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Impact of Enhanced Recovery After Surgery (ERAS) program in gynecologic oncology and patient satisfaction. J Gynecol Obstet Hum Reprod 2023; 52:102528. [PMID: 36608803 DOI: 10.1016/j.jogoh.2022.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The primary objective of this study was to compare lengths of stay since ERAS program implementation. We also evaluated ERAS protocol compliance, compared the outpatient rate, the complication rate and the readmission rate within 30 days after surgery and performed a satisfaction study. METHODS This is a monocentric comparative study with a historical control group, performed in the gynecological surgery department of the University Hospital of Saint-Etienne. We compared a group of patients who underwent surgery in 2016, before the implementation of ERAS program, with a group of patients who underwent surgery from July 2021 to July 2022, for whom ERAS program was applied. RESULTS 187 patients were included in this study, including 84 patients in the historical group before ERAS and 103 in the group with ERAS. Considering all approaches, the average length of stay decreased by 2 days (p<0.0001). Considering minimally invasive surgery, the outpatient rate increased from 5% to 50% (p<0.0001) and complication rate decreased from 23 to 11% (p = 0,04). The readmissions rate was similar. Satisfaction score for patients managed with ERAS program was 8.9/10. CONCLUSION The implementation of ERAS program in gynecological oncology surgery allowed a reduction in length of stay, with a high outpatient rate, decreasing complications in case of minimally invasive surgery, without increasing the readmission rate, and was associated with good patient satisfaction.
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Chronic kidney disease is more prevalent among women but more men than women are under nephrological care : Analysis from six outpatient clinics in Austria 2019. Wien Klin Wochenschr 2023; 135:89-96. [PMID: 36044092 PMCID: PMC9938018 DOI: 10.1007/s00508-022-02074-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/24/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND A discrepancy between sex-specific treatment of kidney failure by dialysis (higher in men) and the prevalence of chronic kidney disease in the general population (higher in women) has been reported internationally, but the prevalence by sex has not been described for Austria. Sex disparity among nephrology outpatients has not been studied. METHODS We employed two formulae (2009 CKD-EPI suppressing the race factor, and race-free 2021 CKD-EPI) to estimate the sex distribution of CKD in Austrian primary care, based on creatinine measurements recorded in a medical sample of 39,800 patients from general practitioners' offices (1989-2008). Further, we collected information from all clinic appointments scheduled at nephrology departments of 6 Austrian hospitals (Wien, Linz, Wels, St. Pölten, Villach, Innsbruck) during 2019 and calculated visit frequencies by sex. RESULTS Using the 2009 CKD-EPI formula, the prevalence of CKD in stages G3-G5 (estimated glomerular filtration rate < 60 mL/min/1.73 m2) was 16.4% among women and 8.5% among men aged > 18 years who had attended general practitioners' offices in Austria between 1989 and 2008 and had at least one creatinine measurement performed. Using the 2021 CKD-EPI formula, the respective CKD prevalence was 12.3% among women and 6.1% among men. In 2019, 45% of all outpatients at 6 participating nephrology departments were women. The median of nephrology clinic visits in 2019 was two (per year) for both sexes. CONCLUSION CKD is more prevalent among Austrian women than men. Men are more prevalent in nephrology outpatient services. Research into causes of this sex disparity is urgently needed.
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Feasibility of a Hospital-at-Home Program for Autologous Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:111.e1-111.e7. [PMID: 36436783 DOI: 10.1016/j.jtct.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
The Hospital at Home (HaH) model has been positioned as an appropriate therapeutic strategy for selected patients undergoing autologous hematopoietic stem cell transplantation (ASCT). This care model provides hospital-equivalent care, in terms of both quality and quantity, with medical and nursing staff that go to the patient's home. Here we describe our experience with a full HaH model for patients undergoing ASCT during the phase of aplasia. The patients met the eligibility criteria between January 1997 and December 2019 and were discharged from the hospital and admitted into the HaH-ASCT program on the same day they in which hematopoietic stem cells were infused. A total of 84 patients were included. The median patient age was 54 years (range, 16 to 74 years), and the median duration of participation in the HaH program was 17 days (range, 3 to 86 days). Only 10 of these patients (12%) required hospital readmission to the hematology department, 9 of them due to sepsis and 1 because of family care support claudication. Seventy-two patients (86%) experienced an episode of neutropenic fever during the HAH admission, with a median duration of 2 days (interquartile range [IQR], 1 to 11 days); all were treated with empiric i.v. antimicrobial therapy. Most patients (88%) presented with mucositis (44% with grade 3-4). Parenteral nutrition was administered in 26% of patients for a median of 6 days (IQR, 1 to 12 days). Most patients (94%) required at least 1 blood product transfusion at home. There was no transplantation-related mortality during the HaH-ASCT program or in the patients who were readmitted. With careful selection of patients and a comprehensive and well- experienced multidisciplinary team (doctors, nurses, and auxiliary nurses) in the HaH department and in close collaboration with the hematology department, complete at-home management of ASCT recipients immediately after transplantation is possible. This allows patients undergoing an aggressive procedure such as ASCT to remain in their own familiar environment, providing a better quality of life with a program that has demonstrated to be effective and safe, with a low incidence of complications and no associated mortality.
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Hospital at home treatment with remdesivir for patients with COVID-19: real-life experience. Int J Infect Dis 2023; 127:124-128. [PMID: 36521589 PMCID: PMC9744477 DOI: 10.1016/j.ijid.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Access and appropriateness of therapeutics for COVID-19 vary because of access or regulatory barriers, the severity of the disease, and for some therapies, the stage of the pandemic and circulating variants. Remdesivir has shown benefits in clinical recovery and is the treatment of choice for selected patients, both hospitalized and nonhospitalized, in main international guidelines. The use of remdesivir in alternatives to conventional hospitalization such as hospital at home (HaH) units remains incompletely explored. In this study, we aim to describe the real-life experience of outpatient remdesivir infusion for COVID-19 in a HaH unit. METHODS We selected all the consecutive patients receiving remdesivir from a prospective cohort of 507 COVID-19 patients admitted at a HaH unit. Admission criteria included COVID-19 with a fraction of inspired oxygen requirement under 0.35 and respiratory rate under 22 rpm. Patients were daily assessed in person by a nurse and a physician. RESULTS A total of 236 patients admitted at the HaH unit received remdesivir, 172 of whom were treated at home. Only 2% presented any adverse event related to the infusion, all of them mild. HaH saved 1416 day-beds, with only 5% of the patients requiring transfer back to the hospital. CONCLUSION Remdesivir infusion in HaH units seems to be a safe and efficient alternative to conventional hospitalization for treating patients with nonsevere COVID-19.
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True " outpatient discharge" following single-stage bilateral unicompartmental knee arthroplasty may be unrealistic for most. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04778-1. [PMID: 36653485 DOI: 10.1007/s00402-023-04778-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Single-stage bilateral unicompartmental knee arthroplasty (BUKA) has shown post-operative function and cost benefits over staged bilateral procedures, without increased complications. A rapid discharge protocol at the current study site has reported outpatient discharge for the unilateral procedure exceeding 97%. However, the feasibility of outpatient discharge following BUKA remains unclear. Therefore, the purpose of this study was to determine the success of achieving outpatient (< 24 h) discharge following BUKA, and identify patient variables associated with failure. METHODS A retrospective chart review was completed for 104 BUKA patients. All patients with bilateral, symptomatic unicompartmental knee arthritis were offered the single-stage procedure. Data collection included patient demographics, discharge status, and disposition location. Independent t tests (continuous) and Chi-squared tests (categorical) determined differences between discharge (outpatient/inpatient) and disposition (home/other) groups. Variables associated with discharge status and location were assessed with multivariable regression. RESULTS While 96 (92.3%) patients discharged within 24 h, only 63.5% were able to discharge directly home. Patients requiring a longer hospital stay (> 24 h) were more likely to require a pre-operative assistive device (62.5% and 25.0%, p = 0.037) and live alone (37.5 vs 8.3%, p = 0.033). For those discharged within 24 h, living alone significantly increased the risk (odds ratio: 5.800, p = 0.038) of requiring an acute inpatient facility prior to transition home. CONCLUSION Achieving "true" outpatient discharge is only modestly successful for most BUKA patients, as many required an acute inpatient or short-term rehabilitation facility prior to returning home. BUKA should be differentiated from the unilateral procedure regarding outpatient discharge expectations. LEVEL OF EVIDENCE III, Case-control study; Retrospective comparative study.
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Inguinal hernia treatment in Switzerland: inpatient vs. outpatient setting - HerStAmb Study (prospective observational two-centre comparative study). Langenbecks Arch Surg 2023; 408:14. [PMID: 36622458 DOI: 10.1007/s00423-023-02766-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/27/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Since 01/2018, AVOS (ambulant vor stationär = outpatient to inpatient) regulation has been progressively implemented in hernia surgery in Switzerland. The aim of this prospective, observational, two-centre comparative study was to compare the outcome of outpatient and inpatient post-operative care in terms of AVOS by examining the re-admission rate, complication rate and quality of life in patients with primary unilateral inguinal hernia repair. METHODS The study ran between 01/2019 and 04/2020 and included 237 patients with a primary unilateral inguinal hernia. Treatment setting was decided according to AVOS guidelines. Primary endpoint was re-admission rate within 6 weeks postoperatively. Secondary endpoints were the complication rate and patient outcome (quality of life) at 6 weeks follow-up postoperatively, as measured by the Short Form 36 Health Survey Questionnaire (SF-36). RESULTS Complications occurred in 11 (14%) inpatient patients, but none required re-admitting for revision until follow-up at 6 weeks after discharge. In the outpatient group, there were 27 (17%) complications reported, while 6 (4%) of these patients crossed over to the inpatient group immediately after surgery. None of the other complications required re-admission until follow-up at 6 weeks. No significant relationship between treatment setting and number of complications/re-admission rate (p=0.458, p=0.061) was observed. The mean outcome (SF-36) between the treatment groups was not significantly different (p=0.16-0.856). CONCLUSION In terms of AVOS selection criteria in Switzerland, primary unilateral inguinal hernia can be safely treated in both treatment settings. Re-admission rates, complications and quality of life do not significantly differ. Day surgery in terms of AVOS might be as effective and efficient, both from the patient's perspective and that of the institution. TRIAL REGISTRATION NUMBER NCT05234242.
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Telehealth and Application of Appropriate Use Criteria for Pediatric Transthoracic Echocardiography. Pediatr Cardiol 2023; 44:640-646. [PMID: 35962201 PMCID: PMC9374290 DOI: 10.1007/s00246-022-02985-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/27/2022] [Indexed: 11/27/2022]
Abstract
Appropriate use criteria (AUC) for the performance of outpatient transthoracic echocardiography are based on history, physical examination and electrocardiograms. Telehealth provides access to clinical care in the absence of a physical examination. We assessed application of AUC for performance of echocardiography following a telehealth visit. In this single center study, we retrospectively reviewed the charts of pediatric patients whose originally scheduled in person visits were converted to telehealth visits between March and May 2020. Patients were referred for echocardiogram by the telehealth cardiologist. Echocardiograms requested during the telehealth visit were retrospectively classified as appropriate [A], may be appropriate [M], or rarely appropriate [R] by two independent reviewers. Findings from the echocardiogram were classified as normal, abnormal, or abnormal and motivating treatment by the same two independent reviewers based upon results from the echocardiogram report and physician office visit note. Of the 441 patients seen by telehealth, interquartile range of 1.9-15.3 years, 114 (26%) patients were referred for an echocardiogram. Of the patients for whom echocardiograms were requested, 56/114 (49%) were new to cardiology. Echocardiograms were rated: A-85 (75%), M-5 (4%), and R-24 (21%). Of the 108 completed studies, 61 (56%) were normal, 44 (41%) were abnormal, and three (3%) were abnormal motivating treatment. Abnormal TTE findings were not detected in the R encounters compared with abnormal findings in 46/82 (56%) of the A completed studies. Seventy-one percent (15/21) of the R-rated studies were performed for murmur evaluation.
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Expected changes in physician outpatient interventional practices as a result of coronavirus disease 2019 and recent changes in Medicare physician fee schedule. J Vasc Surg Venous Lymphat Disord 2023; 11:1-9.e4. [PMID: 36179786 PMCID: PMC9514954 DOI: 10.1016/j.jvsv.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/22/2022] [Accepted: 08/18/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE We examined the economic and practice effects of the coronavirus disease 2019 (COVID-19) pandemic and decreased Medicare physician payments on outpatient vascular interventional procedures. METHODS A 21-point survey was constructed and sent electronically to the physician members of the Outpatient Endovascular and Interventional Society and the American Vein and Lymphatic Society. The survey responses were converted to a Likert scale and statistical analyses performed to examine the associations between the response variables and the characteristics and practice patterns of the physician respondents. RESULTS A total of 165 physicians responded to the survey, of whom 33% were vascular surgeons, 18% were radiologists, and 15% were general surgeons. For slightly more than one half (55%), their interventional practice was limited to the office setting, with the remainder also performing procedures in an office-based laboratory (OBL), ambulatory surgery center (ASC), or hospital. Almost all respondents had performed superficial venous interventions, with slightly more than one third also performing either deep venous procedures and/or peripheral arterial interventions. The COVID-19 pandemic had affected 98% of the practices, with a staff shortage reported by 63%. The most-established physicians, those with the longest interval since training completion, were the least likely to have experienced staff shortages. Almost all (94%) the respondents expected that the recent Medicare payment changes will have a negative effect on their practice. Physicians with only an office-based practice were less likely to add a physician associate compared with those with an OBL (P = .036). More than one quarter reported that it was likely they would close or sell their interventional practice in the next 2 years and 43% reported they were planning to retire early. The anticipated ameliorative responses to the decreased Medicare physician payments included adding wound care (24%) or other clinical services (36%) to their practices, with the alternatives considered more by younger physicians (P = .002) and nonsurgeons (P = .047). Only 10% expected to convert their practices to an ASC or hybrid ASC/OBL (16%). CONCLUSIONS The emotional and economic effects of the COVID-19 pandemic and the decreased Medicare physician reimbursement rates for vascular outpatient interventionalists have been significant. Even greater challenges for the financial viability of office practices and OBLs can be expected in the near future if additional further planned cuts are put into effect.
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Discussion on the Clinical Course of Adverse Effects after COVID-19 Vaccination: A Retrospective Analysis of Case Series in an Outpatient Department. Korean J Fam Med 2023; 44:28-34. [PMID: 36709958 PMCID: PMC9887448 DOI: 10.4082/kjfm.21.0212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/03/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND A total of 8,303 individuals (4.3%) with adverse reactions (n=191,860) after vaccination developed serious conditions or died. Such health developments could cause people not vaccinated yet or waiting for a booster shot to become fearful of the vaccination. METHODS The 3-month (July-September 2021) clinical data of 41 patients from the family medicine department of a single medical center were analyzed retrospectively to determine risk factors and to investigate the clinical course to identify the cause of symptoms in detail. RESULTS A significant number of older adults aged over 50 years reported experiencing general weakness (P=0.026) but fewer incidences of fever than patients aged 50 years or younger (P=0.011). Eighteen of the 41 patients were requested to visit more than twice or consult a specialist. In 14 patients, the symptoms were explained by other medical causes. CONCLUSION The primary physician has a pivotal role in thoroughly evaluating patients who complain of adverse effects after vaccination, considering the broad multitude of symptoms and medical conditions presented. To thoroughly evaluate and appropriately advise patients with adverse reactions to their chosen vaccine, taking detailed medical history and nutritional counseling are required to identify possible underlying causes, resolve symptoms, and educate them on self-care and regarding vaccines.
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Assessment of Healthcare Resource Utilization and Hospitalization Costs in Patients With Relapsed or Refractory Follicular Lymphoma Undergoing CAR-T Cell Therapy With Tisagenlecleucel: Results From the ELARA Study. Transplant Cell Ther 2023; 29:60.e1-60.e4. [PMID: 36182104 DOI: 10.1016/j.jtct.2022.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 02/09/2023]
Abstract
Follicular lymphoma (FL) is generally considered an indolent disease, although patients with relapsing FL experience progressively shorter durations of response to second or later lines of therapy. The ongoing ELARA trial in adult patients with relapsed/refractory (r/r) FL treated with tisagenlecleucel demonstrated an overall response rate of 86.2% and a complete response rate of 69.1%, with no treatment-related deaths. Tisagenlecleucel was administered in the outpatient setting in 18% of patients in ELARA; however, there is limited knowledge concerning the impact of inpatient versus outpatient tisagenlecleucel administration on healthcare resource utilization (HCRU) among patients with r/r FL. Here, we present the first HCRU analysis among patients with r/r FL who received tisagenlecleucel in the Phase II, single-arm, multicenter ELARA trial. HCRU was characterized using hospitalization data from day 1 to month 2 after tisagenlecleucel infusion. Information on length of stay, facility use, and discharge was assessed in patients who received tisagenlecleucel in the outpatient or inpatient setting. All costs were inflated to 2020 US dollars. As of August 3, 2021 (20-month median follow-up), 17/97 (18%) r/r FL patients were infused in an outpatient setting. Patients infused in the outpatient setting generally had favorable Eastern Cooperative Oncology Group performance status and Follicular Lymphoma International Prognostic Index scores, and less bulky disease at baseline. However, the outpatients had higher proportions of patients with grade 3A FL, primary refractory disease, and >5 lines of prior therapy compared with inpatients. Forty-one percent of patients treated in the outpatient setting did not require hospitalization within 30 days after infusion, and outpatients who did require hospitalization had a shorter average length of stay compared with inpatients (5 versus 13 days). No outpatients required intensive care unit (ICU) admission, whereas 9% of inpatients were admitted to the ICU. The mean postinfusion hospitalization costs were $7477 and $40,054 in the outpatient and inpatient settings, respectively. Efficacy between both groups was similar. Tisagenlecleucel can be safely administered to some patients in the outpatient setting, which may reduce HCRU for patients with r/r FL.
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Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:946-962. [PMID: 35951077 PMCID: PMC9366132 DOI: 10.1007/s00167-022-07094-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/24/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of day-case unicompartmental knee arthroplasty (UKA) by assessment of successful same-day discharge (SDD), readmission, complication and reoperation rates in the recent literature. METHODS For this systematic review and meta-analysis, PubMed, Embase and Cochrane Library were comprehensively searched to identify all eligible studies reporting outcomes of day-case UKA. Studies with intended same-day home discharge after UKA were included. A meta-analysis of proportions, using a random-effects model, was performed to estimate overall rates of successful SDD and adverse events. Subgroup analyses were performed for studies including selected patients (i.e., patients had to meet certain patient-specific criteria to be eligible for day-case UKA) and unselected patients (i.e., no additional criteria for day-case UKA), as well as for clinical and registry-based studies. Additional outcomes included reasons for the failure of SDD and patient satisfaction. RESULTS A total of 29 studies and 9694 patients were included with a mean age of 66 ± 9 years and mean follow-up of 59 days (mean range 30-270 days). Based on 24 studies (2733 patients), the overall successful SDD rate was 88% (95% confidence interval [CI] 80-92). These rates were 91% (95% CI 84-95) across studies with selected patients and 76% (95% CI 55-89) across studies with unselected patients. Overall readmission, complication and reoperation rates were 3% (95% CI 1.9-4.4), 4% (95% CI 2.8-5.2) and 1% (95% CI 0.8-1.3), respectively. Inability to mobilize, nausea and uncontrolled pain were frequently reported reasons for failed SDD. The overall patient satisfaction rate was 94%. CONCLUSION This systematic review with meta-analysis found an overall successful SDD rate of 88% after UKA in a heterogeneous cohort of selected and unselected patients. Readmission, complication and reoperation rates suggest UKA can be performed safely and effectively as a same-day discharge procedure. LEVEL OF EVIDENCE Level IV, systematic review of level III and IV studies.
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Re-initiation of elective total knee arthroplasty with an adapted pathway during the 2020 COVID-19 pandemic was safe and effective. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04732-7. [PMID: 36550383 PMCID: PMC9778452 DOI: 10.1007/s00402-022-04732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In June 2020 when elective total knee arthroplasty (TKA) resumed after the initial COVID-19 surge, we adapted our TKA pathway focusing on a shorter hospitalization, increased home discharge, and use of post-discharge telemedicine and telerehabilitation. The purpose of this study was to evaluate if changes in postoperative care affected early TKA outcomes. MATERIALS AND METHODS Five hundred and fifty-four patients who underwent elective primary unilateral TKA for primary osteoarthritis between June and August 2020 (study group) were matched 1:1 for age, sex, body mass index, and Charlson comorbidity index with control patients who underwent surgery between August and November 2019. Study patients were discharged 25 h earlier on average compared to controls, more frequently on the same-day or postoperative day-1 (24.9% vs. 16.1%; p = 0.001), and more frequently home (97.3% vs. 83.8%; p < 0.001). Study patients used telemedicine (11.7% vs. 0%; p < 0.001) and telerehabilitation (19.7% vs. 2.5%; p < 0.001) at higher rates than controls. Generalized estimating equations, Mann-Whitney U, and Chi-Square tests were used to compare outcomes between groups including unscheduled office visits, ER visits, readmissions, Center for Medicare and Medicaid Services (CMS) complications, manipulation under anesthesia (MUA), and patient-reported outcomes measures (PROMs). RESULTS Rates of emergency room visits, readmissions, CMS complications, MUA, and improvements in PROMs were similar between cohorts. Study patients experienced higher rates of unscheduled outpatient visits (9.2% vs. 4.9%; p = 0.004), predominantly due to wound complications. CONCLUSIONS A protocol implemented during the COVID-19 pandemic that leveraged a shortened hospitalization, higher rates of home discharge, and increased use of telemedicine and telerehabilitation was safe and effective.
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Responsiveness of the healthcare system in the Kingdom of Saudi Arabia: evidence from a nationally representative survey. BMC Health Serv Res 2022; 22:1524. [PMID: 36517822 PMCID: PMC9749241 DOI: 10.1186/s12913-022-08779-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Responsiveness is one of the widely used metrics in assessing the performance of healthcare systems. An analysis of the determinants of health care demand and supply and how the Saudi health system responds to the needs of patients (inpatient and outpatient) is needed; hence the need for this study. METHODS We analysed data from the Saudi Health Systems Responsiveness survey - a nationally representative survey of 10,000 households interviewed in 2017. Using this dataset, we descriptively analysed the level of responsiveness of inpatient and outpatient services (using the standard World Health Organization (WHO) responsiveness dimensions). Based on a logit modelling approach, the relationship between responsiveness and its key determinants was analysed in terms of healthcare demand and supply. RESULTS Over four fifths of respondents are satisfied with the level of inpatient and outpatient responsiveness. Furthermore, we find that those in bad health tend to show lower levels of satisfaction with inpatient and outpatient care. We also find some evidence that age, gender, and to some extent nationality act as correlates of health system responsiveness. Specifically, we find evidence that Saudi nationals are less satisfied with health services compared to foreign nationals. CONCLUSION Based on these findings improving the responsiveness of public healthcare facilities would need to be prioritized. Focusing on patients in worse health and lower socio-economic status should also be one of the main priorities.
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Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral. BMC Palliat Care 2022; 21:221. [PMID: 36503625 PMCID: PMC9743520 DOI: 10.1186/s12904-022-01114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center. METHODS Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category. RESULTS LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER. CONCLUSION A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.
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Delayed onset catatonia after COVID-19. PSYCHIATRY RESEARCH CASE REPORTS 2022; 1:100043. [PMID: 36164580 PMCID: PMC9394091 DOI: 10.1016/j.psycr.2022.100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 06/16/2023]
Abstract
COVID-19 has many complications that are associated with this infection. Neuropsychiatric symptoms are common and can present with symptoms documented both during acute COVID-19 infection and developing after the resolution of respiratory symptoms. Patients have presented with a variety of symptoms such as anosmia, seizures, cognitive and attention deficits, new or progression of existing anxiety, depression, psychosis, and rarely catatonia. Although rare, catatonia and each of its subtypes have now been reported as complications of COVID-19 and therefore, should be considered known to occur in both during the acute and postinfectious states. Diagnosis of catatonia in the context of COVID-19 should be considered when work-up for more common medical causes of encephalopathy are negative. There have been cases documented in the literature of patients presenting to the hospital with catatonia during COVID-19 infection. However, we present a case of akinetic catatonia in setting of COVID-19 infection and premorbid serious mental illness that was diagnosed and treated on an outpatient basis with close collaboration between primary care and psychiatry.
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Telerehabilitation acceptance among patients during Circuit Breaker period: A retrospective study. DIALOGUES IN HEALTH 2022; 1:100049. [PMID: 38515891 PMCID: PMC10953890 DOI: 10.1016/j.dialog.2022.100049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/09/2022] [Accepted: 09/20/2022] [Indexed: 03/23/2024]
Abstract
Background and objectives During the COVID-19 pandemic, telerehabilitation (TR) was viewed as an ideal alternative to minimize infection risks with in-person rehabilitation. However, TR acceptability remains unclear as it is an unfamiliar mode of interaction for most patients. We aim to retrospectively: (i) review the uptake rate of TR among patients, and (ii) explore their perceived barriers and facilitators of the service. Design A cross-sectional retrospective study was conducted among eligible patients who were offered TR. Research data was extracted from medical records. Additionally, an anonymous patient satisfaction survey was conducted among the successfully enrolled patients, and the feedback was extracted from the form.gov.sg server. Results 24·2% of the 314 eligible patients were successfully enrolled into TR. Preference for in-person rehabilitation was the top reason cited for declining the service. Among the 157 patients who declined the service, 38·2% of them preferred in-person rehabilitation over TR. Conclusions A low uptake of TR services was demonstrated, with preference for in-person rehabilitation being the majority cited reason for decline. Reconciling the differences in patients' perceptions between in-person rehabilitation and TR may improve uptake rates.
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Predicting Need for Skilled Nursing or Rehabilitation Facility after Outpatient Total Hip Arthroplasty. Hip Pelvis 2022; 34:227-235. [PMID: 36601616 PMCID: PMC9763827 DOI: 10.5371/hp.2022.34.4.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/02/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Outpatient classified total hip arthroplasty (THA) is a safe option for a select group of patients. An analysis of a national database was conducted to understand the risk factors for unplanned discharge to a skilled nursing facility (SNF) or acute rehabilitation (rehab) after outpatient classified THA. Materials and Methods A query of the National Surgical Quality Improvement Program (NSQIP) database for THA (Current Procedural Terminology [CPT] 27130) performed from 2015 to 2018 was conducted. Patient demographics, American Society of Anesthesiologists (ASA) classification, functional status, NSQIP morbidity probability, operative time, length of stay (LOS), 30-day reoperation rate, readmission rate, and associated complications were collected. Results A total of 2,896 patients underwent outpatient classified THA. The mean age of patients was 61.2 years. The mean body mass index (BMI) was 29.6 kg/m2 with median ASA 2. The results of univariate comparison of SNF/rehab versus home discharge showed that a significantly higher percentage of females (58.7% vs. 46.8%), age >70 years (49.3% vs. 20.9%), ASA ≥3 (58.0% vs. 25.8%), BMI >35 kg/m2 (23.3% vs. 16.2%), and hypoalbuminemia (8.0% vs. 1.5%) (P<0.0001) were discharged to SNF/rehab. The results of multivariable logistic regression showed that female sex (odds ratio [OR] 1.47; P=0.03), age >70 years (OR 3.08; P=0.001), ASA ≥3 (OR 2.56; P=0.001), and preoperative hypoalbuminemia (<3.5 g/dL) (OR 3.76; P=0.001) were independent risk factors for SNF/rehab discharge. Conclusion Risk factors associated with discharge to a SNF/rehab after outpatient classified THA were identified. Surgeons will be able to perform better risk stratification for patients who may require additional postoperative intervention.
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Doing things you never imagined: Professional and ethical issues in the U.S. outpatient physical therapy setting during the COVID-19 pandemic. Musculoskelet Sci Pract 2022; 62:102684. [PMID: 36356408 PMCID: PMC9617680 DOI: 10.1016/j.msksp.2022.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Despite being the most prevalent physical therapy practice setting in the United States, no literature to date has examined the professional and ethical issues faced by outpatient physical therapists during the COVID-19 pandemic. The purpose of this study was to explore professional and ethical issues experienced by outpatient physical therapists in the United States during the COVID-19 pandemic. DESIGN An explorative semi-structured interview study using reflexive thematic analysis METHODS: Virtual semi-structured interviews explored physical therapists' experiences during COVID-19 in the OP setting. Data was analyzed using reflexive thematic analysis as described by Braun and Clarke. RESULTS Respondents worked predominantly with patients with orthopaedic impairments. Six primary themes and associated subthemes were identified: 1) Disruption of routine professional and personal life. 2) Negative impacts on health and wellbeing (physical, mental, and social). 3) Barriers to relationships, communication, and providing quality care. 4) Telehealth as a safe option to increase access with opportunities and challenges. 5) Discomfort practicing in an environment of misinformation, mistrust, and divisiveness. 6) New & pre-existing ethical issues in the COVID-19 context. CONCLUSIONS Results of this study indicate that physical therapists in the outpatient setting wrestled with critical questions regarding outpatient physical therapy practice during the COVID-19 pandemic: the role of touch in professional identity, challenges to the therapeutic alliance, effect of productivity and fiscal expectations and whether outpatient physical therapy is essential during public emergencies.
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Safety and efficacy of four drug regimens versus standard-of-care for the treatment of symptomatic outpatients with COVID-19: A randomised, open-label, multi-arm, phase 2 clinical trial. EBioMedicine 2022; 86:104322. [PMID: 36332361 PMCID: PMC9624152 DOI: 10.1016/j.ebiom.2022.104322] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/09/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background This exploratory study investigated four repurposed anti-infective drug regimens in outpatients with COVID-19. Methods This phase 2, single centre, randomised, open-label, clinical trial was conducted in South Africa between 3rd September 2020 and 23rd August 2021. Symptomatic outpatients aged 18–65 years, with RT-PCR confirmed SARS-CoV-2 infection were computer randomised (1:1:1:1:1) to standard-of-care (SOC) with paracetamol, or SOC plus artesunate-amodiaquine (ASAQ), pyronaridine-artesunate (PA), favipiravir plus nitazoxanide (FPV + NTZ), or sofosbuvir-daclatasvir (SOF-DCV). The primary endpoint was the incidence of viral clearance, i.e., the proportion of patients with a negative SARS-CoV-2 RT-PCR on day 7, compared to SOC using a log-binomial model in the modified intention-to-treat (mITT) population. Findings The mITT population included 186 patients: mean age (SD) 34.9 (10.3) years, body weight 78.2 (17.1) kg. Day 7 SARS-CoV-2 clearance rates (n/N; risk ratio [95% CI]) were: SOC 34.2% (13/38), ASAQ 38.5% (15/39; 0.80 [0.44, 1.47]), PA 30.3% (10/33; 0.69 [0.37, 1.29]), FPV + NTZ 27.0% (10/37; 0.60 [0.31, 1.18]) and SOF-DCV 23.5% (8/34; 0.47 [0.22, 1.00]). Three lower respiratory tract infections occurred (PA 6.1% [2/33]; SOF-DCV 2.9% [1/34]); two required hospitalisation (PA, SOF-DCV). There were no deaths. Adverse events occurred in 55.3% (105/190) of patients, including one serious adverse event (pancytopenia; FPV + NTZ). Interpretation There was no statistical difference in viral clearance for any regimen compared to SOC. All treatments were well tolerated. Funding 10.13039/501100004167Medicines for Malaria Venture, with funding from the UK Foreign, Commonwealth and Development Office, within the Covid-19 Therapeutics Accelerator in partnership with 10.13039/100004440Wellcome, the 10.13039/100000865Bill and Melinda Gates Foundation, and Mastercard.
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Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study. BMC Palliat Care 2022; 21:203. [PMID: 36419072 PMCID: PMC9686086 DOI: 10.1186/s12904-022-01099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Proper advance care planning (ACP) documentation both improves patient care and is increasingly seen as a marker of high quality by governmental payers. The transition of most medical documentation to electronic health records (EHR) allows for ACP documents to be rapidly disseminated across diverse ambulatory practice settings. At the same time, the complexity and heterogeneity of the EHR, as well as the multiple potential storage locations for documentation, may lead to confusion and inaccessibility. There has been movement to promote structured ACP (S-ACP) documentation within the EHR. METHODS We performed a retrospective cohort study at a single, large university medical center in California to analyze rates of S-ACP documentation. S-ACP was defined as ACP documentation contained in standardized locations, auditable, and not in free-text format. The analytic cohort composed of all patients 65 and older with at least one ambulatory encounter at Stanford Health Care between 2012 and 2020, and without concurrent hospice care. We then analyzed clinic-level, provider-level, insurance, and temporal factors associated with S-ACP documentation rate. RESULTS Of 187,316 unique outpatient encounters between 2012 and 2020, only 7,902 (4.2%) contained S-ACP documentation in the EHR. The most common methods of S-ACP documentation were through problem list diagnoses (3,802; 40.3%) and scanned documents (3,791; 40.0%). At the clinic level, marked variability in S-ACP documentation was observed, with Senior Care (46.6%) and Palliative Care (25.0%) demonstrating highest rates. There was a temporal trend toward increased S-ACP documentation rate (p < 0.001). CONCLUSION This retrospective, single-center study reveals a low rate of S-ACP documentation irrespective of clinic and specialty. While S-ACP documentation rate should not be construed as a proxy for ACP documentation rate, it nonetheless serves as an important quality metric which may be reported to payers. This study highlights the need to both centralize and standardize reporting of ACP documentation in complex EHR systems.
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The sociodemographic characteristics and clinical features of the late-life depression patients: results from the Beijing Anding Hospital mental health big data platform. BMC Psychiatry 2022; 22:677. [PMID: 36324116 PMCID: PMC9628045 DOI: 10.1186/s12888-022-04339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/26/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The sociodemographic characteristics and clinical features of the Late-life depression (LLD) patients in psychiatric hospitals have not been thoroughly studied in China. This study aimed to explore the psychiatric outpatient attendance of LLD patients at a psychiatric hospital in China, with a subgroup analysis, such as with or without anxiety, gender differences. METHODS This retrospective study examined outpatients with LLD from January 2013 to August 2019 using data in the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM) in Beijing Anding Hospital. Age, sex, number of visits, use of drugs and comorbid conditions were extracted from medical records. RESULTS In a sample of 47,334 unipolar depression patients, 31,854 (67.30%) were women, and 15,480 (32.70%) were men. The main comorbidities of LDD are generalized anxiety disorder (GAD) (83.62%) and insomnia (74.52%).Among patients with unipolar depression, of which benzodiazepines accounted for the largest proportion (77.77%), Selective serotonin reuptake inhibitors (SSRIs) accounted for 59.00%, a noradrenergic and specific serotonergic antidepressant (NaSSAs) accounted for 36.20%. The average cost of each visit was approximately 646.27 yuan, and the cost of each visit was primarily attributed to Western medicine (22.97%) and Chinese herbal medicine (19.38%). For the cost of outpatient visits, depression comorbid anxiety group had a higher average cost than the non-anxiety group (p < 0.05). There are gender differences in outpatient costs, men spend more than women, for western medicine, men spend more than women, for Chinese herbal medicine, women spend more than men (all p < 0.05). The utilization rate of SSRIs and benzodiazepines in female patients is significantly higher than that in male patients (p < 0.05). CONCLUSION LLD patients are more commonly women than men and more commonly used SSRIs and NaSSAs. Elderly patients with depression often have comorbid generalized anxiety. LLD patients spend most of their visits on medicines, and while the examination costs are lower.
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Implementation of Machine Learning to Predict Cost of Care Associated with Ambulatory Single-Level Lumbar Decompression. World Neurosurg 2022; 167:e1072-e1079. [PMID: 36089278 DOI: 10.1016/j.wneu.2022.08.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the emergence of the concept of value-based care, efficient resource allocation has become an increasingly prominent factor in surgical decision-making. Validated machine learning (ML) models for cost prediction in outpatient spine surgery are limited. As such, we developed and internally validated a supervised ML algorithm to reliably identify cost drivers associated with ambulatory single-level lumbar decompression surgery. METHODS A retrospective review of the New York State Ambulatory Surgical Database was performed to identify patients who underwent single-level lumbar decompression from 2014 to 2015. Patients with a length of stay of >0 were excluded. Using pre- and intraoperative parameters (features) derived from the New York State Ambulatory Surgical Database, an optimal supervised ML model was ultimately developed and internally validated after 5 candidate models were rigorously tested, trained, and compared for predictive performance related to total charges. The best performing model was then evaluated by testing its performance on identifying relationships between features of interest and cost prediction. Finally, the best performing algorithm was entered into an open-access web application. RESULTS A total of 8402 patients were included. The gradient-boosted ensemble model demonstrated the best performance assessed via internal validation. Major cost drivers included anesthesia type, operating room time, race, patient income and insurance status, community type, worker's compensation status, and comorbidity index. CONCLUSIONS The gradient-boosted ensemble model predicted total charges and associated cost drivers associated with ambulatory single-level lumbar decompression using a large, statewide database with excellent performance. External validation of this algorithm in future studies may guide practical application of this clinical tool.
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Novel portable apparatus for outpatient high-dose-rate (HDR) brachytherapy in penile cancer. Brachytherapy 2022; 21:839-847. [PMID: 35915039 DOI: 10.1016/j.brachy.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Penile squamous cell carcinoma (PSC) is traditionally treated with surgical resection with significant morbidity. Penile sparing approaches, such as brachytherapy, require expertise, prolonged inpatient stays, poor patient convenience, and heterogenous plans with variable long-term toxicity. In this study, we describe the protocol for novel portable apparatus created for PSC, allowing outpatient hybrid interstitial/surface brachytherapy, improving homogeneity and patient convenience. METHODS A portable brachytherapy apparatus was developed utilizing a foley catheter, prostate template, 6F interstitial catheters, 5 mm bolus, and a jock strap. The apparatus allowed for internal and external catheter placement housed in a jock strap to allow mobility and defecation without affecting the implant. High-dose-rate brachytherapy was performed as an outpatient. RESULTS The apparatus was then used on a 62-year-old male with cT2pN0M0 (stage IIA) PSC with bilateral glans and urethral meatus involvement, who elected for definitive brachytherapy (4000cGy in 10 fractions over 5-days). Given external dwell positions, heterogeneity correction of the template was calculated (AAPM TG186) with <2% variation. Patient had minimal impact on his active lifestyle during treatment and had complete clinical response at 3-months. Grade 2 skin desquamation resolved at 2-months, with no necrosis. At 6-months, he was able to resume sexual intercourse, and at 12-months, he remained disease-free with sexual and urinary function intact. CONCLUSIONS Novel portable implant allows for improved patient convenience, reduced inpatient stay, capable of optimizing dosimetry with hybrid brachytherapy. This outpatient treatment allows the opportunity to increase fractionation, offering high local-control and lower toxicity. Future studies utilizing this apparatus for more fractionated regimens with further lower dose-per-fraction (∼3 Gy/fraction) is recommended.
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Impact of Ambulatory Setting for Workers' Compensation Patients Undergoing One-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion and Review of the Literature. World Neurosurg 2022; 167:e251-e267. [PMID: 35948231 DOI: 10.1016/j.wneu.2022.07.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To compare perioperative characteristics and patient-reported outcome measures (PROMs) in workers' compensation (WC) patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in either the inpatient/outpatient setting. METHODS Patients with WC undergoing 1-level MIS-TLIF were included. Patients were separated into inpatient/outpatient groups and demographically propensity score matched. PROMs included visual analog scale (VAS) back/VAS leg/Oswestry Disability Index (ODI)/12-item Short Form Physical Composite Score (SF-12 PCS)/Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) preoperatively and 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Results were compared preoperatively and postoperatively and between cohorts. Minimum clinically important difference (MCID) achievement was determined through comparison with values established in the literature. RESULTS A total of 216 patients were included (184 inpatient). The inpatient cohort (IC) showed worse perioperative outcomes in multiple measures (P < 0.034; all). The IC improved in all PROMs (P < 0.038; all), besides ODI at 6 weeks, SF-12 PCS at 6 weeks/6 months/1 year, and PROMIS-PF at 6 weeks. The outpatient cohort (OC) improved in VAS back at all time points and VAS leg at 6 months (P < 0.033; all). Between cohorts, the OC showed better scores with VAS leg/ODI/SF-12 PCS/PROMIS-PF at multiple time points (P < 0.031; all). Most of the IC achieved MCID, aside from ODI, whereas the OC achieved MCID in SF-12 PCS. MCID achievement between cohorts was higher in the IC at PROMIS-PF at 1 year and VAS back overall (P < 0.034; all). CONCLUSIONS Despite more comorbidities and worse perioperative measures, the IC showed improved PROMs from preoperative to ≥1 follow-up visit, whereas the OC had improvement with only VAS back and leg. The IC showed multiple MCID achievements, whereas the OC showed MCID in only SF-12 PCS. These findings may help guide a surgeon's decision making between inpatient/outpatient lumbar surgery in the WC population.
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Count data models for outpatient health services utilisation. BMC Med Res Methodol 2022; 22:261. [PMID: 36199028 PMCID: PMC9533534 DOI: 10.1186/s12874-022-01733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/15/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Count data from the national survey captures healthcare utilisation within a specific reference period, resulting in excess zeros and skewed positive tails. Often, it is modelled using count data models. This study aims to identify the best-fitting model for outpatient healthcare utilisation using data from the Malaysian National Health and Morbidity Survey 2019 (NHMS 2019) and utilisation factors among adults in Malaysia. METHODS The frequency of outpatient visits is the dependent variable, and instrumental variable selection is based on Andersen's model. Six different models were used: ordinary least squares (OLS), Poisson regression, negative binomial regression (NB), inflated models: zero-inflated Poisson, marginalized-zero-inflated negative binomial (MZINB), and hurdle model. Identification of the best-fitting model was based on model selection criteria, goodness-of-fit and statistical test of the factors associated with outpatient visits. RESULTS The frequency of zero was 90%. Of the sample, 8.35% of adults utilized healthcare services only once, and 1.04% utilized them twice. The mean-variance value varied between 0.14 and 0.39. Across six models, the zero-inflated model (ZIM) possesses the smallest log-likelihood, Akaike information criterion, Bayesian information criterion, and a positive Vuong corrected value. Fourteen instrumental variables, five predisposing factors, six enablers, and three need factors were identified. Data overdispersion is characterized by excess zeros, a large mean to variance value, and skewed positive tails. We assumed frequency and true zeros throughout the study reference period. ZIM is the best-fitting model based on the model selection criteria, smallest Root Mean Square Error (RMSE) and higher R2. Both Vuong corrected and uncorrected values with different Stata commands yielded positive values with small differences. CONCLUSION State as a place of residence, ethnicity, household income quintile, and health needs were significantly associated with healthcare utilisation. Our findings suggest using ZIM over traditional OLS. This study encourages the use of this count data model as it has a better fit, is easy to interpret, and has appropriate assumptions based on the survey methodology.
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Effects of Empagliflozin on Diuretics Reduction in Outpatient Heart Failure Patients. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:183-192. [PMID: 36381017 PMCID: PMC9634028 DOI: 10.36628/ijhf.2022.0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Inhibitors of sodium-glucose cotransporter 2 (SGLT2i) reduce the risk of hospitalization for heart failure (HF). We aimed to examine the effect of empagliflozin on change of diuretics dose in outpatient HF patients. METHODS We retrospectively reviewed the medical records of 612 patients who were treated using both empagliflozin and diuretics. We excluded patients who did not meet the criteria for HF. Dose and duration of empagliflozin and diuretics were measured. RESULTS Of 612 patients, a total of 251 was analyzed and followed for a mean 430.0±175.4 days. The mean age was 69.3, 51.8% were female, and 93.2% had type 2 diabetes. The distribution of initial diuretics type when starting empagliflozin showed that furosemide comprised 24.7%, spironolactone 20.7%, thiazide 36.9%, and others. Total 23.1% of patients reduced diuretic dose, 13.1% increased diuretic dose, 41.4% continued at the same diuretic dose, and 22.3% switched to different diuretics. Among patients who were using furosemide, 36.0% reduced diuretics dose. There was a diuretic reduction in 22.6% of HF preserved ejection fraction (HFpEF, left ventricular ejection fraction [LVEF] ≥50%) and in 26.5% of HF reduced EF (HFrEF, LVEF <50%). The average doses furosemide at the start of empagliflozin decreased from 16.3mg/day to 8.5mg/day at the time of follow-up. CONCLUSIONS Among outpatient clinic HF patients treated with both diuretics and empagliflozin, 23.1% of patients had their diuretics reduced, and the mean dose of furosemide was reduced by about half. This suggests that empagliflozin has clinical advantages in managing outpatient HF patients.
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Does Preoperative Symptom Duration Impact Clinical Outcomes After Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting? World Neurosurg 2022; 166:e599-e606. [PMID: 35863643 DOI: 10.1016/j.wneu.2022.07.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of prolonged symptom duration in patients undergoing ambulatory MIS-TLIF on postoperative clinical outcomes has not been well studied. We aim to compare symptom duration of pain and/or weakness on postoperative outcomes in patients undergoing outpatient MIS-TLIF. METHODS Patients undergoing outpatient MIS-TLIF were gathered in a single-surgeon database. Exclusion criteria were patients missing onset of symptoms, date of surgery, or diagnosis of malignancy, trauma, or infection. Patients were grouped by symptoms <1 year or symptoms ≥1 year. Propensity score matching for demographics was utilized. Minimal clinically important difference (MCID) achievement was calculated by comparing change in patient-reported outcome measures (PROMs) to previously established values. Inferential statistics for demographics, perioperative characteristics, PROMs, and MCID were utilized to compare between groups and/or postoperative improvement. RESULTS After matching, there were a total of 56 patients, with 30 patients with symptoms <1-year. The <1-year cohort reported significant improvement in all time points in VAS back/leg and 12-week/6-months in ODI. The ≥1-year cohort demonstrated significant improvement in 6-month Patient-Reported Outcomes Measurement-Information System Physical Function, 6-week to 1-year VAS back, 6-week VAS leg, and 6-month ODI. The <1-year cohort had higher MCID attainment rates in 1-year VAS back/leg. CONCLUSIONS Independent of symptom duration, patients reported significant improvement in back pain at all postoperative periods. Patients presenting with shorter symptom duration consistently reported significant improvement in leg pain postoperatively. Patients with shorter symptom duration demonstrated greater MCID achievement in back and leg pain. Patients indicated for outpatient MIS-TLIF may benefit more from earlier intervention following onset of symptoms.
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Use of antibiotics in pyogenic flexor tenosynovitis. HAND SURGERY & REHABILITATION 2022; 41:624-630. [PMID: 35933026 DOI: 10.1016/j.hansur.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
Pyogenic flexor tenosynovitis is a frequent and serious condition. However, there is no consensus on the use of antibiotics. The objective of our study was to describe the treatment of this condition and to identify the surgical and medical management parameters to propose an effective and consensual postoperative antibiotic therapy protocol. We retrospectively reviewed pyogenic flexor tenosynovitis of the thumb or fingers treated between 01/01/2013 and 01/01/2018 at a teaching hospital. Inclusion criteria were confirmation of the clinical diagnosis intraoperatively and a minimum post-antibiotic follow-up of 6 months. Comorbidities, type of surgery, antibiotic therapy parameters, and treatment outcome were assessed. One hundred and thirteen patients were included. Fifty-four percent had comorbidities. The most frequent germ was staphylococcus, all patients received postoperative antibiotic therapy. Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment (p = 0.46). The duration of postoperative antibiotic therapy (less than 7 days, between 7 and 14 days or more than 14 days) did not lead to any difference in healing rate (p = 0.67). However, treating for less than 7 days versus 7-14 days seemed to be associated with a higher risk of failure, although not statistically significant. Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7-14 days appears to be effective, allowing for outpatient management.
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Hip Arthroplasty, a mature surgical technique with room for improvement. Orthop Traumatol Surg Res 2022; 108:103379. [PMID: 35905900 DOI: 10.1016/j.otsr.2022.103379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023]
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A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty. Shoulder Elbow 2022; 14:523-533. [PMID: 36199506 PMCID: PMC9527489 DOI: 10.1177/17585732211007443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. The aim of this study was to investigate literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty. METHODS We conducted a systematic review of Medline, Embase and Cochrane Library databases from inception to 6 April 2020. Methodological quality was assessed using MINORS and GRADE criteria. RESULTS We included 17 studies, with 11 included in meta-analyses and 6 in narrative review. A meta-analysis of hospital readmissions demonstrated no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, p = 0.49). Pooled post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70, p = 0.02). Considerable cost saving of between $3614 and $53,202 (19.7-69.9%) per patient were present in the outpatient setting. Overall study quality was low and presented a serious risk of bias. DISCUSSION Shoulder arthroplasty in the outpatient setting appears to be as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. However, this is based on low quality evidence and high risk of bias suggests further research is needed to substantiate these findings.
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Symptomatology and imaging findings in early post-Covid period: A comparative study in older vs younger patients. Exp Gerontol 2022; 167:111907. [PMID: 35940388 PMCID: PMC9355744 DOI: 10.1016/j.exger.2022.111907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND While there are substantial reports on the acute phase of Covid-19, the data on post-Covid phase are limited. AIM To report the data on older post-Covid patients comparatively with the young adults. STUDY DESIGN Retrospective, single-center study in post-Covid outpatient clinic. Clinical characteristics, laboratory examination, chest imagings were examined. RESULTS 665 patients were included (median age, 46; 53 %, male; 10.5 %, aged ≥65). We assessed patients at 47th day (median) after recovery. 43.6 % were suffering from one or more ongoing symptomatology. The prevalence of symptoms or physical examination findings were not different between older and younger groups. Most prevalent ongoing symptom was dyspnea (14.3 % and 11.8 % older and younger group, respectively). Most common laboratory abnormality was high pro-BNP (12.2 %, in both age groups). Despite there was no differences regarding imaging findings at acute-phase, there were higher rates of control imaging abnormalities in older subgroup (35.7 % vs 19.4 %; p = 0.006). On admission 28.4 % younger patients had normal imaging, of whom 12.4 % developed some form of sequela; however, in older group, 40.0 % had normal imaging, of whom 25.0 % developed sequela. CONCLUSION Complaints related to Covid-19 persisted in about half of the patients at about 1.5 months after Covid. More than 1/3 older post-Covid patients displayed pulmonary sequela in the post-acute period which was more prevalent than those in younger adults. Hence, compared to the younger counterparts, the clinicians should be alert in follow-up of older adults for subsequent pulmonary sequela, even among those that had normal imaging finding on initial presentation.
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Improved clinical outcomes of outpatient enhanced recovery hip and knee replacements in comparison to standard inpatient procedures: A study of patients who experienced both. Orthop Traumatol Surg Res 2022; 108:103236. [PMID: 35150928 DOI: 10.1016/j.otsr.2022.103236] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/02/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. This study's main objective was to evaluate adverse events with an ERAS-outpatient compared to standard-inpatient care and secondary objectives were to compare pain, functional recovery, PROMs and satisfaction. HYPOTHESIS The ERAS-outpatient program would result in reduced adverse events compared to standard-inpatient care. METHODS An ambidirectional single subject cohort study was conducted on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). Adverse event rate according to the Clavien-Dindo scale, the Comprehensive Complications Index (CCI) and the number of unplanned episodes of care were assessed. Postoperative pain on a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient reported outcome measures (PROMs) (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs. 4.4, p<0.001), CCI was significantly lower (12.3 vs. 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs. 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p>0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p<0.002). CONCLUSION Compared to the conventional inpatient care, the ERAS-outpatient program proved to be safer, enable faster functional recovery, and improve patients' satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program. LEVEL OF EVIDENCE III; Ambidirectional Cohort study.
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Cross-sectional Census Survey of Patients With Cancer who Received a Pharmacist Consultation in a Pharmacist Led Anti-cancer Clinic. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1553-1561. [PMID: 35867307 PMCID: PMC9305046 DOI: 10.1007/s13187-022-02196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
Pharmacists have a critical consulting role in patients undergoing oral antineoplastic drug therapy to ensure harm minimisation. Studies exploring the benefits of pharmacists in this role are limited. This study evaluated patient perceptions, experiences and overall satisfaction with clinical pharmacist consultations in patients treated with oral antineoplastic drugs. Data on 160 patients initiated on oral antineoplastic drugs between January 2019 and February 2021 were collected retrospectively from an outpatient Comprehensive Cancer Centre of a quaternary hospital in Western Australia (demographics, cancer type, oral antineoplastic drugs prescribed). In addition, patients were mailed a hard copy questionnaire in March 2021 to assess their satisfaction with pharmacist consultations in the pharmacist clinic, using a 5-point Likert scale. The statements included perceptions of the patient's understanding, medication adherence, experiences and overall satisfaction with the clinical pharmacist consultation. There were 76 (47.5%) completed questionnaires returned (52.6% female; average age was 63.2 ± 13.9 years). The majority of patients were satisfied with the service offered by the clinical pharmacist (73/76; 96.1%), perceived that clinical pharmacists provided an important service in outpatient cancer care (71/76; 93.4%) and improved their understanding of the use of oral antineoplastic drugs and side-effect management (48/74; 64.9%). Patients' perceived understanding of their medication regimen and additional health services available improved after pharmacist counselling. The patients also reported overall satisfaction with the service provided by the clinical pharmacist and found it beneficial to their care. The study supports the expanding role of the clinical pharmacist in an outpatient cancer centre.
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Fighting the obesity pandemic during the COVID-19 pandemic. Surg Endosc 2022:10.1007/s00464-022-09628-6. [PMID: 36163563 PMCID: PMC9512967 DOI: 10.1007/s00464-022-09628-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/11/2022] [Indexed: 01/22/2023]
Abstract
Background The COVID-19 pandemic created delays in surgical care. The population with obesity has a high risk of death from COVID-19. Prior literature shows the most effective way to combat obesity is by weight loss surgery. At different times throughout the COVID-19 pandemic, elective inpatient surgeries have been halted due to bed availability. Recognizing that major complications following bariatric surgery are extremely low (bleeding 0–4%, anastomotic leaks 0.8%), we felt outpatient bariatric surgery would be safe for low-risk patients. Complications such as DVT, PE, infection, and anastomotic leaks typically present after 7 days postoperatively, well outside the usual length of stay. Bleeding events, severe postoperative nausea, and dehydration typically occur in the first few days postoperatively. We designed a pathway focused on detecting and preventing these early post-op complications to allow safe outpatient bariatric surgery. Methods We used a preoperative evaluation tool to risk stratify bariatric patients. During a 16-month period, 89 patients were identified as low risk for outpatient surgery. We designed a postoperative protocol that included IV hydration and PO intake goals to meet a safe discharge. We sent patients home with a pulse oximeter and had them self-monitor their pulse and oxygen saturation. We called all patients at 10 pm for a postoperative assessment and report of their vitals. Patients returned to clinic the following day and were seen by a provider, received IV hydration, and labs were drawn. RESULTS: 80 of 89 patients (89.8%) were successfully discharged on POD 0. 3 patients were readmitted within 30 days. We had zero deaths in our study cohort and no morbidity that would have been prevented with postoperative admission. Conclusion We demonstrate that by identifying low-risk patients for outpatient bariatric surgery and by implementing remote monitoring of vitals early outpatient follow-up, we were able to safely perform outpatient bariatric surgery. Graphical abstract ![]()
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Can ED chest pain patients with intermediate HEART scores be managed as outpatients? CAN J EMERG MED 2022; 24:770-779. [PMID: 36129627 DOI: 10.1007/s43678-022-00355-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics. METHODS This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score. RESULTS There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8). CONCLUSION This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.
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Gender differences in psychiatric outpatients: a before and during COVID-19 pandemic study in general hospitals from China. Ann Gen Psychiatry 2022; 21:35. [PMID: 36071451 PMCID: PMC9450837 DOI: 10.1186/s12991-022-00412-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 08/30/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Little is known about the gender characteristics and the Corona Virus Disease 2019 (COVID-19) impact on psychiatric department outpatients in general hospitals in China. METHODS We retrospectively collected 225,947 outpatient clinic records before and during COVID-19 pandemic from January 1, 2019 to December 31, 2020 in the psychiatric clinic of 3 general hospitals, gender composition of patients was analyzed in different five age groups and nine diagnostic categories at three levels: total patient visits, number of patients and number of first-visit patients. RESULTS The total male-to-female ratio of psychiatric outpatient records in 3 general hospitals from 2019 to 2020 was 1:1.69. Women were more common in all age groups. Overall, the proportion of women was further increased in 2020 compared to that in 2019, especially in age group below 34 years and anxiety disorders category. Most mental disorders showed higher demands for females than that for males except mental and behavioral disorders due to psychoactive substance use with the male-to-female ratio was 1:0.05. CONCLUSIONS The demand for female psychiatric outpatient services is obviously higher than that for males. It is necessary to pay more attention to explore targeted mechanism or psychosocial service strategy for female patients with mental disorders. Trial registration ChiCTR2100044894, March 31, 2021 retrospectively registered.
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Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021. Am J Med 2022; 135:1069-1074. [PMID: 35367181 DOI: 10.1016/j.amjmed.2022.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.
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Impact evaluation of subsidized health insurance programs on utilization of healthcare facilities: evidence from Indonesia. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:315-331. [PMID: 35028789 DOI: 10.1007/s10754-021-09321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/06/2021] [Indexed: 06/14/2023]
Abstract
Despite subsidized health insurance has long been proclaimed by many countries including Indonesia, the variety of evaluation results showing that the optimization of benefits obtained by recipients is still questionable. The objective of this study is to analyze the impact of subsidized health insurance programs (ASKESKIN and JAMKESMAS) on the utilization of healthcare facilities in Indonesia. Data from two waves longitudinal data, the Indonesian Family Life Survey (IFLS), were analyzed using the propensity score matching method. This study found that in general, ASKESKIN and JAMKESMAS had very small impacts on the utility of healthcare facilities measured by outpatient and inpatient visits by program's beneficiaries. It implies that being subsidized health insurance holders does not necessarily encourage them to visit formal healthcare facilities. In addition, the comparison of average treatment effect on the treated (ATT) between ASKESKIN and JAMKESMAS also did not show any significant improvement even though the program had tried to be improved. The results of this study provide the basis for advising policy makers that there needs to revisit the effectiveness of subsidized health insurance program implementation.
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[Direct admission of patients to doctors' offices by prehospital emergency services-an effective method to relieve emergency departments? : Analysis of routine pre- and in-hospital emergency data]. Med Klin Intensivmed Notfmed 2022; 117:447-456. [PMID: 34468771 PMCID: PMC8408819 DOI: 10.1007/s00063-021-00860-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/17/2021] [Accepted: 07/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the 2018 advisory opinion concerning the realignment of healthcare, it is advocated that in order to relieve pressure on emergency departments (ED) prehospital medical emergency services should be given the option to directly transport suitable patients to doctors' offices. OBJECTIVES To determine the prevalence of patients treated by prehospital emergency services that have the potential to be directly allocated to a primary care provider. MATERIALS AND METHODS Preclinical and clinical data of adult patients who in a 2-month period were transported to the ED of a university hospital by an ambulance were evaluated. To determine a safe and meaningful transport directly to a doctor's office, a stepwise assessment was carried out: patients were categorized on the basis of the prehospital assessment of urgency as "urgent" (contact to doctor necessary within a maximum time of 30 min) and "less urgent" (contact to doctor not necessary within 30 min, maximum 120 min). "Less urgent" patients were further divided and those treated as outpatients were identified. This group was further restricted to cases whose administrative reception in the ED was documented Monday-Friday between 8 am and 7 pm. In addition, these cases were further differentiated with regard to medical content and compared with the triage results in the ED (Manchester Triage, MTS). RESULTS In all, 1260 patients were brought to the ED by ambulance within the study period (total number of patients treated in this time period n = 11,506); 894 cases had a documented prehospital level of urgency and could therefore be included. Of these n = 477 (53.4%) were categorized as "less urgent"; 317 (66.5%) of these "less urgent" cases were treated as outpatients in the ED, and n = 114 (23.9%) in a time frame potentially suitable for direct transport to doctors' offices, which is 1% of all patients treated in the ED in the time period examined. However, 70 of the cases suitable for doctors' office (63.6% of n = 110 with documented MTS) were rated more urgent in the ED. With regards to prehospital complaints and documented diagnosis we assume employment of a relevant amount of resources in the treatment of these cases. CONCLUSIONS EDs could be relieved from every tenth patient brought in by prehospital emergency services (1% of all patients treated) during normal offices hours by direct allocation to doctors' offices. Regarding patient's safety this process however has to be seen critically as > 60% of these cases were potentially undertriaged. Necessary resources for diagnostics and treatment have to be available in the doctors' offices and known to prehospital emergency services. Primary assignment of patients to doctors' offices by prehospital emergency can only relieve urban EDs to a negligible extent, is potentially dangerous and linked to a tremendous logistic effort.
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Medical economic study of outpatient versus inpatient surgical management of distal radius fractures. Orthop Traumatol Surg Res 2022; 108:103333. [PMID: 35605934 DOI: 10.1016/j.otsr.2022.103333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/17/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION France aims to have more than 70% of its surgical procedures performed in an outpatient setting by 2022. HYPOTHESIS The primary hypothesis of this study was that outpatient management of distal radius fractures with volar plating was more cost-effective than inpatient hospitalization. The secondary hypothesis was that more than 70% of these cases could be managed in an outpatient setting. MATERIALS AND METHODS The series included 255 fractures that were operated on between February 2015 and February 2016. These were reviewed using 4 patient-specific criteria (age, ASA score, eligibility for an outpatient procedure, and anticoagulant therapy) and 4 injury-specific criteria (AO classification, open wound, nerve involvement, and other locations). Our outpatient rate was compared to the national rate and the net income was calculated according to the length of stay. RESULTS Our series reported an outpatient rate of 77.25% with a mean age of 54years (19/95) and an inpatient rate of 22.75% with a mean age of 74 years (30/94). The national rate in 2018 was 34.8%. While outpatient procedures generated an operating profit of +€191.64, hospitalizations of 1 to 17 nights resulted in an operating loss. The overall economic assessment of the 255 fractures included in our series showed an operating loss of €22,113.78. DISCUSSION Our primary hypothesis was confirmed since the outpatient management of distal radius fractures was more cost-effective than inpatient hospitalization. The secondary hypothesis was also confirmed since more than 70% of cases in our series were treated in an outpatient setting. CONCLUSION Most distal radius fractures requiring a surgical intervention should be treated in an outpatient setting. LEVEL OF EVIDENCE IV.
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Long-term results of the treatment of adolescents and adults with acute lymphoblastic leukemia with a pediatric-inspired regimen delivered on an outpatient basis: A single institution experience. Leuk Res 2022; 121:106935. [PMID: 36037624 DOI: 10.1016/j.leukres.2022.106935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022]
Abstract
The results of treatment of adolescents and adults with acute lymphoblastic leukemia (ALL) remain unsatisfactory. Pediatric-inspired treatments seem to be related with better outcomes. 126 adolescent and adult patients with ALL were treated in a 37-year period with a pediatric inspired combined chemotherapy (PICC) schedule, delivered on an outpatient basis and based on the St. Jude´s TOTAL XI pediatric protocol employing vincristine, prednisone, asparaginase, daunorubicin, etoposide, cytarabine, methotrexate, mercaptopurine and triple intrathecal therapy. 80 % of patients were able to receive the initial seven-week period of induction / consolidation fully as outpatients and 77 % achieved a complete remission. In adolescents and young adults (AYAs) the median probability of overall survival (OS) was 44 months, whereas the 5-year OS was 48 %. In adults, the median probability of OS was 24 months, and the 5-year OS was 32 %. Patients with T-cell ALL did significantly worse than those with a B cell phenotype (OS at 5 years 17 versus 40 %, respectively). These figures are better than those informed in our country employing more aggressive, in-hospital schedules such as the hyper-CVAD. We found that, in AYAs and adult patients with ALL, the use of an asparaginase-containing PICC delivered on an outpatient basis renders acceptable results, better than those obtained in similar socioeconomic circumstances employing adult-oriented schedules. Additional studies are needed to assess the usefulness of these PICC treatments in adult individuals with ALL treated in underprivileged circumstances, such as those prevailing in LMIC.
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A National Survey of Outpatient Platelet Transfusion Practice. Am J Clin Pathol 2022; 158:687-691. [PMID: 36017577 DOI: 10.1093/ajcp/aqac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/20/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Platelets are a limited resource frequently subject to inventory shortages. It benefits all to transfuse judiciously, according to evidence-based guidelines. Several organizations have published recommendations for platelet transfusions, but none specifically focused on outpatients. The Clinical Hemotherapy subsection of the Association for the Advancement of Blood & Biotherapies (AABB) Transfusion Medicine Subsection Coordinating Committee conducted a survey targeting outpatient transfusions to understand current practice in the United States. METHODS To determine use of platelets in the outpatient setting, a survey was developed, piloted, validated, and distributed by email to 735 AABB members. Frequencies were calculated and free-text comments categorized. RESULTS A total of 317 responses were received (43% response rate) from 44 states. Half the respondents' institutions have formal outpatient platelet guidelines. Slightly more than half the respondents (51%) with guidelines used a threshold of less than 10,000/µL when transfusing stable, afebrile outpatients, with 29% using less than 20,000/µL. Fewer than half (45%) monitored outpatient platelet use by prospective and retrospective audits, with the next-largest group (25%) using retrospective audits only. CONCLUSIONS Approximately half the respondents had outpatient guidelines, and half used a threshold of less than 10,000/µL when transfusing platelets to stable outpatients. Greater adoption of this threshold and monitoring may improve the nation's platelet inventory.
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The perspectives of oncology healthcare providers on the role of palliative care in a comprehensive cancer center. Palliat Care 2022; 21:148. [PMID: 35999560 PMCID: PMC9400235 DOI: 10.1186/s12904-022-01039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Palliative care (PC) is an essential part of oncologic care, but its optimal role within a cancer center remains unclear. This study examines oncology healthcare providers' perspectives about the role of PC at a comprehensive cancer center (CCC). METHODS Physicians, nurses, and other oncology healthcare providers at a CCC were surveyed for their opinions about the role of inpatient and outpatient PC, preferences for PC services, and barriers to referral. Chi-squared tests and multiple regression analyses were performed to explore associations. RESULTS We received 137/221 completed questionnaires (61% response rate). Respondents were generally female (78%), had ≤ 10 years of service (69%), and included physicians (32%), nurses (32%), and advanced practice providers (17%). Most respondents (82%) agreed that more patients could benefit from PC. They also agreed that PC is beneficial for both outpatient and inpatient management of complex pain (96 and 88%), complex symptoms (84 and 74%), and advanced cancer patients (80 and 64%). Transition to hospice (64 vs. 42%, p = 0.007) and goals of care (62 vs. 49%, p = 0.011) provided by PC services were more valued by respondents for the inpatient than for the outpatient setting. Barriers to utilizing PC included lack of availability, unsure of when to refer, and poor communication. The majority of respondents (83%) preferred a cancer focused PC team to provide high-quality care. CONCLUSIONS Overall, the majority of oncology health care providers believe that more patients could benefit from PC, but opinions vary regarding the roles of inpatient and outpatient PC. Barriers and areas for improvement include availability, referral process, and improved communication.
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Outcomes of Tisagenlecleucel in Lymphoma Patients With Predominant Management in an Ambulatory Setting. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e730-e737. [PMID: 35595619 PMCID: PMC10965010 DOI: 10.1016/j.clml.2022.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/18/2022] [Accepted: 04/03/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Chimeric antigen receptor T-cell therapy (CAR T) is a revolutionary adoptive immunotherapy approach in lymphoma; however, substantial resources are necessary for administration and care of these patients. Our institution has administered tisagenlecleucel primarily in an outpatient setting, and here we report our clinical outcomes. PATIENTS AND METHODS We conducted a single institution, retrospective study investigating outcomes of adult lymphoma patients treated with commercial tisagenlecleucel between 10/2017 and 12/2020. We analyzed patient characteristics and outcomes of efficacy and safety including overall response rate, progression-free survival, overall survival and cytokine-release syndrome, neurotoxicity, and hospitalizations. RESULTS Seventy-two patients with relapsed or refractory non-Hodgkin lymphoma (NHL) who received commercial tisagenlecleucel were identified; 68 (94.4%) patients received outpatient tisagenlecleucel. The overall response rate was 43% with a complete response observed in 25 patients (34.7%). At a median follow-up of 9.1 months, the median progression-free survival was 3.3 months. Grade 3-4 cytokine release syndrome was not observed in the study group and two patients had grade 3-4 neurotoxicity. Twenty-six patients (36.1%) were admitted within 30 days after infusion with a median length of stay of 5 days. Fourteen patients (19.4%) were admitted within 72 hours of infusion. No patient died of CAR T cell-related toxicity. CONCLUSION Our experience affirms treatment with tisagenlecleucel in the outpatient setting is safe and feasible with close supervision and adequate institutional experience. After infusion, adverse events were manageable and the majority of patients did not require hospitalization.
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Clinical features of patients who visited the outpatient clinic for long COVID in Japan. eNeurologicalSci 2022; 28:100418. [PMID: 35919910 PMCID: PMC9335519 DOI: 10.1016/j.ensci.2022.100418] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background The clinical course, comorbidity, and management of symptoms after the acute phase of coronavirus disease 2019 (COVID-19) remain controversial. Methods This was a descriptive case series study, examining the characteristics of patients with longstanding symptoms related to COVID-19 who visited our outpatient clinic between 1 June and 31 December 2021. We analyzed patients’ background, chief complaints, clinical course after COVID-19 onset, and clinical examination results. Results A total of 90 patients with a mean age of 39.8 years were confirmed as having long COVID. The median time between diagnosis of COVID-19 and visiting our clinic was 66.8 days, and 89 patients (98.9%) were unvaccinated. Depression was the most common comorbidity (nine patients, 10.0%). The most common chief complaint was disturbance of smell and/or taste (35, 38.9%), followed by memory disturbance (22, 24.4%) and fatigue (29, 31.1%). Head MRI was performed for 42 (46.7%) patients, and the most common finding was sinusitis (four patients). Olfactory testing was conducted in 25 patients (27.8%) using a T&T olfactometer, and 14 patients (56%) had mild olfactory impairment. Of the five odors in the T&T, recognition of β-phenylethyl alcohol was most impaired. Conclusions This study describes the basic characteristics of long COVID in Japan. It suggests that long COVID is complex because it results in a wide range of symptoms. Overall, 90 patients with long COVID were confirmed and examined by neurologists. Disturbance of smell and/or taste was the most common complaint. Olfactory tests showed different disturbance of the five main odors. Only one patient with long COVID had been vaccinated against COVID-19. Cross-disciplinary approaches are needed for treating patients with long COVID.
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Developing a Structural Intervention for Outpatient Mental Health Care: Mapping Vulnerability and Privilege. Am J Psychother 2022; 75:134-140. [PMID: 35903912 DOI: 10.1176/appi.psychotherapy.20200057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Mapping Vulnerability and Privilege (MVP) exercise is a clinical intervention based on a structural competency framework that emphasizes societal structures-social determinants of health and of biology, behavior, and culture-and their impact on health outcomes. The exercise comprises the MVP Tool, Visual Guide, and Processing Guide. It was created with the goals of helping clinicians to develop structural humility and introducing a structural lens for viewing the therapeutic milieu and the structural barriers that affect both intrapsychic experiences and interactions with the health care system, while encouraging patients and clinicians to take action to address the systemic and structural issues that affect patients' well-being. This article provides an overview of the development of the MVP exercise as an educational and clinical intervention.
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Potential of outpatient steroid therapy in elderly patients with early COVID-19. Aging Clin Exp Res 2022; 34:2585-2590. [PMID: 35781679 PMCID: PMC9252560 DOI: 10.1007/s40520-022-02181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
Corticosteroids lower mortality in hospitalized patients with COVID-19 pneumonia requiring oxygen support. In this observational retrospective study (September 2020–June 2021), we explored the association between receiving home corticosteroids without oxygen supply and 30-day mortality in hospitalized patients with COVID-19 pneumonia. Among a total of 794 COVID-19 pneumonia patients, 763 were included into the study (males 68%; mean age 65 ±12 years), of whom 197 (26%) received home corticosteroids (mean daily prednisone equivalent-dose 40 mg ± 12 mg; range 10–50 mg; median 50 mg; IQR 25–50 mg; for 4 days). The overall 30-day mortality of the study population was 12%. The risk of death—adjusted for age, comorbidities, administration of remdesivir and respiratory failure severity—was lower (HR 0.405; p = 0.024) in patients receiving home corticosteroids. After stratifying the study population by age categories, home corticosteroids were associated with an adjusted decrease in mortality risk in patients > 77 years (HR 0.346; p = 0.040). Home corticosteroids may lower the 30-day mortality in elderly COVID-19 patients.
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Feasibility of Closed-Loop Insulin Delivery with a Pregnancy-Specific Zone Model Predictive Control Algorithm. Diabetes Technol Ther 2022; 24:471-480. [PMID: 35230138 PMCID: PMC9464083 DOI: 10.1089/dia.2021.0521] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: Evaluating the feasibility of closed-loop insulin delivery with a zone model predictive control (zone-MPC) algorithm designed for pregnancy complicated by type 1 diabetes (T1D). Research Design and Methods: Pregnant women with T1D from 14 to 32 weeks gestation already using continuous glucose monitor (CGM) augmented pump therapy were enrolled in a 2-day multicenter supervised outpatient study evaluating pregnancy-specific zone-MPC based closed-loop control (CLC) with the interoperable artificial pancreas system (iAPS) running on an unlocked smartphone. Meals and activities were unrestricted. The primary outcome was the CGM percentage of time between 63 and 140 mg/dL compared with participants' 1-week run-in period. Early (2-h) postprandial glucose control was also evaluated. Results: Eleven participants completed the study (age: 30.6 ± 4.1 years; gestational age: 20.7 ± 3.5 weeks; weight: 76.5 ± 15.3 kg; hemoglobin A1c: 5.6% ± 0.5% at enrollment). No serious adverse events occurred. Compared with the 1-week run-in, there was an increased percentage of time in 63-140 mg/dL during supervised CLC (CLC: 81.5%, run-in: 64%, P = 0.007) with less time >140 mg/dL (CLC: 16.5%, run-in: 30.8%, P = 0.029) and time <63 mg/dL (CLC: 2.0%, run-in:5.2%, P = 0.039). There was also less time <54 mg/dL (CLC: 0.7%, run-in:1.6%, P = 0.030) and >180 mg/dL (CLC: 4.9%, run-in: 13.1%, P = 0.032). Overnight glucose control was comparable, except for less time >250 mg/dL (CLC: 0%, run-in:3.9%, P = 0.030) and lower glucose standard deviation (CLC: 23.8 mg/dL, run-in:42.8 mg/dL, P = 0.007) during CLC. Conclusion: In this pilot study, use of the pregnancy-specific zone-MPC was feasible in pregnant women with T1D. Although the duration of our study was short and the number of participants was small, our findings add to the limited data available on the use of CLC systems during pregnancy (NCT04492566).
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Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study. PATIENT EDUCATION AND COUNSELING 2022; 105:2531-2536. [PMID: 35123835 DOI: 10.1016/j.pec.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/17/2021] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy. METHODS A qualitative study using semi-structured interviews. RESULTS 23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations. CONCLUSIONS Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration. PRACTICE IMPLICATIONS Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.
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Outpatient management of uncomplicated enteric fever: A case series of 93 patients from the Hospital of Tropical Diseases, London. J Infect 2022; 85:397-404. [PMID: 35781016 DOI: 10.1016/j.jinf.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/04/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Enteric fever is predominantly managed as an outpatient condition in endemic settings but there is little evidence to support this approach in non-endemic settings. This study aims to review the outcomes of outpatients treated for enteric fever at the Hospital of Tropical Diseases in London, UK. METHODS We conducted a retrospective analysis of all patients with confirmed enteric fever between August 2009 and September 2020. Demographic, clinical, laboratory and microbiological data were collected and compared between the inpatient and outpatient populations. Outcomes investigated were complicated enteric fever, treatment failure and relapse. RESULTS Overall, 93 patients (59% male, median age 31) were identified with blood and/or stool culture confirmed enteric fever and 49 (53%) of these were managed as outpatients. The commonest empirical treatment for outpatients was azithromycin (70%) and for inpatients was ceftriaxone (84%). Outpatients were more likely than inpatients to receive only one antibiotic (57% vs 19%, p < 0.01) and receive a shorter duration of antibiotics (median 7 vs 11 days, p <0.01). There were no cases of complicated disease or relapse in either the inpatient or outpatient groups. There was one treatment failure in the outpatient group. Azithromycin was well-tolerated with no reported side effects. CONCLUSIONS Our findings suggest that outpatient management of uncomplicated imported enteric fever is safe and effective with the use of oral azithromycin. Careful monitoring of patients is recommended as treatment failure can occur.
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