registry of patients admitted with (suspected) acute coronary syndrome. Both non-interventional and interventional cardiac centers in different regions of the Netherlands are currently participating. Patients are treated according to local protocols, enabling the evaluation of different diagnostic and treatment strategies used in daily practice. Data collection is performed using electronic medical records and quality-of-life questionnaires, which are sent 1, 12, 24 and 36 months after initial admission. Major end points are all-cause mortality, myocardial infarction, stent thrombosis, stroke, revascularization and all bleeding requiring medical attention. Invasive therapy, antithrombotic therapy including patient-tailored strategies, such as the use of risk scores, pharmacogenetic guided antiplatelet therapy and patient reported outcome measures are monitored. The FORCE-ACS registry provides insight into numerous aspects of the (quality of) care for acute coronary syndrome patients.

8.
N Z Med J ; 133(1523): 76-86, 2020 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-33032305

RESUMO

AIMS: Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists are classes of medications shown to reduce cardiovascular events and slow decline in renal function in people with type 2 diabetes (T2DM). They are recommended for many people as second-line agents after metformin by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD). PHARMAC have proposed criteria for funding in New Zealand. This clinical audit compares which patients would be eligible for treatment under each criterion. METHODS: This retrospective audit was conducted in December 2019 of all registered patients with T2DM at three general practices within the Wellington/Porirua region. Relevant data were extracted from the electronic health records to enable assessment of eligibility under PHARMAC and ADA/EASD criteria. RESULTS: Of the 23,517 patients enrolled, 1,160 had T2DM. Under PHARMAC criteria 399 (34.4%) patients would be eligible for funded access compared with 339 (27.2%) by the 2018 ADA/EASD criteria and 559 (48.2%) by the revised 2020 ADA/EASD criteria. Differences in eligibility relate to threshold of HbA1c and inclusion of microalbuminuria for treatment. CONCLUSION: The proposed PHARMAC criteria will give access to these important drugs to those people with T2DM who will likely benefit the most.

9.
Sci Rep ; 10(1): 16879, 2020 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-33037233

RESUMO

This study aimed to analyse the trajectories and mortality of multimorbidity patterns in patients aged 65 to 99 years in Catalonia (Spain). Five year (2012-2016) data of 916,619 participants from a primary care, population-based electronic health record database (Information System for Research in Primary Care, SIDIAP) were included in this retrospective cohort study. Individual longitudinal trajectories were modelled with a Hidden Markov Model across multimorbidity patterns. We computed the mortality hazard using Cox regression models to estimate survival in multimorbidity patterns. Ten multimorbidity patterns were originally identified and two more states (death and drop-outs) were subsequently added. At baseline, the most frequent cluster was the Non-Specific Pattern (42%), and the least frequent the Multisystem Pattern (1.6%). Most participants stayed in the same cluster over the 5 year follow-up period, from 92.1% in the Nervous, Musculoskeletal pattern to 59.2% in the Cardio-Circulatory and Renal pattern. The highest mortality rates were observed for patterns that included cardio-circulatory diseases: Cardio-Circulatory and Renal (37.1%); Nervous, Digestive and Circulatory (31.8%); and Cardio-Circulatory, Mental, Respiratory and Genitourinary (28.8%). This study demonstrates the feasibility of characterizing multimorbidity patterns along time. Multimorbidity trajectories were generally stable, although changes in specific multimorbidity patterns were observed. The Hidden Markov Model is useful for modelling transitions across multimorbidity patterns and mortality risk. Our findings suggest that health interventions targeting specific multimorbidity patterns may reduce mortality in patients with multimorbidity.

10.
Am J Kidney Dis ; 2020 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-32890592

RESUMO

Kidney disease is a common, complex, costly and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national United States Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to CKD without kidney replacement therapy (KRT). Data from VA's Corporate Data Warehouse were processed and linked with national Medicare Data on CKD patients receiving KRT. Operational definitions for 'VA user', chronic kidney disease (CKD), acute kidney injury (AKI), and kidney failure were developed. Among seven million VA users in fiscal year 2014, CKD was identified using either a 'strict' or a 'liberal' operational definition, in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an eGFR laboratory phenotype, some via proteinuria assessment, and very few via ICD-9 coding. The VA spent approximately $18 billion for the care of patients with CKD without KRT, the majority of which was for CKD Stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, improving quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.

11.
Technol Health Care ; 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32894257

RESUMO

BACKGROUND: The prevalence of health information technology (HIT) as an adjunct to increase safety and quality in healthcare applications is well known. There is a relationship between the use of HIT and safer-prescribing practices in long-term care. OBJECTIVE: The objective of this systematic review is to determine an association between the use of HIT and the improvement of prescription administration in long-term care facilities. METHODS: A systematic review was conducted using the MEDLINE and CINAHL databases. With the use of certain key terms, 66 articles were obtained. Each article was then reviewed by two researchers to determine if the study was germane to the research objective. If both reviewers agreed with using the article, it became a source for our review. The review was conducted and structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: The researchers identified 14 articles to include in a group for analysis from North America, Europe, and Australia. Electronic health records and electronic medication administration records were the two most common forms of technological interventions (6 of 14, 43%). Reduced risk, decreased error, decreased missed dosage, improved documentation, improved clinical process, and stronger clinical focus comprised 92% of the observations. CONCLUSIONS: HIT has shown beneficial effects for many healthcare organizations. Long-term care facilities that implemented health information technologies, have shown reductions in adverse drug events caused by medication errors overall reduced risk to the organization. The implementation of new technologies did not increase the time nurses spent on medication rounds.

12.
BMC Health Serv Res ; 20(1): 813, 2020 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-32867780

RESUMO

BACKGROUND: The goal of this study was to describe the expenses related to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) management and care in Nantong Infectious Disease Hospital from October 2013 through June 2017. METHODS: The information of 610 HIV/AIDS inpatients were collected from the Electronic Medical Record System of the hospital. Univariate and path analysis were employed to evaluate the association between hospitalization expense and its related factors. RESULTS: The average hospitalization expenses per person was 5454 RMB (Renminbi, the currency of China, about $808 USD) and 23,555 RMB (about $3489 USD), respectively for HIV/AIDS patients. The average length of hospital stay was 10.0 ± 5.5 days for HIV patients and 21.7 ± 12.4 days for AIDS patients. For HIV patients, laboratory test fees constituted 37.46% of total expenses; while drug fees accounted for the largest proportion for AIDS patients. Path analysis indicated that the length of hospital stay was the most important factor affecting total expenses (total path coefficient = 0.563 for HIV patients and 0.649 for AIDS patients). Total expenses for HIV-infected females was higher than that of males (total path coefficient = 0.217), and the more complications led to higher expenses for AIDS patients. CONCLUSIONS: Though antiretroviral therapy (ART) is provided for free in China, associated medical care, particularly hospitalizations and fees, continue to drive up the medical costs of patients living with HIV and AIDS. Understanding the factors influencing these costs are crucial for determining policies and strategies that can reduce the economic burden of HIV/AIDS patients in China.

13.
Artigo em Inglês | MEDLINE | ID: mdl-32885240

RESUMO

Health and healthcare disparities continue despite clinical, research, and policy efforts. Large clinical datasets may not contain data relevant to healthcare disparities and leveraging these for research may be crucial to improve health equity. The Health Disparities Collaborative Research Group was commissioned by the Patient-Centered Outcomes Research Institute to examine the data science needs for quality and complete data and provide recommendations for improving data science around health disparities. The group convened content experts, researchers, clinicians, and patients to produce these recommendations and suggestions for implementation. Our desire was to produce recommendations to improve the usability of healthcare datasets for health equity research. The recommendations are summarized in 3 primary domains: patient voice, accurate variables, and data linkage. The implementation of these recommendations in national datasets has the potential to accelerate health disparities research and promote efforts to reduce health inequities.

14.
J Gen Intern Med ; 2020 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-32885374

RESUMO

BACKGROUND: Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. OBJECTIVE: This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. DESIGN: A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. PARTICIPANTS: Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. INTERVENTIONS: A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. MAIN MEASURES: Patient-level CW compliance. KEY RESULTS: CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). CONCLUSIONS: The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NIH TRIAL REGISTRY NUMBER: NCT03409523.

15.
Artigo em Inglês | MEDLINE | ID: mdl-32896632

RESUMO

BACKGROUND & AIMS: Chronic viral hepatitis is a leading cause of worldwide liver-related morbidity and mortality, despite the availability of effective treatments that reduce or prevent complications in most patients. Electronic-health (eHealth) technologies have potential to intervene along the whole cascade of care. We aimed to summarize available literature on eHealth interventions with respect to conventional screening, diagnostic and treatment outcomes in chronic hepatitis B (HBV) and hepatitis C (HCV) METHODS: We systematically reviewed MEDLINE, EMBASE, Cochrane Library and international conference abstracts, including studies published from 2009 - 2020. Overall 80 studies were included, covering electronic medical record (EMR) interventions (n=39), telemedicine (n=20), mHealth (n=5), devices (n=4), clinical decision support (n=3), web-based (n=5), social media (n=1) and electronic communication (n=3). RESULTS: Compared to standard care, EMR alerts increase screening rates in eligible populations including birth cohort screening in HCV, universal HCV screening in Emergency Departments, ethnic groups with high HBV prevalence, and HBV screening prior to immunosuppression. Direct messaging alerts to providers and automated testing may have a greater effect. No significant difference was found in sustained virological response outcomes between telemedicine and face-to-face management for community, rural and prison cohorts in HCV in the direct acting antiviral era of treatment, with higher patient satisfaction in telemedicine groups. CONCLUSIONS: EMR alerts significantly increases screening rates in eligible cohorts in both chronic HBV and HCV. Telemedicine is equally efficacious to face-to-face care in HCV treatment. Other eHealth technologies show promise however rigorous studies are lacking.

16.
Pain Med ; 2020 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-32869082

RESUMO

OBJECTIVE: High-quality chronic pain care emphasizes multimodal treatments that include medication and nonpharmacological treatments. But it is not clear which patients will participate in nonpharmacological treatments, such as physical therapy or mental health care, and previous research has shown conflicting evidence. METHODS: We used the Patient Outcomes Repository for Treatment (PORT) registry, which combines patient-reported outcomes data with electronic medical records. In this retrospective observational study, we performed two separate multinomial regression analyses with feature selection to identify PORT variables that were predictive of 1) recommendation of a nonpharmacological treatment by the provider and 2) patient participation in nonpharmacological treatments. Two hundred thirty-six patients were recommended (REC) or not recommended (NO REC) a nonpharmacological treatment, and all REC patients were classified as participating (YES) or not participating (NO) in the recommendations. RESULTS: Female gender and a diagnosis of Z79 "Opioid drug therapy" were significant positive and negative predictors of nonpharmacological treatment recommendations, respectively. Schedule II opioid use at initial presentation and recommendations for rehabilitation therapy were significant predictors of nonparticipation. CONCLUSIONS: Patients using opioids are less likely to be recommended nonpharmacological treatments as part of multimodal chronic pain care and are less likely to participate in nonpharmacological treatments once recommended. Males are also less likely to be recommended nonpharmacological treatments. Patients referred for rehabilitation therapies are less likely to comply with those recommendations. We have identified patients in vulnerable subgroups who may require additional resources and/or encouragement to comply with multimodal chronic pain treatment recommendations.

17.
J Gen Intern Med ; 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32875501

RESUMO

BACKGROUND: Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied. OBJECTIVE: Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system. DESIGN: Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018). PARTICIPANTS: Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider. INTERVENTIONS: The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results. MAIN MEASURES: Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates. KEY RESULTS: During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05). CONCLUSIONS: In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.

18.
Artigo em Inglês | MEDLINE | ID: mdl-32925233

RESUMO

OBJECTIVE: The goal of this implementation project was to improve postoperative outcomes in the Day Surgery Podiatric patient population with the implementation of an enhanced recovery after surgery (ERAS) protocol at a large urban health system in the northeastern United States. We aimed to improve postoperative patient pain scores and reduce patient length of stay (LOS) with the implementation of the podiatric ERAS protocol (PEP). INTRODUCTION: ERAS provides an evidence-based interdisciplinary approach to the preparation and care of surgical patients. The core goals of ERAS promote accelerated patient recovery after surgery by incorporating broad patient education with strategies to reduce the physiologic stress associated with surgery and anesthesia. This strategy has been applied to many major surgical specialties but has not been established in podiatric patients. METHODS: The PEP evidence implementation initiative integrates two Joanna Briggs Institute tools: the Getting Research into Practice audit and feedback tool, and Practical Application of Clinical Evidence System, by incorporating proactive planning and data analyses. Baseline electronic health record data were collected in July 2019, followed by interdisciplinary PEP review, revision, implementation, and three data collection cycles. Strategic education was provided to stakeholders throughout data collection cycles. RESULTS: This use of ERAS in the outpatient podiatric surgery population demonstrated excellence in compliance with best practice recommendations. The proactive multimodal approach of PEP revealed improvement in four measures of patient pain, with improvement from 83 to 100% of patients having a pain goal higher than their admission postoperative pain score. Patient pain goal greater than discharge pain score was also found but not sustained. Baseline data collection established that 29% of podiatric patients had a LOS less than 90 min, which improved to 42% with PEP. This finding was also not sustained in the third cycle of audit data. Missing data may have influenced these results, reinforcing the need for further study. CONCLUSION: The use of ERAS in orthopedic patients has an established empirical basis for use, demonstrating a reduction in both postoperative pain and LOS. This novel use of ERAS in a podiatric surgery outpatient population has similar findings but was not sustained in all audit criteria. PEP demonstrated promising reductions in postoperative pain and LOS; however, further implementation replication is needed to confirm this expansion of ERAS and the promising results.

19.
Artigo em Inglês | MEDLINE | ID: mdl-32929458

RESUMO

OBJECTIVE: Disease surveillance systems are expanding using electronic health records (EHRs). However, there are many challenges in this regard. In the present study, the solutions and challenges of implementing EHR-based disease surveillance systems (EHR-DS) have been reviewed. MATERIALS AND METHODS: We searched the related keywords in ProQuest, PubMed, Web of Science, Cochrane Library, Embase, and Scopus. Then, we assessed and selected articles using the inclusion and exclusion criteria and, finally, classified the identified solutions and challenges. RESULTS: Finally, 50 studies were included, and 52 unique solutions and 47 challenges were organized into 6 main themes (policy and regulatory, technical, management, standardization, financial, and data quality). The results indicate that due to the multifaceted nature of the challenges, the implementation of EHR-DS is not low cost and easy to implement and requires a variety of interventions. On the one hand, the most common challenges include the need to invest significant time and resources; the poor data quality in EHRs; difficulty in analyzing, cleaning, and accessing unstructured data; data privacy and security; and the lack of interoperability standards. On the other hand, the most common solutions are the use of natural language processing and machine learning algorithms for unstructured data; the use of appropriate technical solutions for data retrieval, extraction, identification, and visualization; the collaboration of health and clinical departments to access data; standardizing EHR content for public health; and using a unique health identifier for individuals. CONCLUSIONS: EHR systems have an important role in modernizing disease surveillance systems. However, there are many problems and challenges facing the development and implementation of EHR-DS that need to be appropriately addressed.

20.
Artigo em Inglês | MEDLINE | ID: mdl-32897913

RESUMO

OBJECTIVES: The current project aimed to implement evidence-based recommendations for the management of inpatient aggressive and violent behaviors in four behavioral health units (BHUs) in a mental healthcare area within an academic medical center. INTRODUCTION: Patient violence against healthcare workers is a global concern, particularly in mental health care. All employees who work in inpatient psychiatric environments are at higher risk for targeted violence than are other healthcare workers. For healthcare organizations and staff, violent episodes involving patients can bring about medical expenses, potential legal expenditure, sick leave and a high turnover rate. The hospital at which this project was implemented had been experiencing a steady increase in violence and aggressive behavior. METHODS: The project used the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting practice change in four BHUs. A baseline retrospective audit of 10 electronic health records from four BHUs assessed compliance with best practice regarding violent episodes. The Getting Research into Practice tool was used to identify barriers and develop an evidence-based educational strategy for 70 BHU staff aimed to improve compliance with best practice for managing aggression and violence. Staff education compliance was assessed via hospital education department records. A pre and postimplementation staff satisfaction survey assessed perceptions about education, confidence and unit safety. RESULTS: The baseline audit indicated that one of the three criteria had 0% compliance. Following implementation of an educational strategy using mock codes for BHU staff, there was 96% improvement in compliance for the BHU staff education audit criterion. Staff de-escalated patients in 83% of the episodes postimplementation. There was a slight decrease (9.1%) in the rate of violence across all four inpatient BHUs. Staff satisfaction survey findings did not show a statistically significant difference. CONCLUSION: Enhanced evidence-based education and mock codes resulted in BHU staff competence and confidence in managing aggressive and/or violent patients. Early signs of a decrease in the violence rate and improvement in the efficient use of de-escalation will be sustained with on-going yearly education, quarterly mock codes and future audits. This project was limited by its small size and short timeframe (21 weeks), making results not generalizable.

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