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Bojoga A, Balasubramanian SP, Mihai R. Surgery for phaeochromocytomas and paragangliomas: Current practice in the United Kingdom. Ann R Coll Surg Engl 2024. [PMID: 38362758 DOI: 10.1308/rcsann.2023.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION There is wide variability in the perioperative management of phaeochromocytoma and paraganglioma (PPGL) in different centres. This study aimed to summarise the management of PPGLs as reported in the United Kingdom Registry for Endocrine and Thyroid Surgery (UKRETS) database and to determine current perioperative management of PPGLs by surveying UK clinicians. METHODS Data recorded on UKRETS from 2005 to 2021 were subjected to descriptive analyses. British Association of Endocrine and Thyroid Surgeons members were invited to participate in an open survey relating to the perioperative management of patients with PPGLs. RESULTS A total of 2,007 operations for PPGL from 49 participating centres were included. The median annual workload in each centre was four cases. Operations were performed predominantly laparoscopically (69%). The median length of stay (4 days) was the same in groups of surgeons stratified by volume. The survey had 29 respondents from 22 centres across the UK, and a formal protocol for perioperative management exists in 48% of the centres. Phenoxybenzamine (72%) was preferred for alpha-blockade. The practice of admitting patients for optimisation from 1 to 7 days before the day of surgery was common (62%). Central venous pressure and blood glucose monitoring were mentioned as routine intraoperative adjuncts by 72% of the responders. CONCLUSIONS There is significant variation in the workload and perioperative management of PPGLs in the UK. This is potentially detrimental to patient outcomes and a consensus document might be beneficial to harmonise practice across the UK.
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Affiliation(s)
- A Bojoga
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - S P Balasubramanian
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
- University of Sheffield, UK
| | - R Mihai
- Oxford University Hospitals NHS Foundation Trust, UK
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Benevides Santos Paiva M, de Gouvêa Viana L, Melo de Andrade MV. Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre-post study. BMJ Open Qual 2024; 13:e002399. [PMID: 38191217 PMCID: PMC10806560 DOI: 10.1136/bmjoq-2023-002399] [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: 05/07/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND In 2018, the National Health System released the 'Guide to reducing long hospital stays' to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow bundle and Red2Green tool were described as strategies to be implemented in inpatient wards to reduce discharge delays. OBJECTIVE To verify if implementing the SAFER patient flow bundle and Red2Green days tool is associated with LOS reduction in the internal medicine unit (IMU) wards of a university hospital in Brazil. METHODS In this pre post study, we compared the LOS of patients discharged from the IMU wards in 2019, during the implementation of the SAFER bundle and Red2Green tool, to the LOS of patients discharged in the same period in 2018. The Diagnosis-Related Group Brazil algorithm compared groups according to complexity and resource requirements. In-hospital mortality, readmission rates, the number of hospital acquired conditions and the number and causes of inappropriate hospital days were also evaluated. RESULTS Two hundred and eight internal medicine patients were discharged in 2018, and 252 were discharged in 2019. The median hospital LOS was significantly lower during the intervention period (14.2 days (IQR, 8-23) vs 19 days (IQR, 12-32); p<0.001). In-hospital mortality, 30-day mortality, readmission in 30 days and the number of hospital acquired conditions were the same between groups. Of the 3350 patient days analysed, 1482 (44.2%) were classified as green and 1868 (55.8%) as red. The lack of senior review was the most frequent cause of a red day (42.4%). CONCLUSION The SAFER patient flow bundle and Red2Green days tool implementation were associated with a significant decrease in hospital LOS in a university hospital IMU ward. There is a considerable improvement opportunity for hospital LOS reduction by changing the multidisciplinary team's attitude during patient hospitalisation using these strategies.
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Affiliation(s)
| | - Luciana de Gouvêa Viana
- Departamento de Propedeutica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcus Vinícius Melo de Andrade
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital Sirio-Libanes, Sao Paulo, Brazil
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Sarkies M, Francis-Auton E, Long J, Roberts N, Westbrook J, Levesque JF, Watson DE, Hardwick R, Sutherland K, Disher G, Hibbert P, Braithwaite J. Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms. Implement Sci 2023; 18:71. [PMID: 38082301 PMCID: PMC10714549 DOI: 10.1186/s13012-023-01324-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation. METHODS Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff. RESULTS The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy. CONCLUSIONS Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.
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Affiliation(s)
- Mitchell Sarkies
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
- School of Health Sciences, University of Sydney, Sydney, Australia.
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Janet Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Natalie Roberts
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, Australia
- NSW Agency for Clinical Innovation, Sydney, Australia
| | - Diane E Watson
- Bureau of Health Information, St Leonards, NSW, Australia
| | - Rebecca Hardwick
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | | | | | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, SA, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Verga M, Viganò GL, Capuzzo M, Duri C, Ignoti LM, Picozzi P, Cimolin V. The digitization process and the evolution of Clinical Risk Management concept: The role of Clinical Engineering in the operational management of biomedical technologies. Front Public Health 2023; 11:1121243. [PMID: 36817927 PMCID: PMC9932586 DOI: 10.3389/fpubh.2023.1121243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Digital transformation and technological innovation which have influenced several areas of social and productive life in recent years, are now also a tangible and concrete reality in the vast and strategic sector of public healthcare. The progressive introduction of digital technologies and their widespread diffusion in many segments of the population undoubtedly represent a driving force both for the evolution of care delivery methods and for the introduction of new organizational and management methods within clinical structures. Methods The CS Clinical Engineering of the "Spedali Civili Hospital in Brescia" decided to design a path that would lead to the development of a software for the management of biomedical technologies within its competence inside the hospital. The ultimate aim of this path stems from the need of Clinical Engineering Department to have up-to-date, realistic, and systematic control of all biomedical technologies present in the company. "Spedali Civili Hospital in Brescia" is not just one of the most important corporate realities in the city, but it is also the largest hospital in Lombardy and one of the largest in Italy. System development has followed the well-established phases: requirement analysis phase, development phase, release phase and evaluating and updating phase. Results Finally, cooperation between the various figures involved in the multidisciplinary working group led to the development of an innovative management software called "SIC Brescia". Discussion The contribution of the present paper is to illustrate the development of a complex implementation model for the digitization of processes, information relating to biomedical technologies and their management throughout the entire life cycle. The purpose of sharing this path is to highlight the methodologies followed for its realization, the results obtained and possible future developments. This may enable other realities in the healthcare context to undertake the same type of pathway inspired by an accomplished model. Furthermore, future implementation and data collection related to the proposed Key Performance Indicators, as well as the consequent development of new operational management models for biomedical technologies and maintenance processes will be possible. In this way, the Clinical Risk Management concept will also be able to evolve into a more controlled, safe, and efficient system for the patient and the user.
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Affiliation(s)
- Matteo Verga
- ASST Spedali Civili di Brescia - SC Ingegneria Clinica, Brescia, Italy
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Gian Luca Viganò
- ASST Spedali Civili di Brescia - SC Ingegneria Clinica, Brescia, Italy
| | - Martina Capuzzo
- ASST Spedali Civili di Brescia - SC Ingegneria Clinica, Brescia, Italy
| | - Claudia Duri
- ASST Spedali Civili di Brescia - SC Ingegneria Clinica, Brescia, Italy
| | | | - Paola Picozzi
- ASST Spedali Civili di Brescia - SC Ingegneria Clinica, Brescia, Italy
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Veronica Cimolin
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- S. Giuseppe Hospital, Istituto Auxologico Italiano, IRCCS, Piancavallo, Italy
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Katona K, Menting MD, Pisters YM. Assessment of variation in long-term outcomes of integrated care initiatives in Dutch health care. INTERNATIONAL JOURNAL OF CARE COORDINATION 2022. [DOI: 10.1177/20534345221109429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The care for many patients with diabetes mellitus type 2 in the Netherlands, is contracted by a local care group. The healthcare providers, who collectively shape a care group, provide protocolled diabetes care. Differences exist between care groups in terms of their organizational and financial arrangements. These differences may result in variation in outcomes. The aim of this study is to assess whether variation in healthcare costs, diabetes complications and related hospital admissions on the level of care groups exist. Methods A quantitative cohort study was conducted. Patients who used diabetes medication (more than 180 days of defined daily doses per year) for the first time between the years 2014 and 2019 were included. Data were extracted from health insurance claims between 2014 and 2019. Generalized linear mixed models were used to analyse patient variation in healthcare costs (two and six years follow-up), diabetes-related complications and hospital admission days. Intraclass correlation coefficients were calculated to estimate the amount of variation that was attributable to the care groups. Results A large variation in outcome variables was observed between patients and a small variation between care groups. The intraclass correlation coefficient for long-term costs was 0.4%; for short-term costs between 0.1% and 0.3%; for complications 1% and for hospital days 4%. Discussion A large variation between patients with diabetes mellitus type 2 exists in terms of their healthcare costs and complications. In our study, care groups accounted minimally for this variation. A generalized linear mixed model in combination with year cohorts is a tool to study variations in the long-term outcomes of integrated care initiatives.
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Affiliation(s)
- Katalin Katona
- Dutch Healthcare Authority, Utrecht, The Netherlands
Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Malou Dorine Menting
- Dutch Healthcare Authority, Utrecht, The Netherlands
Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ylva Michelle Pisters
- Dutch Healthcare Authority, Utrecht, The Netherlands
Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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One-Year Clinical Outcomes of Minimal-Invasive Dorsal Percutaneous Fixation of Thoracolumbar Spine Fractures. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050606. [PMID: 35630022 PMCID: PMC9144472 DOI: 10.3390/medicina58050606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Introduction: Minimal-invasive instrumentation techniques have become a workhorse in spine surgery and require constant clinical evaluations. We sought to analyze patient-reported outcome measures (PROMs) and clinicopathological characteristics of thoracolumbar fracture stabilizations utilizing a minimal-invasive percutaneous dorsal screw-rod system. Methods: We included all patients with thoracolumbar spine fractures who underwent minimal-invasive percutaneous spine stabilization in our clinics since inception and who have at least 1 year of follow-up data. Clinical characteristics (length of hospital stay (LOS), operation time (OT), and complications), PROMs (preoperative (pre-op), 3-weeks postoperative (post-op), 1-year postoperative: eq5D, COMI, ODI, NRS back pain), and laboratory markers (leucocytes, c-reactive protein (CRP)) were analyzed, finding significant associations between these study variables and PROMs. Results: A total of 68 patients (m: 45.6%; f: 54.4%; mean age: 76.9 ± 13.9) were included. The most common fracture types according to the AO classification were A3 (40.3%) and A4 (40.3%), followed by B2 (7.46%) and B1 (5.97%). The Median American Society of Anesthesiologists (ASA) score was 3 (range: 1−4). Stabilized levels ranged from TH4 to L5 (mean number of targeted levels: 4.25 ± 1.4), with TH10-L2 (12/68) and TH11-L3 (11/68) being the most frequent site of surgery. Mean OT and LOS were 92.2 ± 28.2 min and 14.3 ± 6.9 days, respectively. We observed 9/68 complications (13.2%), mostly involving screw misalignments and loosening. CRP increased from 24.9 ± 33.3 pre-op to 34.8 ± 29.9 post-op (p < 0.001), whereas leucocyte counts remained stable. All PROMs showed a marked significant improvement for both 3-week and 1-year evaluations compared to the preoperative situation. Interestingly, we did not find an impact of OT, LOS, lab markers, complications, and other clinical characteristics on PROMs. Notably, a higher number of stabilized levels did not affect PROMs. Conclusions: Minimal-invasive stabilization of thoracolumbar fractures utilizing a dorsal percutaneous approach resulted in significant PROM outcome improvements, although we observed a complication rate of 13.2% for up to 1 year of follow-up. PROMs were not significantly associated with clinicopathological characteristics, technique-related variables, or the number of targeted levels.
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Mansour A, Givens J, Whitaker JE, Carlson J, Hartley B. Immediate outcomes of early versus late definitive fixation of acetabular fractures: A narrative literature review. Injury 2022; 53:821-826. [PMID: 35164955 DOI: 10.1016/j.injury.2022.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The ideal timing of acetabular fractures fixation remains contentious. Early immediate fixation was thought to increase the surgery duration and blood loss while facilitating earlier mobilization and shorter hospital stay; and vice versa for the late fixation after 7 days. The purpose of this review was to compare the impact of early (defined as within 48 hours) versus later definitive fixation of acetabular fractures on postoperative outcomes. It was found that early surgical treatment has certain advantages with regards to blood loss, operative time, and LOS especially in patients with lower ISS. However, further studies are necessary to provide more evidence in terms of long-term outcomes.
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Affiliation(s)
- Ali Mansour
- Department of Orthopaedic Surgery, University of Louisville, KY, United States
| | - Justin Givens
- Department of Orthopaedic Surgery, University of Louisville, KY, United States
| | - John Eric Whitaker
- Department of Orthopaedic Surgery, University of Louisville, KY, United States
| | - Jon Carlson
- Department of Orthopaedic Surgery, University of Louisville, KY, United States
| | - Brandi Hartley
- Department of Orthopaedic Surgery, University of Louisville, KY, United States.
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Understanding variations and influencing factors on length of stay for T2DM patients based on a multilevel model. PLoS One 2021; 16:e0248157. [PMID: 33711043 PMCID: PMC7954328 DOI: 10.1371/journal.pone.0248157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/20/2021] [Indexed: 12/13/2022] Open
Abstract
Aim Shortening the length of stay (LOS) is a potential and sustainable way to relieve the pressure that type 2 diabetes mellitus (T2DM) patients placed on the public health system. Method Multi-stage random sampling was used to obtain qualified hospitals and electronic medical records for patients discharged with T2DM in 2018. A box-cox transformation was adopted to normalize LOS. Multilevel model was used to verify hospital cluster effect on LOS variations and screen potential factors for LOS variations from both individual and hospital levels. Result 50 hospitals and a total of 12,888 T2DM patients were included. Significant differences in LOS variations between hospitals, and a hospital cluster effect on LOS variations (t = 92.188, P<0.001) was detected. The results showed that female patients, patients with new rural cooperative’ medical insurance, hospitals with more beds, and hospitals with faster bed turnovers had shorter LOS. Conversely, elderly patients, patients with urban workers’ medical insurance, patients requiring surgery, patients with the International Classification of Diseases coded complication types E11.1, E11.2, E11.4, E11.5, and other complications cardiovascular diseases, grade III hospitals, hospitals with a lower doctor-to-nurse ratio, and hospitals with more daily visits per doctor had longer LOS. Conclusions The evidence proved that hospital cluster effect on LOS variation did exist. Complications and patients features at individual level, as well as organization and resource characteristics at hospital level, had impacted LOS variations to varying degrees. To shorten LOS and better meet the medical demand for T2DM patients, limited health resources must be allocated and utilized rationally at hospital level, and the patients with the characteristics of longer LOS risk must be identified in time. More influencing factors on LOS variations at different levels are still worth of comprehensive exploration in the future.
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Cawich SO, Dapri G, Fa Si Oen P, Thomas D, Naraynsingh V. Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars. Cureus 2020; 12:e10742. [PMID: 33145144 PMCID: PMC7599059 DOI: 10.7759/cureus.10742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction As single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit. Methods This was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae. Results There were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected. Conclusion Even in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.
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Affiliation(s)
| | - Giovanni Dapri
- Surgery, International School of Reduced Scar Laparoscopy, Brussels, BEL
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Atsma F, Elwyn G, Westert G. Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems. Int J Qual Health Care 2020; 32:271-274. [PMID: 32319525 PMCID: PMC7270826 DOI: 10.1093/intqhc/mzaa023] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 12/16/2022] Open
Abstract
In the past decades, extensive research has been performed on the phenomenon of unwarranted clinical variation in clinical practice. Many studies have been performed on signaling, describing and visualizing clinical variation. We argue that it is time for next steps in practice variation research. In addition to describing and signaling variation patterns, we argue that a better understanding of causes of variation should be gained. Moreover, target points for improving and decreasing clinical variation should be created. Key elements in this new focus should be research on the complex interaction of networks, reflective medicine, patient beliefs and objective criteria for treatment choices. By combining these different concepts, alternative research objectives and new targets for improving and reducing unwarranted variation may be defined. In this perspective, we reflect on these concepts and propose target points for future research.
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Affiliation(s)
- Femke Atsma
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Noord 21, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Glyn Elwyn
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Noord 21, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Gert Westert
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Noord 21, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Barcot O, Dosenovic S, Boric M, Pericic TP, Cavar M, Jelicic Kadic A, Puljak L. Assessing risk of bias judgments for blinding of outcome assessors in Cochrane reviews. J Comp Eff Res 2020; 9:585-593. [PMID: 32459105 DOI: 10.2217/cer-2019-0181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Adequate judging of risk of bias (RoB) for blinding of outcome assessors (detection bias) is important for supporting highest level of evidence. Materials & methods: Judgments and supporting comments for detection bias were retrieved from RoB tables reported in Cochrane reviews. We categorized comments, and then compared judgment and supporting comment with instructions from the Cochrane Handbook. Results: We analyzed 8656 judgments for detection bias from 7626 trials included in 575 reviews. Overall, 1909 judgments (22%) were not in line with the Cochrane Handbook. In 9% of trials, the authors split the detection bias domain according to outcomes. Here, prevalence of inadequate judgments was 19%. Conclusion: Interventions to improve RoB assessments in systematic reviews should be explored.
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Affiliation(s)
- Ognjen Barcot
- Department of Abdominal Surgery, University Hospital Split, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology & Intensive Care, University Hospital Split, Croatia
| | - Matija Boric
- Department of Abdominal Surgery, University Hospital Split, Split, Croatia
| | - Tina Poklepovic Pericic
- Department of Research in Biomedicine & Health, University of Split School of Medicine, Split, Croatia
| | - Marija Cavar
- Department of Radiology, University Hospital Split, Split, Croatia
| | | | - Livia Puljak
- Center for Evidence-Based Medicine & Health Care, Catholic University of Croatia, Zagreb, Croatia
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DePesa CD, El Hechi MW, McKenzie R, Waak K, Woodis L, Chang Y, Gervasini A, Velmahos GC, Kaafarani HMA. A multidisciplinary approach to decreasing length of stay in acute care surgery patients. J Adv Nurs 2020; 76:1364-1370. [PMID: 32090371 DOI: 10.1111/jan.14335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/18/2020] [Accepted: 02/18/2020] [Indexed: 11/30/2022]
Abstract
AIM To decrease hospital length of stay in acute care surgery patients. DESIGN An observational cohort quality improvement project at a single tertiary referral centre. METHODS A multidisciplinary team of physicians, nurses, case managers, and physical and occupational therapists was created to identify patients at risk for prolonged length of stay and implement weekly multidisciplinary rounding, with a systematic method of tracking progress in real time. The main outcome measure was hospital length of stay. The observed/expected ratios for length of stay 2 years before (2012-2014) and after (2014-2016) the intervention were compared. RESULTS A total of 6,120 patients was analysed. Early identification and action on barriers to discharge created a significant decrease in risk-adjusted acute care surgery patient days per year (96 days) with limited added cost (1-2 hr per week). Patients discharged to home with or without services benefited most. CONCLUSION Decreasing length of stay in acute care surgery patients is possible without adding a significant burden to healthcare providers. IMPACT We describe a comprehensive, multidisciplinary initiative to decrease the length of stay of acute care surgery patients. Institutions can use existing resources in a sustainable manner to create a significant decrease in patient days per year with limited added cost. REGISTRATION: https://osf.io/zfc3t.
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Affiliation(s)
- Christopher D DePesa
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Majed W El Hechi
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Rachael McKenzie
- Case Management, Massachusetts General Hospital, Boston, MA, USA
| | - Karen Waak
- Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Leslie Woodis
- Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alice Gervasini
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Bostosn, MA, USA
| | - George C Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Bostosn, MA, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Bostosn, MA, USA
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Hollands S. Receipt of Promotional Payments at the Individual and Physician Network Level Associated with Higher Branded Antipsychotic Prescribing Rates. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 47:73-85. [PMID: 31515636 PMCID: PMC7288218 DOI: 10.1007/s10488-019-00974-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pharmaceutical promotion can lead to market size expansion, which is beneficial if previously untreated patients access treatment but deleterious if it leads to overuse, an area of concern for second generation antipsychotics (SGA). We contribute to a growing body of work suggesting that networks of social and professional relationships shape prescribing behavior. We examined 88,439 Medicare Part D prescribing physicians, finding that promotion is associated with SGA market size expansion (elasticity: 0.062) and that network-level promotional activity is associated with network members' branded product prescribing. Research on the effects of promotion should account for its effects in prescribers' networks.
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Affiliation(s)
- Simon Hollands
- Pardee RAND Graduate School, 1776 Main St., Santa Monica, CA, 90401, USA.
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14
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McHugh JP, Keohane L, Grebla R, Lee Y, Trivedi AN. Association of daily copayments with use of hospital care among medicare advantage enrollees. BMC Health Serv Res 2019; 19:961. [PMID: 31830987 PMCID: PMC6909444 DOI: 10.1186/s12913-019-4770-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/22/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND While the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay. METHODS We used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans - similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007-2010 period. RESULTS The imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI - 1.8 to - 0.9), 6.9 inpatient days/100 enrollees (95% CI - 10.1 to - 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI - 1.0 to - 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI - 8.4 to 1.4), 31.1 days/100 (95% CI - 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI - 3.8 to - 0.6) in intervention plans relative to control plans. CONCLUSIONS Instituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.
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Affiliation(s)
- John P. McHugh
- Columbia University, Mailman School of Public Health, 722 West 168th Street, 4th Floor, New York, NY 10032 USA
| | - Laura Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1200, Nashville, TN 37203 USA
| | - Regina Grebla
- Center for Gerontology and Health care Research, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Yoojin Lee
- Center for Gerontology and Health care Research, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Amal N. Trivedi
- Department of Health Services Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
- Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA
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15
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Wiering B, de Boer D, Delnoij D. Meeting patient expectations: patient expectations and recovery after hip or knee surgery. Musculoskelet Surg 2018; 102:231-240. [PMID: 29168164 PMCID: PMC6223986 DOI: 10.1007/s12306-017-0523-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/09/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although patient-centred care could help increase the value of healthcare, practice variations in hip and knee surgery suggest that physicians guide clinical decisions more than patients do. This raises the question whether treatment outcomes still meet patients' expectations. This study investigated whether treatment outcomes measured by patient-reported outcome measures fulfil patients' main expectations (i.e. decreased pain or improved functioning). METHODS Patients who underwent hip or knee surgery in 20 Dutch hospitals in 2014 were invited to a survey consisting of the KOOS Physical Function Short Form or the HOOS Physical Function Short Form, the NRS pain and the EQ-5D. Patients were asked their main reason for surgery and whether the expectations regarding this reason were fulfilled. RESULTS A total of 2776 patients completed the survey. The most common reason for surgery was improved functioning (43.7%). Patients who were unable to choose between pain relief and improved functioning and patients who aimed for pain relief experienced more problems before surgery. However, patients who were unable to choose improved more than patients who wanted to improve their functioning on the NRS pain during use and the EQ-5D. More patients who aimed for pain relief felt that their expectations were fulfilled compared to other patients. CONCLUSIONS Although an expectation for an outcome was not related to a greater improvement on that outcome, patient expectations were an indication of patients' improvement due to surgery. Differences in expectation fulfilment may be due to unrealistic expectations. To achieve optimal value, tailoring treatment using patient preferences and managing patient expectations is vital.
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Affiliation(s)
- B. Wiering
- Tranzo (Scientific Centre for Transformation in Care and Welfare), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - D. de Boer
- NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - D. Delnoij
- Tranzo (Scientific Centre for Transformation in Care and Welfare), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
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16
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Gil LA, Kothari AN, Brownlee SA, Ton-That H, Patel PP, Gonzalez RP, Luchette FA, Anstadt MJ. Superusers: Drivers of health care resource utilization in the national trauma population. Surgery 2018; 164:848-855. [PMID: 30093276 DOI: 10.1016/j.surg.2018.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/13/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population. METHODS The National Trauma Data Bank for 2008-2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser. RESULTS A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P < .001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury. CONCLUSION Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention.
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Affiliation(s)
- Lindsay A Gil
- One:MAP, Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL; Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Anai N Kothari
- One:MAP, Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL; Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Sarah A Brownlee
- One:MAP, Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL; Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Hieu Ton-That
- Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Purvi P Patel
- Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Richard P Gonzalez
- Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- One:MAP, Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL; Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines Jr., Veterans Administration Medical Center, Surgery Service Line, Hines, IL
| | - Michael J Anstadt
- One:MAP, Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL; Division of Trauma, Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Maywood, IL.
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17
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The burden of excess length of stay in trauma patients. Am J Surg 2018; 216:881-885. [PMID: 30082028 DOI: 10.1016/j.amjsurg.2018.07.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 07/15/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Disposition of trauma patients frequently results in excessive hospital-stay. The aim of this study was to assess the risk of developing complications due to excessive stay in the hospital. METHODS Over a period of 4 years (2012-2015) we analyzed all trauma patients with hospital length-of-stay (h-LOS) >30 days. Outcome measures were complications after termination of medical care. RESULTS 416 patients were identified having h-LOS>30 days of which 61.0% (254) had an excess hospital stay and were included. The most common causes of excess hospital stay were placement in SNiF followed by placement in Inpatient-Rehabilitation. Excessive hospital-stay was independently associated with the development of complications (p = 0.004). Each excess day in the hospital after completion of medical care was associated with 5% higher odds of complications (OR [95%CI]: 1.05[1.02-1.09]) independent of presenting condition of the patient. CONCLUSION Each extra day spent in the hospital after completion of medical care was associated with higher odds of developing complications.
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18
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Wang SY, Hsu SH, Huang S, Doan KC, Gross CP, Ma X. Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care. Health Serv Res 2018; 53:4291-4309. [PMID: 29951996 DOI: 10.1111/1475-6773.12998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether regional practice patterns impact racial/ethnic differences in intensity of end-of-life care for cancer decedents. DATA SOURCES The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. STUDY DESIGN We classified hospital referral regions (HRRs) based on mean 6-month end-of-life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end-of-life care across levels of HRR expenditures. PRINCIPAL FINDINGS There was greater variation in intensity of end-of-life care among Hispanics, Asians, and whites in high-expenditure HRRs than in low-expenditure HRRs. CONCLUSIONS Local practice patterns may influence racial/ethnic differences in end-of-life care.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Sylvia H Hsu
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Schulich School of Business, York University, Toronto, ON, Canada
| | - Siwan Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT.,Beijing PricewaterhouseCoopers Management Consulting (Shanghai) Limited, Beijing, China
| | - Kathy C Doan
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
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19
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Buttigieg SC, Abela L, Pace A. Variables affecting hospital length of stay: a scoping review. J Health Organ Manag 2018; 32:463-493. [DOI: 10.1108/jhom-10-2017-0275] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose
Tertiary hospitals have registered an incremental rise in expenditure mostly because of the increasing demands by ageing populations. Reducing the length of stay (LOS) of patients within tertiary hospitals is one of the strategies, which has been used in the last decades to ensure health care systems’ sustainability. Furthermore, LOS is one of the key performance indicators, which is widely used to assess hospital efficiency. Hence, it is crucial that policy makers use evidence-based practices in health care to aim for optimal LOS. The purpose of this paper is to identify and summarize empirical research that brings together studies on the various variables that directly or indirectly impact on LOS within tertiary hospitals so as to develop a LOS causal systems model.
Design/methodology/approach
This scoping review was guided by the following research question: “What is affecting the LOS of patients within tertiary-level health care?” and by the guidelines specified by Arksey and O’Malley (2005), and by Armstrong et al. (2011). Relevant current literature was retrieved by searching various electronic databases. The PRISMA model provided the process guidelines to identify and select eligible studies.
Findings
An extensive literature search yielded a total of 30,350 references of which 46 were included in the final analysis. These articles yielded variables, which directly/indirectly are linked to LOS. These were then organized according to the Donabedian model – structure, processes and outcomes. The resultant LOS causal model reflects its complexity and confirms the consideration by scholars in the field that hospitals are complex adaptive systems, and that hospital managers must respond to LOS challenges holistically.
Originality/value
This paper illustrates a complex LOS causal model that emerged from the scoping review and may be of value for future research. It also highlighted the complexity of the construct under study.
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20
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Mercuri M, Gafni A. Examining the role of the physician as a source of variation: Are physician-related variations necessarily unwarranted? J Eval Clin Pract 2018; 24:145-151. [PMID: 28556526 DOI: 10.1111/jep.12770] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The physician is often implicated as an important cause of observed variations in health care service use. However, it is not clear if physician-related variation is problematic for patient care. This paper illustrates that observed physician-related variation is not necessarily unwarranted. METHODS This is a narrative review. RESULTS Many studies have attributed observed variations to the physician, but little attention is given towards discriminating between those variations that exist for good reasons and those that are unwarranted. Two arguments can be made for why physician-related variation is unwarranted. The first posits that physician-related factors should not play a role in management of care decisions because such decisions should be driven by science (which is imagined to be definitive). The second considers the possibility of supplier-induced demand as a factor driving observed variations. We show that neither argument is sufficient to rule out that physician-related variations may be warranted. Furthermore, the claim that such variations are necessarily problematic for patients has yet to be substantiated empirically. CONCLUSIONS It is not enough to simply show that physician-related variation can exist-one must also show where it is unwarranted and what is the magnitude of unwarranted variations. Failure to show this can have significant implications on how we interpret and respond to observed variations. Improved measurement of the sources of variation, especially with respect to patient preferences and context, may help us start to disentangle physician-related variation that is desirable from that which is unwarranted.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada.,African Centre for Epistemology and Philosophy of Science, Department of Philosophy, University of Johannesburg, Auckland Park, South Africa
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis, Department of Health Services Research, Evaluation and Impact, McMaster University, Hamilton, Ontario, Canada
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21
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Gallagher T, Leahy MF, Darby S, Campbell L, Howman R, Watts S, Vodanovich M, Tovey J, Esson A, Koay A. Assembling a state-wide patient blood management program as a standard of care: the Western Australian experience. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- T. Gallagher
- Department of Health Western Australia; Perth WA Australia
| | - M. F. Leahy
- Fremantle Hospital; Fremantle WA Australia
- Royal Perth Hospital; Perth WA Australia
- PathWest Laboratory Medicine; Perth WA Australia
- The University of Western Australia; Perth WA Australia
| | - S. Darby
- Sir Charles Gairdner Hospital; Nedlands WA Australia
| | - L. Campbell
- Sir Charles Gairdner Hospital; Nedlands WA Australia
| | - R. Howman
- Sir Charles Gairdner Hospital; Nedlands WA Australia
| | - S. Watts
- Sir Charles Gairdner Hospital; Nedlands WA Australia
| | | | - J. Tovey
- Fremantle Hospital; Fremantle WA Australia
| | - A. Esson
- Department of Health Western Australia; Perth WA Australia
| | - A. Koay
- Department of Health Western Australia; Perth WA Australia
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22
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada. Soc Sci Med 2017; 181:24-33. [DOI: 10.1016/j.socscimed.2017.03.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 03/02/2017] [Accepted: 03/18/2017] [Indexed: 01/13/2023]
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23
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van Vliet M, Huisman M, Deeg DJH. Decreasing Hospital Length of Stay: Effects on Daily Functioning in Older Adults. J Am Geriatr Soc 2017; 65:1214-1221. [DOI: 10.1111/jgs.14767] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Majogé van Vliet
- Department of Epidemiology and Biostatistics; VU University Medical Center; Amsterdam the Netherlands
- EMGO Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Martijn Huisman
- Department of Epidemiology and Biostatistics; VU University Medical Center; Amsterdam the Netherlands
- EMGO Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
- Department of Sociology; VU University; Amsterdam the Netherlands
| | - Dorly J. H. Deeg
- Department of Epidemiology and Biostatistics; VU University Medical Center; Amsterdam the Netherlands
- EMGO Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
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24
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Kalkan A, Husberg M, Hallert E, Roback K, Thyberg I, Skogh T, Carlsson P. Physician Preferences and Variations in Prescription of Biologic Drugs for Rheumatoid Arthritis: A Register-Based Study of 4,010 Patients in Sweden. Arthritis Care Res (Hoboken) 2016; 67:1679-85. [PMID: 26097219 DOI: 10.1002/acr.22640] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 04/20/2015] [Accepted: 06/09/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The prescription of biologic drugs for rheumatoid arthritis (RA) patients has varied considerably across different regions. Previous studies have shown physician preferences to be an important determinant in the decision to select biologic disease-modifying antirheumatic drugs (bDMARDs) rather than nonbiologic, synthetic DMARDs (sDMARDs) alone. The aim of this study was to test the hypothesis that physician preferences are an important determinant for prescribing bDMARDs for RA patients in Sweden. METHODS Using data from the Swedish Rheumatology Quality Register, we identified 4,010 RA patients who were not prescribed bDMARDs during the period 2008-2012, but who, on at least 1 occasion, had an sDMARD prescription and changed treatment for the first time to either a new sDMARD or a bDMARD. Physician preference for the use of bDMARDs was calculated using data on each physician's prescriptions during the study period. The relationship between prescription of a bDMARD and physician preference, controlling for patient characteristics, disease activity, and the physician's local context was evaluated using multivariate logistic regression. RESULTS When adjusting for patient characteristics, disease activity, and the physician's local context, physician preference was an important predictor for prescription of bDMARDs. Compared with patients of a physician in the lowest preference tertile, patients of physicians in the highest and middle tertiles had an odds ratio for receiving bDMARDs of 2.8 (95% confidence interval [95% CI] 2.13-3.68) and 1.28 (95% CI 1.05-1.57), respectively. CONCLUSION Physician preference is an important determinant for prescribing bDMARDs.
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Affiliation(s)
| | | | | | | | - Ingrid Thyberg
- Linköping University and County Council of Östergötland, Linköping, Sweden
| | - Thomas Skogh
- Linköping University and County Council of Östergötland, Linköping, Sweden
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25
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Tiessen J, Kambara H, Sakai T, Kato K, Yamauchi K, McMillan C. What causes international variations in length of stay: a comparative analysis for two inpatient conditions in Japanese and Canadian hospitals. Health Serv Manage Res 2015; 26:86-94. [PMID: 25595005 DOI: 10.1177/0951484813512287] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hospital average length of stay varies considerably between countries. However, there is limited patient-level research identifying or discounting possible reasons for these differences. This study compares the length of stay of patients in Japan, where it is the longest in the OECD, and Canada, where length of stay is closer to the OECD mean. Administrative patient-level data, including age, gender, co-morbidities, intervention, discharge plan, outcome and length of stay were collected from two Japanese and two Ontario, Canada hospitals for two diagnoses: colorectal cancer surgery and acute myocardial infarction. Analyses examined linkages between patient characteristics, hospitals and countries and length of stay. When controlling for patient demographic characteristics, the incidence of co-morbidities and discharge plan practices, Japanese length of stay tended to be significantly longer than that in Canada for both diagnoses. Mortality rates were not significantly different; however, the readmission rate (28 days or less) for acute myocardial infarction was higher in the Canadian hospitals. The findings indicate that non-clinical factors contribute to sustained international differences in length of stay. These factors may include professional or cultural norms, differing payment schemes and access to long-term care facilities. The study also introduces a protocol that can be used for international patient-level comparisons that can enable effective policy and management learning.
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Affiliation(s)
| | | | | | - Ken Kato
- Aichi Medical Association Research Institute, Japan
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26
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Goodman BA, Batterham AM, Kothmann E, Cawthorn L, Yates D, Melsom H, Kerr K, Danjoux GR. Validity of the Postoperative Morbidity Survey after abdominal aortic aneurysm repair-a prospective observational study. Perioper Med (Lond) 2015; 4:10. [PMID: 26464796 PMCID: PMC4603826 DOI: 10.1186/s13741-015-0020-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/23/2015] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Currently, there is no standardised tool used to capture morbidity following abdominal aortic aneurysm (AAA) repair. The aim of this prospective observational study was to validate the Postoperative Morbidity Survey (POMS) according to its two guiding principles: to only capture morbidity substantial enough to delay discharge from hospital and to be a rapid, simple screening tool. METHODS A total of 64 adult patients undergoing elective infrarenal AAA repair participated in the study. Following surgery, the POMS was recorded daily, by trained research staff with the clinical teams blinded, until hospital discharge or death. We modelled the data using Cox regression, accounting for the competing risk of death, with POMS as a binary time-dependent (repeated measures) internal covariate. For each day for each patient, 'discharged' (yes/no) was the event, with the elapsed number of days post-surgery as the time variable. We derived the hazard ratio for any POMS morbidity (score 1-9) vs. no morbidity (zero), adjusted for type of repair (endovascular versus open), age and aneurysm size. RESULTS The hazard ratio for alive discharge with any POMS-recorded morbidity versus no morbidity was 0.130 (95 % confidence interval 0.070 to 0.243). The median time-to-discharge was 13 days after recording any POMS morbidity vs. 2 days after scoring zero for POMS morbidity. Compliance with POMS completion was 99.5 %. CONCLUSIONS The POMS is a valid tool for capturing short-term postoperative morbidity following elective infrarenal AAA repair that is substantial enough to delay discharge from hospital. Daily POMS measurement is recommended to fully capture morbidity and allow robust analysis. The survey could be a valuable outcome measure for use in quality improvement programmes and future research.
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Affiliation(s)
- Ben A Goodman
- Department of Perioperative Care, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Alan M Batterham
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Elke Kothmann
- Department of Academic Anaesthesia, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW UK
| | - Louise Cawthorn
- Department of Academic Anaesthesia, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW UK
| | - David Yates
- Department of Anaesthesia, York Hospital, York, UK
| | - Helen Melsom
- Department of Anaesthesia, University Hospital of North Durham, Durham, UK
| | - Karen Kerr
- Department of Anaesthesia, Northern General Hospital, Sheffield, UK
| | - Gerard R Danjoux
- Health and Social Care Institute, Teesside University, Middlesbrough, UK ; Department of Academic Anaesthesia, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW UK
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27
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van de Vijsel AR, Heijink R, Schipper M. Has variation in length of stay in acute hospitals decreased? Analysing trends in the variation in LOS between and within Dutch hospitals. BMC Health Serv Res 2015; 15:438. [PMID: 26423895 PMCID: PMC4590267 DOI: 10.1186/s12913-015-1087-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 09/21/2015] [Indexed: 12/20/2022] Open
Abstract
Background We aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care. Methods Using Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix. Results We found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals’ performances in terms of LOS. Conclusions The results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1087-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aart R van de Vijsel
- National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands.
| | - Richard Heijink
- National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands.
| | - Maarten Schipper
- National Institute for Public Health and the Environment, Richard Heijink, P.O. Box 1, 3720, BA, Bilthoven, The Netherlands.
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Fernández-de-Maya J, Richart-Martínez M. Factors associated with variability in management of vascular access ports. Eur J Cancer Care (Engl) 2015; 25:871-82. [DOI: 10.1111/ecc.12342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- J. Fernández-de-Maya
- Day Hospital and Home Hospitalization; Vinalopó Hospital-Torrevieja Hospital; Alicante Spain
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Seematter-Bagnoud L, Fustinoni S, Dung D, Santos-Eggimann B, Koehn V, Bize R, Oettli A, Wasserfallen JB. Comparison of different methods to forecast hospital bed needs. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2014.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Offerhaus PM, Geerts C, de Jonge A, Hukkelhoven CWPM, Twisk JWR, Lagro-Janssen ALM. Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study. BMC Pregnancy Childbirth 2015; 15:42. [PMID: 25885706 PMCID: PMC4342018 DOI: 10.1186/s12884-015-0471-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 02/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The primary aim of this study was to describe the variation in intrapartum referral rates in midwifery practices in the Netherlands. Secondly, we wanted to explore the association between the practice referral rate and a woman's chance of an instrumental birth (caesarean section or vaginal instrumental birth). METHODS We performed an observational study, using the Dutch national perinatal database. Low risk births in all primary care midwifery practices over the period 2008-2010 were selected. Intrapartum referral rates were calculated. The referral rate among nulliparous women was used to divide the practices in three tertile groups. In a multilevel logistic regression analysis the association between the referral rate and the chance of an instrumental birth was examined. RESULTS The intrapartum referral rate varied from 9.7 to 63.7 percent (mean 37.8; SD 7.0), and for nulliparous women from 13.8 to 78.1 percent (mean 56.8; SD 8.4). The variation occurred predominantly in non-urgent referrals in the first stage of labour. In the practices in the lowest tertile group more nulliparous women had a spontaneous vaginal birth compared to the middle and highest tertile group (T1: 77.3%, T2:73.5%, T3: 72.0%). For multiparous women the spontaneous vaginal birth rate was 97%. Compared to the lowest tertile group the odds ratios for nulliparous women for an instrumental birth were 1.22 (CI 1.16-1.31) and 1.33 (CI 1.25-1.41) in the middle and high tertile groups. This association was no longer significant after controlling for obstetric interventions (pain relief or augmentation). CONCLUSIONS The wide variation between referral rates may not be explained by medical factors or client characteristics alone. A high intrapartum referral rate in a midwifery practice is associated with an increased chance of an instrumental birth for nulliparous women, which is mediated by the increased use of obstetric interventions. Midwives should critically evaluate their referral behaviour. A high referral rate may indicate that more interventions are applied than necessary. This may lead to a lower chance of a spontaneous vaginal birth and a higher risk on a PPH. However, a low referral rate should not be achieved at the cost of perinatal safety.
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Affiliation(s)
- Pien M Offerhaus
- KNOV (Royal Dutch Organisation for Midwives), P.O. Box 2001, 3500GA, Utrecht, the Netherlands.
| | - Caroline Geerts
- Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007MB, Amsterdam, the Netherlands.
| | - Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007MB, Amsterdam, the Netherlands.
| | | | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, VU University Medical Center, P.O. Box 7057, 1007MB, Amsterdam, the Netherlands.
| | - Antoine L M Lagro-Janssen
- Radboud University Nijmegen Medical Centre, Internal postal code 118, P.O. Box 9101, 6500HB, Nijmegen, the Netherlands.
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De Regge M, Gemmel P, Verhaeghe R, Hommez G, Degadt P, Duyck P. Aligning service processes to the nature of care in hospitals: an exploratory study of the impact of variation. OPERATIONS MANAGEMENT RESEARCH 2015. [DOI: 10.1007/s12063-015-0098-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pannick S, Beveridge I, Wachter RM, Sevdalis N. Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base. Eur J Intern Med 2014; 25:874-87. [PMID: 25457434 DOI: 10.1016/j.ejim.2014.10.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/13/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022]
Abstract
Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.
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Affiliation(s)
- Samuel Pannick
- NIHR Patient Safety Translational Research Centre, Imperial College London, and West Middlesex University Hospital NHS Trust, UK.
| | | | - Robert M Wachter
- Division of Hospital Medicine, University of CA, San Francisco, USA.
| | - Nick Sevdalis
- NIHR Patient Safety Translational Research Centre, Imperial College London, UK.
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Cawich SO, Albert M, Singh Y, Dan D, Mohanty S, Walrond M, Francis W, Simpson LK, Bonadie KO, Dapri G. Clinical outcomes of single incision laparoscopic cholecystectomy in the anglophone Caribbean: a multi centre audit of regional hospitals. INTERNATIONAL JOURNAL OF BIOMEDICAL SCIENCE : IJBS 2014; 10:191-5. [PMID: 25324700 PMCID: PMC4199470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/07/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION There has been no report on Single-Incision Laparoscopic Surgery (SILS) cholecystectomy outcomes since it was first performed in the Anglophone Caribbean in 2009. METHODS A retrospective audit evaluated the clinical outcomes of SILS cholecystectomies at regional hospitals in the 17 Anglophone Caribbean countries. Any cholecystectomy using a laparoscopic approach in which all instruments were passed through one access incision was considered a SILS cholecystectomy. The following data were collected: patient demographics, indications for operation, intraoperative details, surgeon details, surgical techniques, specialized equipment, conversions, morbidity and mortality. Descriptive statistics were generated using SPSS 12.0. RESULTS There were 85 SILS cholecystectomies in women at a mean age of 37.4 ± 8.5 years with a mean BMI of 30.9 ± 2.8. There were 59 elective and 26 emergent cases. Specialized access platforms were used in the first 35 cases and reusable instruments were passed directly across fascia in the latter 50 cases. The mean operative time was 62.9 ± 17.9 minutes. There was no mortality, 2 conversions to multi-trocar laparoscopy and 5 minor complications. Ambulatory procedures were performed in 43/71 (60.6%) patients scheduled for elective operations. CONCLUSION In the Caribbean setting, SILS cholecystectomy is a feasible and safe alternative to conventional multi-trocar laparoscopic cholecystectomy for gallbladder disease.
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Affiliation(s)
- Shamir O. Cawich
- Department of Surgery, University of the West Indies, St. Augustine Campus, Trinidad & Tobago
| | - Matthew Albert
- Department of Surgery, Florida State University, Tallahassee, Florida, USA
| | - Yardesh Singh
- Department of Surgery, University of the West Indies, St. Augustine Campus, Trinidad & Tobago
| | - Dilip Dan
- Department of Surgery, University of the West Indies, St. Augustine Campus, Trinidad & Tobago
| | - Sanjib Mohanty
- Department of Surgery, Cayman Islands Hospital, Grand Cayman, UK
| | - Maurice Walrond
- Department of Surgery, University of the West Indies, Cave Hill Campus, Barbados
| | - Wesley Francis
- Department of Surgery, Princess Margaret Hosptial, Bahamas
| | | | - Kimon O. Bonadie
- Department of Surgery, University of the West Indies, St. Augustine Campus, Trinidad & Tobago
| | - Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium
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Fitzgerald JD, Weng HH, Soohoo NF, Ettner SL. Regional variation in acute care length of stay after orthopaedic surgery total joint replacement surgery and hip fracture surgery. ACTA ACUST UNITED AC 2013; 2. [PMID: 24363789 DOI: 10.5430/jha.v2n4p71] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine change in regional variations in acute care length of stay (LOS) after orthopedic surgery following expiration of the New York (NY) State exemption to the Prospective Payment System and implementation of the Medicare Short Stay Transfer Policy. METHODS Time series analyses were conducted to evaluate change in LOS across regions after policy implementations. Small area analyses were conducted to examine residual variation in LOS. The dataset included A 100% sample of fee-for-service Medicare patients undergoing surgical repair for hip fracture or elective joint replacement surgery between 1996 and 2001. Data files from Centers for Medicare and Medicaid Services 1996-2001 Medicare Provider Analysis and Review file, 1999 Provider of Service file, and data from the 2000 United States Census were used for analysis. RESULTS In 1996, LOS in NY after orthopedic procedures was much longer than the remainder of the country. After policy changes, LOS fell. However, significant residual variation in LOS persisted. This residual variation was likely partly explained by differences variation in regional managed care market penetration, patient management practices and unmeasured characteristics associated with the hospital location. CONCLUSIONS NY hospitals responded to changes in reimbursement policy, reducing variation in LOS. However, even after 5 years of financial pressure to constrain costs, other factors still have a strong impact on delivery of patient care.
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Affiliation(s)
- John D Fitzgerald
- Department of Medicine, University of California, Los Angeles, CA, USA
| | | | - Nelson F Soohoo
- Department of Orthopedic Surgery, University of California, Los Angeles, CA, USA
| | - Susan L Ettner
- Department of Medicine, University of California, Los Angeles, CA, USA
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Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. J Gen Intern Med 2013; 28:370-6. [PMID: 23129162 PMCID: PMC3579964 DOI: 10.1007/s11606-012-2255-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND There have been no prior population-based studies of variation in performance of hospitalists. OBJECTIVE To measure the variation in performance of hospitalists. DESIGN Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models. SUBJECTS 131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006-2009. MAIN MEASURES We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits. KEY RESULTS In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008-2009 vs. 2006-2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively. CONCLUSIONS There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.
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Affiliation(s)
- James S Goodwin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.
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Caminiti C, Meschi T, Braglia L, Diodati F, Iezzi E, Marcomini B, Nouvenne A, Palermo E, Prati B, Schianchi T, Borghi L. Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial. BMC Health Serv Res 2013; 13:14. [PMID: 23305251 PMCID: PMC3577481 DOI: 10.1186/1472-6963-13-14] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 12/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Over 20% of hospital bed use is inappropriate, implying a waste of resources and the increase of patient iatrogenic risk. METHODS This is a cluster, pragmatic, randomised controlled trial, carried out in a large University Hospital of Northern Italy, aiming to evaluate the effect of a strategy to reduce unnecessary hospital days. The primary outcome was the percentage of patient-days compatible with discharge. Among secondary objectives, to describe the strategy's effect in the long-term, as well as on hospital readmissions, considered to be a marker of the quality of hospital care. The 12 medical wards with the longest length of stay participated. Effectiveness was measured at the individual level on 3498 eligible patients during monthly index days. Patients admitted or discharged on index days, or with stay >90 days, were excluded. All ward staff was blinded to the index days, while staff in the control arm and data analysts were blinded to the trial's objectives and interventions. The strategy comprised the distribution to physicians of the list of their patients whose hospital stay was compatible with discharge according to a validated Delay Tool, and of physician length of stay profiles, followed by audits managed autonomously by the physicians of the ward. RESULTS During the 12 months of data collection, over 50% of patient-days were judged to be compatible with discharge. Delays were mainly due to problems with activities under medical staff control. Multivariate analysis considering clustering showed that the strategy reduced patient-days compatible with discharge by 16% in the intervention vs control group, (OR=0.841; 95% CI, 0.735 to 0.963; P=0.012). Follow-up at 1 year did not yield a statistically significant difference between the percentages of patient-days judged to be compatible with discharge between the two arms (OR=0.818; 95% CI, 0.476 to 1.405; P=0.47). There was no significant difference in 30-day readmission and mortality rates for all eligible patients (N=3498) between the two arms. CONCLUSIONS Results indicate that a strategy, involving physician direct accountability, can reduce unnecessary hospital days. Relatively simple interventions, like the one assessed in this study, should be implemented in all hospitals with excessive lengths of stay, since unnecessary prolongation may be harmful to patients. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT01422811.
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Affiliation(s)
- Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, Via Gramsci 14, Parma, 43126, Italy.
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Grytten J, Monkerud L, Sørensen R. Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway. Health Serv Res 2012; 47:2169-89. [PMID: 22594486 PMCID: PMC3523370 DOI: 10.1111/j.1475-6773.2012.01419.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway. DATA SOURCES The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units. STUDY DESIGN The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses. PRINCIPAL FINDING There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography. CONCLUSION Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.
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Affiliation(s)
- Jostein Grytten
- Section of Community Dentistry, University of Oslo and Akershus University Hospital, Blindern, Oslo, Norway.
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Jin R, Zelinka ES, McDonald J, Byrnes T, Grunkemeier GL, Brevig J. Effect of hospital culture on blood transfusion in cardiac procedures. Ann Thorac Surg 2012; 95:1269-74. [PMID: 23040823 DOI: 10.1016/j.athoracsur.2012.08.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/29/2012] [Accepted: 08/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND In our effort to reduce the use of blood products in cardiac operations in a health care system, we noted variations in transfusion practices among facilities. Interestingly, surgeons practicing at the same hospital had similar transfusion rates. We sought to quantitate the contribution of hospital influence on individual surgeons' transfusion practices. METHODS Blood transfusion data for coronary artery bypass graft operations at 12 Providence Health & Services facilities between January 2008 and June 2011 were reviewed. Frequency of perioperative blood transfusion, amount of transfusion, components transfused, and timing of transfusions were compared. Variation among surgeons at the same institution vs between institutions was computed based on multilevel mixed-effect logistic and linear regression models. Intraclass correlation coefficients were calculated. RESULTS A total of 5,744 nonemergency first-time coronary artery bypass graft procedures were performed by 42 not-low volume (n>30 in 2.5 years) surgeons at 12 Providence Health & Services hospitals during the 3.5-year study period. Frequency, amount, timing, and blood component usage were different among facilities but relatively similar for surgeons within a facility. The variance of red blood cell transfusion rate among hospitals (.82) is more than two times that among surgeons practicing within the same hospital (.35). Thus, surgeons contribute 30% to the variation, and 70% of the total variation can be explained by the hospital effect. CONCLUSIONS In our multihospital system, the hospital that a surgeon practices at plays a larger role in determining blood utilization than the individual surgeon's preference.
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Affiliation(s)
- Ruyun Jin
- Medical Data Research Center, Providence Health & Services, Portland, Oregon 97225, USA.
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An investigation into the variables associated with length of hospital stay related to primary cleft lip and palate surgery and alveolar bone grafting. Int J Oral Maxillofac Surg 2012; 41:1238-43. [DOI: 10.1016/j.ijom.2012.05.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 03/04/2012] [Accepted: 05/24/2012] [Indexed: 11/19/2022]
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Mercuri M, Natarajan MK, Norman G, Gafni A. An even smaller area variation: Differing practice patterns among interventional cardiologists within a single high volume tertiary cardiac centre. Health Policy 2012; 104:179-85. [DOI: 10.1016/j.healthpol.2010.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 10/27/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
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Mercuri M, Gafni A. Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations. J Eval Clin Pract 2011; 17:671-7. [PMID: 21501341 DOI: 10.1111/j.1365-2753.2011.01689.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required.
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Affiliation(s)
- Mathew Mercuri
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
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Ohlsson H, Vervloet M, van Dijk L. Practice variation in a longitudinal perspective: a multilevel analysis of the prescription of simvastatin in general practices between 2003 and 2009. Eur J Clin Pharmacol 2011; 67:1205-11. [DOI: 10.1007/s00228-011-1082-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/05/2011] [Indexed: 11/29/2022]
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Relating focus to quality and cost in a healthcare setting. OPERATIONS MANAGEMENT RESEARCH 2011. [DOI: 10.1007/s12063-011-0053-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Steenbeek R, Schellart AJ, Mulders H, Anema JR, Kroneman H, Besseling J. The development of instruments to measure the work disability assessment behaviour of insurance physicians. BMC Public Health 2011; 11:1. [PMID: 21199570 PMCID: PMC3086528 DOI: 10.1186/1471-2458-11-1] [Citation(s) in RCA: 250] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 01/03/2011] [Indexed: 11/21/2022] Open
Abstract
Background Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants. Methods Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items. Results Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour. The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'. Conclusions The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.
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Affiliation(s)
- Romy Steenbeek
- TNO Work and Employment, PO Box 718, 2130 AS Hoofddorp, the Netherlands.
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Muntaner C, Li Y, Ng E, Benach J, Chung H. Work or Place? Assessing the Concurrent Effects of Workplace Exploitation and Area-of-Residence Economic Inequality on Individual Health. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2011; 41:27-50. [DOI: 10.2190/hs.41.1.c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Building on previous multilevel studies in social epidemiology, this cross-sectional study examines, simultaneously, the contextual effects of workplace exploitation and area-of-residence economic inequality on social inequalities in health among low-income nursing assistants. A total of 868 nursing assistants recruited from 55 nursing homes in Kentucky, Ohio, and West Virginia were surveyed between 1999 and 2001. Using a cross-classified multilevel design, the authors tested the effects of area-of-residence (income inequality and racial segregation), workplace (type of nursing home ownership and managerial pressure), and individual-level (age, gender, race/ethnicity, health insurance, length of employment, social support, type of nursing unit, preexisting psychopathology, physical health, education, and income) variables on health (self-reported health and activity limitations) and behavioral outcomes (alcohol use and caffeine consumption). Findings reveal that overall health was associated with both workplace exploitation and area-of-residence income inequality; area of residence was associated with activity limitations and binge drinking; and workplace exploitation was associated with caffeine consumption. This study explicitly accounts for the multiple contextual structure and effects of economic inequality on health. More work is necessary to replicate the current findings and establish robust conclusions on workplace and area of residence that might help inform interventions.
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Is the “practice style” hypothesis relevant for general practitioners? An analysis of antibiotics prescription for acute rhinopharyngitis. Soc Sci Med 2010; 70:1176-84. [DOI: 10.1016/j.socscimed.2009.12.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 11/04/2009] [Accepted: 12/07/2009] [Indexed: 11/20/2022]
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Yiannakoulias N, Hill MD, Svenson LW. Geographic hierarchies of diagnostic practice style in cerebrovascular disease. Soc Sci Med 2009; 68:1985-92. [PMID: 19346048 DOI: 10.1016/j.socscimed.2009.02.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Indexed: 11/16/2022]
Abstract
Diagnostic practice style describes the ways in which physicians diagnose information about disease. Like practice style effects in general, diagnostic practice style effects may emerge as the result of training, inter-personal relationships between professionals, medical enthusiasm for particular diagnoses and patient-physician interactions. In this study we analyze the ways in which patterns of diagnostic practice style associated with cerebrovascular disease varies at different socio-geographical scales in the province of Alberta, Canada. We use hierarchical linear models to partition a measure of diagnostic practice style into four levels of observation: the physician level, the facility level, the municipality level and the regional (census division) level. We model a variety of fixed effects related to physician attributes, their practice, the facilities they work in and the municipalities within which their facilities operate. Our results suggest that attributes related to physicians and the facilities and municipalities in which they work all contribute to patterns of diagnostic practice style. Physicians working in rural and urban municipalities have different practice style patterns even after controlling for the types of facilities they work in, their professional medical specialization and their workload. Similar to other research, our results reveal that physicians have different diagnostic practice styles with members of the same sex than members of the opposite sex. Geographic variations in diagnostic practice style may obscure changes in the epidemiology of cerebrovascular disease in rural communities, and provide indirect evidence that the quality and/or timeliness of diagnosis may be worse in rural Alberta.
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Affiliation(s)
- Nikolaos Yiannakoulias
- McMaster University, School of Geography and Earth Sciences, 120 Main Street West, Hamilton, Ontario, Canada.
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Dharmar M, Marcin JP, Romano PS, Andrada ER, Overly F, Valente JH, Harvey DJ, Cole SL, Kuppermann N. Quality of care of children in the emergency department: association with hospital setting and physician training. J Pediatr 2008; 153:783-9. [PMID: 18617191 PMCID: PMC9724612 DOI: 10.1016/j.jpeds.2008.05.025] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Revised: 04/15/2008] [Accepted: 05/14/2008] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. STUDY DESIGN This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. RESULTS A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care. CONCLUSIONS The quality of care provided to children is associated with age, hospital setting, and physician training.
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Affiliation(s)
- Madan Dharmar
- Department of Pediatrics, University of California Davis, Sacramento, CA,Center for Health Services Research in Primary Care, University of California Davis, Sacramento, CA
| | - James P. Marcin
- Department of Pediatrics, University of California Davis, Sacramento, CA,Center for Health Services Research in Primary Care, University of California Davis, Sacramento, CA
| | - Patrick S. Romano
- Department of Pediatrics, University of California Davis, Sacramento, CA,Center for Health Services Research in Primary Care, University of California Davis, Sacramento, CA,Department of Internal MedicineUniversity of California Davis, Sacramento, CA
| | - Emily R. Andrada
- Department of Emergency Medicine, University of California Davis, Sacramento, CA
| | - Frank Overly
- Department of Emergency Medicine, Brown University, Providence, RI
| | | | - Danielle J. Harvey
- Department of Public Health Sciences, University of California Davis, Sacramento, CA
| | - Stacey L. Cole
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis, Sacramento, CA,Center for Health Services Research in Primary Care, University of California Davis, Sacramento, CA,Department of Emergency Medicine, University of California Davis, Sacramento, CA
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Wakkee M, Lugtenberg M, Spuls PI, de Jong EM, Thio HB, Westert GP, Nijsten T. Knowledge, attitudes and use of the guidelines for the treatment of moderate to severe plaque psoriasis among Dutch dermatologists. Br J Dermatol 2008; 159:426-32. [PMID: 18616791 DOI: 10.1111/j.1365-2133.2008.08692.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND In 2003, the Dutch psoriasis guidelines were among the first evidence-based medicine guidelines in dermatology. Although pivotal, the implementation of dermatological guidelines has not been assessed. OBJECTIVES To evaluate various aspects that affect implementation of clinical guidelines such as knowledge, attitudes and practices among dermatologists. METHODS A cross-sectional anonymous postal survey was conducted among all Dutch dermatologists. In addition to questions about knowledge and practices, 24 items assessed guidelines attitudes. Factor analysis was applied to merge these items into attitudinal scales and multiple linear regression was used to identify predictors for these scales. RESULTS Of the 353 dermatologists, 161 (46%) completed the questionnaire. Almost all respondents were aware of the guidelines and 60% reported to have a decent knowledge of their content. Factor analysis retained 22 items divided into three scales: usefulness and content, barriers, and reliability. Apart from some disagreement on the user-friendliness and communication facilitating properties, the dermatologists' attitudes were generally positive. A larger volume of patients with psoriasis was associated with more frequent use of the guidelines [adjusted odds ratio (OR) = 2.42; 95% confidence interval (CI) 1.02-5.72]. Good familiarity predicted a more positive attitude towards the guidelines' usefulness and content (P < 0.001), perceived barriers (P < 0.001), and more frequent use in practice (adjusted OR = 8.38; 95% CI 3.08-22.81). CONCLUSIONS Dutch dermatologists seem to know and appreciate their psoriasis guidelines and use them more often when they have a larger psoriasis population. Enhancing the familiarity of the guidelines among users may result in a more positive attitude towards them and a higher frequency of use.
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Affiliation(s)
- M Wakkee
- Department of Dermatology, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Hollenbeck BK, Dunn RL, Gilbert SM, Strope S, Miller DC. Effects of Laparoscopy on Surgical Discharge Practice Patterns. Urology 2008; 71:1029-34. [DOI: 10.1016/j.urology.2007.12.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 12/12/2007] [Accepted: 12/12/2007] [Indexed: 11/16/2022]
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