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The validity of the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) has been established in the USA and Canada. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied. We performed a medical record review using administrative and electronic medical record data from nine Swiss hospitals. Seven independent reviewers evaluated 1245 cases at various hospitals using retrospective data from the years 2014-18. True positives, false positives, positive predictive values (PPVs), and reasons for misclassification were compared across all investigated PSIs, and the documentation quality of the PSIs was examined. PSIs 6 (iatrogenic pneumothorax), 10 (postoperative acute kidney injury), 11 (postoperative respiratory failure), 13 (postoperative sepsis), 14 (wound dehiscence), 17 (birth trauma), and 18 and 19 (obstetric trauma with or without instrument) showed high PPVs (range: 90-99%) and were not strongly influenced by missing POA information. In contrast, PSIs 3 (pressure ulcer), 5 (retained surgical item), 7 (central venous catheter-related bloodstream infection), 8 (fall with hip fracture), and 15 (accidental puncture/laceration) showed low PPVs (range: 18-49%). In the case of PSIs 3, 8, and 12 (perioperative embolism/thrombosis), the low PPVs were largely due to the lack of POA information. Additionally, it was found that the documentation of PSI 3 in discharge letters could be improved. We found large differences in validity across the 16 PSIs in Switzerland. These results can guide policymakers in Switzerland and comparable health-care systems in selecting and prioritizing suitable PSIs for quality initiatives. Furthermore, the national introduction of a POA flag would allow for the inclusion of additional PSIs in quality monitoring.
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Segurança do Paciente , Indicadores de Qualidade em Assistência à Saúde , Humanos , Estados Unidos , Estudos Retrospectivos , Suíça , Hospitais , Prontuários Médicos , Complicações Pós-OperatóriasRESUMO
BACKGROUND: Population ageing puts pressure on health systems initially designed to handle acute and episodic illnesses. Segmenting an ageing population based on its healthcare utilization may enable policymakers to undertake evidence-based resource planning. We aimed to derive a typology of healthcare utilization trajectories in Swiss older adults. METHODS: Our work used data from the Lc65 + study, a population-based cohort of individuals aged 65 to 70 years at enrolment. The dimensions of healthcare utilization considered were ambulatory care, emergency care, hospitalizations, professional home care and nursing home stay. We applied the Sequence Analysis framework, within which we quantified the variation between each multidimensional pair of sequences, implemented a clustering procedure that grouped together older persons with similar profiles of health services use, and characterized clusters of individuals using selected baseline covariates. RESULTS: Healthcare utilization trajectories were analysed for 2271 community-dwelling older adults over a period of 11 years. Six homogeneous subgroups were identified: constant low utilization (83.3% of participants), increased utilization (4.9%), late health deterioration (4.4%), ambulatory care to nursing home (1.5%), early fatal event (3.8%) and high ambulatory care (2.1%). Associations were found between cluster membership and age, sex, household composition, self-perceived health, grip strength measurement, comorbidities, and functional dependency. CONCLUSIONS: The heterogeneous healthcare utilization profiles can be clustered into six common patterns. Different manifestations of functional decline were apparent in two distinct trajectory groups featuring regular home care use. Furthermore, a small proportion of individuals with a unique set of characteristics was related to the highest levels of ambulatory and emergency care use. New research avenues are outlined to investigate time-varying effects of health factors inside the clusters containing most unfavourable outcomes.
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Atenção à Saúde , Serviços de Assistência Domiciliar , Humanos , Idoso , Idoso de 80 Anos ou mais , Estudos Longitudinais , Suíça , Aceitação pelo Paciente de Cuidados de SaúdeRESUMO
BACKGROUND: Diagnoses that arise after admission are of interest because they can represent complications of health care, acute conditions arising de novo, or acute decompensation of a chronic comorbidity occurring during the hospital stay. Three countries in the world have adopted diagnosis timing codes for a number of years. Their experience demonstrates the feasibility and utility of associating an International Classification of Diseases, Version 9 or International Classification of Diseases, Version 10 diagnostic code with information on diagnosis timing, either as part of a diagnostic field or as a separate field. However, diagnosis timing is not an integrated feature of these two classifications as it will be for International Classification of Diseases, Version 11. METHODS: We examine the different types of diagnosis timing that can be used to describe complex patients and present examples of how the new International Classification of Diseases, Version 11 codes may be used. RESULTS: Extension codes are one of the important new features of International Classification of Diseases, Version 11 and allow more specificity in diagnosis timing. CONCLUSION: Imbedded and standardized diagnosis timing information is possible within the International Classification of Diseases, Version 11 classification system.
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Atenção à Saúde , Classificação Internacional de Doenças , Coleta de Dados , HumanosRESUMO
ICD-11 provides a promising new way to capture healthcare-related harm or injury. In this paper, we elaborate on the framework for describing healthcare-related events where there is a presumed causal link between an event and underlying healthcare-related factors. The three-part model for describing healthcare-related harm or injury in ICD-11 consists of (1) a healthcare-related activity that is the cause of injury or other harm (selected from Chapter 23 of ICD-11); (2) a mode or mechanism of injury or harm, related to the underlying cause (also from Chapter 23 of ICD-11); and (3) the harmful consequences of the event to the patient, selected from any of Chapters 1 through 22 of ICD-11 (most importantly, the injury or harm experienced by the patient). Concepts from these three elements are linked/clustered through postcoordination to reflect the three-part model in a single coded expression. ICD-11 contains many novel features, and the three-part model described here for healthcare-related adverse events is a notable example.
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Instalações de Saúde , Classificação Internacional de Doenças , Atenção à Saúde , HumanosRESUMO
Rapidly growing health-related data have the potential to improve health and healthcare, as well as to make health systems more efficient and focused on patients' needs. Their efficient and secure management represents major technological, organizational and societal challenges. Currently too compartmentalized and insufficiently accessible, these data are often in the hands of private providers and their collection does not necessarily guarantee data security and privacy protection. Professionals as well as some private for-profit companies are on the lookout for this new digital "gold". It is therefore urgent to define a democratic and legal framework for the governance, collection and use of health data in the highly decentralized and fragmented Swiss context.
Les données de santé, dont le volume croît rapidement, ont le potentiel d'améliorer la santé et les soins, de rendre les systèmes de santé plus efficients et centrés sur les besoins des patients. Leur gestion efficace et sécurisée représente des défis technologiques, organisationnels et sociétaux majeurs. Actuellement, trop cloisonnées et insuffisamment accessibles, ces données sont souvent en main de prestataires privés et leur collecte ne garantit pas forcément l'ensemble des éléments de sécurité des données et de protection de la vie privée. Les professionnels, comme certaines entreprises privées à but lucratif, sont à l'affût de ce nouvel « or ¼ numérique. Il apparaît donc urgent de définir un cadre démocratique et légal autour de la gouvernance, de la collecte et de l'utilisation des données de santé dans le contexte suisse fortement décentralisé et fragmenté.
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Segurança Computacional , Privacidade , HumanosRESUMO
BACKGROUND: Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. However, most of those studies were conducted in North America or United Kingdom. Providing new evidence based on French data could fuel the international debate on quality of care indicators and help inform French policy-makers. The objective of our study was to explore whether optimal care delivery in French hospitals as assessed by their Hospital Process Indicators (HPIs) is associated with low Hospital Standardized Mortality Ratios (HSMRs). METHODS: The French National Authority for Health (HAS) routinely collects for each hospital located in France, a set of mandatory HPIs. Five HPIs were selected among the process indicators collected by the HAS in 2009. They were measured using random samples of 60 to 80 medical records from inpatients admitted between January 1st, 2009 and December 31, 2009 in respect with some selection criteria. HSMRs were estimated at 30, 60 and 90 days post-admission (dpa) using administrative health data extracted from the national health insurance information system (SNIIR-AM) which covers 77% of the French population. Associations between HPIs and HSMRs were assessed by Poisson regression models corrected for measurement errors with a simulation-extrapolation (SIMEX) method. RESULTS: Most associations studied were not statistically significant. Only two process indicators were found associated with HSMRs. Completeness and quality of anesthetic records was negatively associated with 30 dpa HSMR (0.72 [0.52-0.99]). Early detection of nutritional disorders was negatively associated with all HSMRs: 30 dpa HSMR (0.71 [0.54-0.95]), 60 dpa HSMR (0.51 [0.39-0.67]) and 90 dpa HSMR (0.52 [0.40-0.68]). CONCLUSION: In absence of gold standard of quality of care measurement, the limited number of associations suggested to drive in-depth improvements in order to better determine associations between process and mortality indicators. A smart utilization of both process and outcomes indicators is mandatory to capture aspects of the hospital quality of care complexity.
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Mortalidade Hospitalar , Indicadores de Qualidade em Assistência à Saúde , França/epidemiologia , Hospitalização , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Indicadores de Qualidade em Assistência à Saúde/normas , Qualidade da Assistência à SaúdeRESUMO
BACKGROUND: In-hospital mortality is widely used to judge the quality of hospital care, but is biased by discharge patterns. Fixed-timeframe indicators have thus been recommended. However, the 30-day postadmission indicator may underestimate hospital-wide mortality, as patients dying in hospital >30 days after admission are considered as survivors. OBJECTIVES: To identify the most relevant timeframes and to assess the contribution of cause-of-death data. METHODS: The 2009 French hospital discharge database was linked to vital status records and to the causes of death register for 11.5 million hospital stays by beneficiaries of French general health insurance. Correlations and agreements between the 30-day hospital standardized mortality ratio (HSMR) and the in-hospital, 60-, 90-, 180-, and 365-day postadmission HSMRs were estimated. RESULTS: A total of 7.8%, 1.5%, and 0.5% of patients who died during their hospital stay were considered as survivors by the 30-, 60-, and 90-day HSMRs, respectively. The 30-day HSMR correlated strongly with the 60-day HSMR (Pearson coefficient=0.92), and their agreement on outlier status was excellent (κ coefficient=0.80). The association remained substantial at 90 days, but weakened at 180 days and even more so at 365 days. Regardless of the timeframe, exclusion of deaths likely due to independent causes barely modified the indicators. CONCLUSIONS: This nationwide study shows that 60- and 90-day HSMRs encompass in-hospital deaths better than the 30-day HSMR, while capturing the same interhospital variations. They should thus be preferred. The contribution of cause-of-death data to hospital-wide indicators seems negligible.
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Mortalidade Hospitalar/tendências , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Causas de Morte , Grupos Diagnósticos Relacionados/estatística & dados numéricos , França/epidemiologia , Humanos , Indicadores de Qualidade em Assistência à SaúdeRESUMO
BACKGROUND: The emergency department has been identified as an area within the health care sector with the highest reports of violence. The best way to control violence is to prevent it before it becomes an issue. Ideally, to prevent violent episodes we should eliminate all triggers of frustration and violence. Our study aims to assess the impact of a quality improvement multi-faceted program aiming at preventing incivility and violence against healthcare professionals working at the ophthalmological emergency department of a teaching hospital. METHODS/DESIGN: This study is a single-center prospective, controlled time-series study with an alternate-month design. The prevention program is based on the successive implementation of five complementary interventions: a) an organizational approach with a standardized triage algorithm and patient waiting number screen, b) an environmental approach with clear signage of the premises, c) an educational approach with informational videos for patients and accompanying persons in waiting rooms, d) a human approach with a mediator in waiting rooms and e) a security approach with surveillance cameras linked to the hospital security. The primary outcome is the rate of incivility or violence by patients, or those accompanying them against healthcare staff. All patients admitted to the ophthalmological emergency department, and those accompanying them, will be enrolled. In all, 45,260 patients will be included in over a 24-month period. The unit analysis will be the patient admitted to the emergency department. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: The strengths of this study include the active solicitation of event reporting, that this is a prospective study and that the study enables assessment of each of the interventions that make up the program. The challenge lies in identifying effective interventions, adapting them to the context of care in an emergency department, and thoroughly assessing their efficacy with a high level of proof.The study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02015884).
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Serviço Hospitalar de Emergência , Saúde Ocupacional , Oftalmologia , Violência no Trabalho/prevenção & controle , Serviço Hospitalar de Emergência/organização & administração , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Estudos Prospectivos , Projetos de Pesquisa , Gestão da SegurançaRESUMO
Background: Toxicity or treatment failure related to drug-drug interactions (DDIs) are known to significantly affect morbidity and hospitalization rates. Despite the availability of numerous databases for DDIs identification and management, their information often differs. Oral anticoagulants are deemed at risk of DDIs and a leading cause of adverse drug events, most of which being preventable. Although many databases include DDIs involving anticoagulants, none are specialized in them. Aim and method: This study aims to compare the DDIs information content of four direct oral anticoagulants and two vitamin K antagonists in three major DDI databases used in Switzerland: Lexi-Interact, Pharmavista, and MediQ. It evaluates the consistency of DDIs information in terms of differences in severity rating systems, mechanism of interaction, extraction and documentation processes and transparency. Results: This study revealed 2'496 DDIs for the six anticoagulants, with discrepant risk classifications. Only 13.2% of DDIs were common to all three databases. Overall concordance in risk classification (high, moderate, and low risk) was slight (Fleiss' kappa = 0.131), while high-risk DDIs demonstrated a fair agreement (Fleiss' kappa = 0.398). The nature and the mechanism of the DDIs were more consistent across databases. Qualitative assessments highlighted differences in the documentation process and transparency, and similarities for availability of risk classification and references. Discussion: This study highlights the discrepancies between three commonly used DDI databases and the inconsistency in how terminology is standardised and incorporated when classifying these DDIs. It also highlights the need for the creation of specialised tools for anticoagulant-related interactions.
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The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.
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Hospitalização , Classe Social , Humanos , Suíça , Fatores Socioeconômicos , Atenção à SaúdeRESUMO
Excessive antibiotic use and antimicrobial resistance are major global public health threats. We developed ePOCT+, a digital clinical decision support algorithm in combination with C-reactive protein test, hemoglobin test, pulse oximeter and mentorship, to guide health-care providers in managing acutely sick children under 15 years old. To evaluate the impact of ePOCT+ compared to usual care, we conducted a cluster randomized controlled trial in Tanzanian primary care facilities. Over 11 months, 23,593 consultations were included from 20 ePOCT+ health facilities and 20,713 from 20 usual care facilities. The use of ePOCT+ in intervention facilities resulted in a reduction in the coprimary outcome of antibiotic prescription compared to usual care (23.2% versus 70.1%, adjusted difference -46.4%, 95% confidence interval (CI) -57.6 to -35.2). The coprimary outcome of day 7 clinical failure was noninferior in ePOCT+ facilities compared to usual care facilities (adjusted relative risk 0.97, 95% CI 0.85 to 1.10). There was no difference in the secondary safety outcomes of death and nonreferred secondary hospitalizations by day 7. Using ePOCT+ could help address the urgent problem of antimicrobial resistance by safely reducing antibiotic prescribing. Clinicaltrials.gov Identifier: NCT05144763.
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Antibacterianos , Saúde Digital , Criança , Humanos , Adolescente , Antibacterianos/uso terapêutico , Atenção Primária à Saúde , Prescrições , Assistência Ambulatorial , AlgoritmosRESUMO
AIM: Antihypertensive drugs are thought to be responsible for adverse drug events in 25% of patients, with severe consequences in 13% of cases. The purpose of this study was to develop an interactive booklet designed to inform and involve patients with a view to preventing adverse drug events. METHODS: The development of the booklet involved several stages, including a literature review, a Delphi survey, a readability assessment, a qualitative study in primary care, a revision process, and graphic design work. 27 experts (patients, general practitioners, public health practitioners, cardiologists, geriatricians, psychologists, economists, pharmacists, nurses and ethicists) participated in the Delphi survey, while the qualitative study was based on a sample that included 7 doctors, 13 patients and 2 healthcare assistants. RESULTS: We developed an interactive booklet containing information items on the benefits and risks of antihypertensive drugs, a care plan to be completed by the patient, and a form for reporting adverse drug events. Ambiguous sentences and incomprehensible medical terms were rephrased. The time required to present the booklet and ease of use were key acceptability criteria for caregivers. Among the patients, the study found that interest in the booklet required clear evidence of an expected benefit. CONCLUSION: An understandable and acceptable interactive booklet was developed using a systematic process to prevent severe adverse drug events in primary care.
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Anti-Hipertensivos/uso terapêutico , Serviços de Informação sobre Medicamentos , Folhetos , Educação de Pacientes como Assunto , Participação do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnica Delphi , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à SaúdeRESUMO
Asylum seekers face multiple language, cultural and administrative barriers that could result in the inappropriate implementation of COVID-19 measures. This study aimed to explore their knowledge and attitudes to recommendations about COVID-19. We conducted a cross-sectional survey among asylum seekers living in the canton of Vaud, Switzerland. We used logistic regressions to analyze associations between knowledge about health recommendations, the experience of the pandemic and belief to rumors, and participant sociodemographic characteristics. In total, 242 people participated in the survey, with 63% of men (n = 150) and a median age of 30 years old (IQR 23-40). Low knowledge was associated with linguistic barriers (aOR 0.36, 95% CI 0.14-0.94, p = 0.028) and living in a community center (aOR 0.43, 95% CI 0.22-0.85, p = 0.014). Rejected asylum seekers were more likely to believe COVID-19 rumors (aOR 2.81, 95% CI 1.24-6.36, p = 0.013). This survey underlines the importance of tailoring health recommendations and interventions to reach asylum seekers, particularly those living in community centers or facing language barriers.
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COVID-19 , Refugiados , Adulto , Humanos , Masculino , Adulto Jovem , COVID-19/epidemiologia , Estudos Transversais , Idioma , Suíça/epidemiologia , FemininoRESUMO
BACKGROUND: Sepsis is a leading cause of morbidity and mortality. Prompt recognition and management are critical to improve outcomes. METHODS: We conducted a survey among nurses and physicians of all adult departments of the Lausanne University Hospital (LUH) and paramedics transporting patients to our hospital. Measured outcomes included professionals' demographics (age, profession, seniority, unit of activity), quantification of prior sepsis education, self-evaluation, and knowledge of sepsis epidemiology, definition, recognition, and management. Correlation between surveyed personnel and sepsis perceptions and knowledge were assessed with univariable and multivariable logistic regression models. RESULTS: Between January and October 2020, we contacted 1'216 of the 4'417 professionals (27.5%) of the LUH, of whom 1'116 (91.8%) completed the survey, including 619 of 2'463 (25.1%) nurses, 348 of 1'664 (20.9%) physicians and 149 of 290 (51.4%) paramedics. While 98.5% of the participants were familiar with the word "sepsis" (97.4% of nurses, 100% of physicians and 99.3% of paramedics), only 13% of them (physicians: 28.4%, nurses: 5.9%, paramedics: 6.8%) correctly identified the Sepsis-3 consensus definition. Similarly, only 48% and 49.3% of the physicians and 10.1% an 11.9% of the nurses knew that SOFA was a sepsis defining score and that the qSOFA score was a predictor of increased mortality, respectively. Furthermore, 15.8% of the physicians and 1.0% of the nurses knew the three components of the qSOFA score. For patients with suspected sepsis, 96.1%, 91.6% and 75.8% of physicians respectively chose blood cultures, broad-spectrum antibiotics and fluid resuscitation as therapeutic interventions to be initiated within 1 (76.4%) to 3 (18.2%) hours. For nurses and physicians, recent training correlated with knowledge of SOFA score (ORs [95%CI]: 3.956 [2.018-7.752] and 2.617 [1.527-4.485]) and qSOFA (ORs [95%CI]: 5.804 [2.653-9.742] and 2.291 [1.342-3.910]) scores purposes. Furthermore, recent training also correlated with adequate sepsis definition (ORs [95%CI]: 1.839 [1.026-3.295]) and the components of qSOFA (ORs [95%CI]: 2.388 [1.110-5.136]) in physicians. CONCLUSIONS: This sepsis survey conducted among physicians, nurses and paramedics of a tertiary Swiss medical center identified a deficit of sepsis awareness and knowledge reflecting a lack of sepsis-specific continuing education requiring immediate corrective measures.
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Enfermeiras e Enfermeiros , Médicos , Sepse , Adulto , Humanos , Suíça/epidemiologia , Estudos Transversais , Paramédico , Centros de Atenção Terciária , Mortalidade Hospitalar , Sepse/diagnóstico , Sepse/epidemiologia , Sepse/terapia , Escores de Disfunção Orgânica , Estudos Retrospectivos , Prognóstico , Unidades de Terapia IntensivaRESUMO
Objectives: The clinical and social burden of the COVID-19 pandemic were high among asylum seekers (ASs). We aimed to understand better ASs' experiences of the pandemic and their sources of worries. Methods: Participants (n = 203) completed a survey about their worries, sleep disorders, and fear of dying. We also conducted semi-structured interviews with ASs living in a community center (n = 15), focusing on how social and living conditions affected their experiences and worries. Results: ASs in community centers experienced more sleep disorders related to the COVID-19 pandemic than those living in private apartments (aOR 2.01, p = 0.045). Similarly, those with lower education had greater fear for their life due to the COVID-19 pandemic (aOR 2.31, p = 0.015). Qualitative findings showed that sharing living spaces was an important source of worries for ASs and that protective measures were perceived to increase social isolation. Conclusion: Our study highlighted the impact of the COVID-19 pandemic for ASs and the importance of tailoring public health measures to their needs and living conditions.
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COVID-19 , Refugiados , Transtornos do Sono-Vigília , Humanos , Pandemias , Suíça/epidemiologia , COVID-19/epidemiologiaRESUMO
BACKGROUND: Common low back pain represents a major public health problem in terms of its direct cost to health care and its socio-economic repercussions. Ten percent of individuals who suffer from low back pain evolve toward a chronic case and as such are responsible for 75 to 80% of the direct cost of low back pain. It is therefore imperative to highlight the predictive factors of low back pain chronification in order to lighten the economic burden of low back pain-related invalidity. Despite being particularly affected by low back pain, Hospices Civils de Lyon (HCL) personnel have never been offered a specific, tailor-made treatment plan. The PRESLO study (with PRESLO referring to Secondary Low Back Pain Prevention, or in French, PREvention Secondaire de la LOmbalgie), proposed by HCL occupational health services and the Centre Médico-Chirurgical et de Réadaptation des Massues - Croix Rouge Française, is a randomized trial that aims to evaluate the feasibility and efficiency of a global secondary low back pain prevention program for the low back pain sufferers among HCL hospital personnel, a population at risk for recurrence and chronification. This program, which is based on the concept of physical retraining, employs a multidisciplinary approach uniting physical activity, cognitive education about low back pain and lumbopelvic morphotype analysis. No study targeting populations at risk for low back pain chronification has as yet evaluated the efficiency of lighter secondary prevention programs. METHODS/DESIGN: This study is a two-arm parallel randomized controlled trial proposed to all low back pain sufferers among HCL workers, included between October 2008 and July 2011 and followed over two years. The personnel following their usual treatment (control group) and those following the global prevention program in addition to their usual treatment (intervention group) are compared in terms of low back pain recurrence and the impairments measured at the beginning and the end of the study. The global prevention program is composed of a two-hour information session about low back pain and pain pathways, followed by five weekly 90-min exercise sessions with one physiotherapist per group of eight to ten personnel. A booklet for home use with patient-managed exercise instructions and information (The Back Book) is given to each participant at the end of the program.An X-ray assessment of the entire spinal column of each participant (in both the control and intervention groups) is performed at the onset of the study in order to analyze sagittal spinopelvic balance as well as lombopelvic morphotype. DISCUSSION: The results of this study, which is innovative and unique in France, will be available in 2014 and will make it possible to draw conclusions regarding the program's impact on the risk of recurrence and chronification of low back pain. TRIAL REGISTRATION: http://www.clinicaltrials.gov # NCT00782925.
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Dor Lombar/prevenção & controle , Doenças Profissionais/prevenção & controle , Saúde Ocupacional , Recursos Humanos em Hospital , Projetos de Pesquisa , Prevenção Secundária , Avaliação da Deficiência , Terapia por Exercício , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Dor Lombar/diagnóstico , Dor Lombar/etiologia , Dor Lombar/fisiopatologia , Doenças Profissionais/diagnóstico , Doenças Profissionais/etiologia , Doenças Profissionais/fisiopatologia , Medição da Dor , Folhetos , Educação de Pacientes como Assunto , Equilíbrio Postural , Prevenção Secundária/métodos , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
Objectives: To assess the differences in the management and prognosis of acute coronary syndrome in men and women who were admitted to hospital for acute coronary syndrome. Design: Cross sectional study. Setting: Discharge data from Swiss hospitals linked at the hospital and patient levels. Participants: 224 249 adults (18 years and older) were admitted to hospital for acute coronary syndrome between 1 January 2009 and 31 December 2017 in any Swiss hospital, of which 72 947 (32.5%) were women. People who were discharged against medical advice were excluded. Results: Women admitted to hospital with acute coronary syndrome were older than their male counterparts (mean age 74.9 years (standard deviation 12.4) v 67.0 years (13.2)). Irrespective of acute coronary syndrome type, women were less likely to undergo diagnostic procedures, such as coronary angiography (adjusted odds ratio 0.79 (95% confidence interval 0.77 to 0.82) for non-ST-segment elevation myocardial infarction v 0.87 (0.84 to 0.91) for ST-segment elevation myocardial infarction)) and ventriculography (0.84 (0.82 to 0.87) v 0.90 (0.87 to 0.91)). Women were also less likely to receive treatments, such as percutaneous coronary intervention (0.67 (0.65 to 0.69) v 0.76 (0.73 to 0.78)) and coronary artery bypass graft (0.57 (0.53 to 0.61) v 0.79 (0.72 to 0.87)). Women had a poorer prognosis than men, with a higher likelihood of healthcare related complications (1.10 (1.06 to 1.15) v 1.14 (1.09 to 1.21)) and of a longer hospital stay (1.24 (1.20 to 1.27) v 1.24 (1.20 to 1.29)). In non-adjusted models, the likelihood of death in hospital was higher among women (odds ratio 1.30 (95% confidence interval 1.24 to 1.37) for non-ST-segment elevation myocardial infarction v 1.75 (1.66 to 1.85) for ST-segment elevation myocardial infarction), but the association was reversed for ST-segment elevation myocardial infarction (adjusted odds ratio 0.87 (0.82 to 0.92)) or was non-significant for non-ST-segment elevation myocardial infarction (1.00 (0.94 to 1.06)) after adjustment for confounding variables. The main effect modifier was age: younger women were more likely to die than men of the same age and older women were less likely to die than men of the same age. For example, women who were younger than 50 years had a 38% increased likelihood of dying compared with men of the same age range (adjusted odds ratio 1.38 (1.04 to 1.83)). Conclusions: Sex inequalities were reported in the management of heart disease in this population of patients from a high income country with good healthcare coverage. These differences affect mortality and morbidity, especially in younger women. Efforts are needed to overcome these inequalities, including educational programmes aimed at healthcare professionals.
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OBJECTIVES: To quantitatively assess the early impact of the COVID-19 pandemic on in-person outpatient care utilisation worldwide, as well as across categories of services, types of care and medical specialties. DESIGN: Rapid review. METHOD: A search of MEDLINE and Embase was conducted to identify studies published from 1 January 2020 to 12 February 2021, which quantitatively reported the impact of the COVID-19 pandemic on the amount of outpatient care services delivered (in-person visits, diagnostic/screening procedures and treatments). There was no restriction on the type of medical care (emergency/primary/specialty care) or target population (adult/paediatric). All articles presenting primary data from studies reporting on outpatient care utilisation were included. Studies describing conditions requiring hospitalisation or limited to telehealth services were excluded. RESULTS: A total of 517 articles reporting 1011 outpatient care utilisation measures in 49 countries worldwide were eligible for inclusion. Of those, 93% focused on the first semester of 2020 (January to June). The reported results showed an almost universal decline in in-person outpatient care utilisation, with a 56% overall median relative decrease. Heterogeneity across countries was high, with median decreases ranging from 10% to 91%. Diagnostic and screening procedures (-63%), as well as in-person visits (-56%), were more affected than treatments (-36%). Emergency care showed a smaller relative decline (-49%) than primary (-60%) and specialty care (-58%). CONCLUSIONS: The provision of in-person outpatient care services has been strongly impacted by the COVID-19 pandemic, but heterogeneously across countries. The long-term population health consequences of the disruption of outpatient care service delivery remain currently unknown and need to be studied. PROSPERO REGISTRATION NUMBER: CRD42021237366.
Assuntos
COVID-19 , Pandemias , Adulto , Assistência Ambulatorial , COVID-19/epidemiologia , Criança , Atenção à Saúde , Humanos , SARS-CoV-2RESUMO
Background: Prompt recognition of sepsis is critical to improving patients' outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. Methodology: A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Results: Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS > 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS > 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). Conclusions: The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints.
RESUMO
BACKGROUND: One-third of older inpatients experience adverse drug events (ADEs), which increase their mortality, morbidity, and health care use and costs. In particular, antithrombotic drugs are among the most at-risk medications for this population. Reporting systems have been implemented at the national, regional, and provider levels to monitor ADEs and design prevention strategies. Owing to their well-known limitations, automated detection technologies based on electronic medical records (EMRs) are being developed to routinely detect or predict ADEs. OBJECTIVE: This study aims to develop and validate an automated detection tool for monitoring antithrombotic-related ADEs using EMRs from 4 large Swiss hospitals. We aim to assess cumulative incidences of hemorrhages and thromboses in older inpatients associated with the prescription of antithrombotic drugs, identify triggering factors, and propose improvements for clinical practice. METHODS: This project is a multicenter, cross-sectional study based on 2015 to 2016 EMR data from 4 large hospitals in Switzerland: Lausanne, Geneva, and Zürich university hospitals, and Baden Cantonal Hospital. We have included inpatients aged ≥65 years who stayed at 1 of the 4 hospitals during 2015 or 2016, received at least one antithrombotic drug during their stay, and signed or were not opposed to a general consent for participation in research. First, clinical experts selected a list of relevant antithrombotic drugs along with their side effects, risks, and confounding factors. Second, administrative, clinical, prescription, and laboratory data available in the form of free text and structured data were extracted from study participants' EMRs. Third, several automated rule-based and machine learning-based algorithms are being developed, allowing for the identification of hemorrhage and thromboembolic events and their triggering factors from the extracted information. Finally, we plan to validate the developed detection tools (one per ADE type) through manual medical record review. Performance metrics for assessing internal validity will comprise the area under the receiver operating characteristic curve, F1-score, sensitivity, specificity, and positive and negative predictive values. RESULTS: After accounting for the inclusion and exclusion criteria, we will include 34,522 residents aged ≥65 years. The data will be analyzed in 2022, and the research project will run until the end of 2022 to mid-2023. CONCLUSIONS: This project will allow for the introduction of measures to improve safety in prescribing antithrombotic drugs, which today remain among the drugs most involved in ADEs. The findings will be implemented in clinical practice using indicators of adverse events for risk management and training for health care professionals; the tools and methodologies developed will be disseminated for new research in this field. The increased performance of natural language processing as an important complement to structured data will bring existing tools to another level of efficiency in the detection of ADEs. Currently, such systems are unavailable in Switzerland. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40456.