157,695 research outputs found
Capturing complexity in clinician case-mix: classification system development using GP and physician associate data.
Background: There are limited case-mix classification systems for primary care settings which are applicable when considering the optimal clinical skill mix to provide services. Aim: To develop a case-mix classification system (CMCS) and test its impact on analyses of patient outcomes by clinician type, using example data from physician associates' (PAs) and GPs' consultations with same-day appointment patients. Design & setting: Secondary analysis of controlled observational data from six general practices employing PAs and six matched practices not employing PAs in England. Method: Routinely-collected patient consultation records (PA n = 932, GP n = 1154) were used to design the CMCS (combining problem codes, disease register data, and free text); to describe the case-mix; and to assess impact of statistical adjustment for the CMCS on comparison of outcomes of consultations with PAs and with GPs. Results: A CMCS was developed by extending a system that only classified 18.6% (213/1147) of the presenting problems in this study's data. The CMCS differentiated the presenting patient's level of need or complexity as: acute, chronic, minor problem or symptom, prevention, or process of care, applied hierarchically. Combination of patient and consultation-level measures resulted in a higher classification of acuity and complexity for 639 (30.6%) of patient cases in this sample than if using consultation level alone. The CMCS was a key adjustment in modelling the study's main outcome measure, that is rate of repeat consultation. Conclusion: This CMCS assisted in classifying the differences in case-mix between professions, thereby allowing fairer assessment of the potential for role substitution and task shifting in primary care, but it requires further validation
Early warning systems and rapid response to the deteriorating patient in hospital: a realist evaluation.
AIM: To identify those contexts and mechanisms that enable or constrain the implementation of Rapid Response Systems on acute general hospital wards to recognise and respond to patient deterioration. BACKGROUND: Rapid Response Systems allow deteriorating patients to be recognised using Early Warning Systems, referred early via escalation protocols and managed at the bedside by competent staff. DESIGN: Realist Evaluation. METHODS: The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland which followed the principles of Realist Evaluation. We used various mixed methods including individual and focus group interviews, observation of nursing practice between June - November 2010 and document analysis of Early Warning Systems audit data between May - October 2010 and hospital acute care training records over 4.5 years from 2003-2008. Data were analysed using NiVivo8 and SPPS. RESULTS: A cross case analysis highlighted similar patterns of factors which enabled or constrained successful recognition, referral and response to deteriorating patients in practice. Key enabling factors were the use of clinical judgement by experienced nurses and the empowerment of nurses as a result of organisational change associated with implementation of Early Warning System protocols. Key constraining factors were low staffing and inappropriate skill mix levels, rigid implementation of protocols and culturally-embedded suboptimal communication processes. CONCLUSION: Successful implementation of Rapid Response Systems was dependent on adopting organisational and cultural changes that facilitated staff empowerment, flexible implementation of protocols and ongoing experiential learning. This article is protected by copyright. All rights reserved
Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis.
STUDY QUESTION: Is there an association between a Caesarean section and subsequent fertility? SUMMARY ANSWER: Most studies report that fertility is reduced after Caesarean section compared with vaginal delivery. However, studies with a more robust design show smaller effects and it is uncertain whether the association is causal. WHAT IS KNOWN ALREADY: A previous systematic review published in 1996 summarizing six studies including 85 728 women suggested that Caesarean section reduces subsequent fertility. The included studies suffer from severe methodological limitations. STUDY DESIGN, SIZE, DURATION: Systematic review and meta-analysis of cohort studies comparing subsequent reproductive outcomes of women who had a Caesarean section with those who delivered vaginally. PARTICIPANTS/MATERIALS, SETTING, METHODS: Searches of Cochrane Library, Medline, Embase, CINAHL Plus and Maternity and Infant Care databases were conducted in December 2011 to identify randomized and non-randomized studies that compared the subsequent fertility outcomes after a Caesarean section and after a vaginal delivery. Eighteen cohort studies including 591 850 women matched the inclusion criteria. Risk of bias was assessed by the Newcastle-Ottawa scale (NOS). Data extraction was done independently by two reviewers. The meta-analysis was based on a random-effects model. Subgroup analyses were performed to assess whether the estimated effect was influenced by parity, risk adjustment, maternal choice, cohort period, and study quality and size. MAIN RESULTS AND THE ROLE OF CHANCE: The impact of Caesarean section on subsequent pregnancies could be analysed in 10 studies and on subsequent births in 16 studies. A meta-analysis suggests that patients who had undergone a Caesarean section had a 9% lower subsequent pregnancy rate [risk ratio (RR) 0.91, 95% confidence interval (CI) (0.87, 0.95)] and 11% lower birth rate [RR 0.89, 95% CI (0.87, 0.92)], compared with patients who had delivered vaginally. Studies that controlled for maternal age or specifically analysed primary elective Caesarean section for breech delivery, and those that were least prone to bias according to the NOS reported smaller effects. LIMITATIONS, REASONS FOR CAUTION: There is significant variation in the design and methods of included studies. Residual bias in the adjusted results is likely as no study was able to control for a number of important maternal characteristics, such as a history of infertility or maternal obesity. WIDER IMPLICATIONS OF THE FINDINGS: Further research is needed to reduce the impact of selection bias by indication through creating more comparable patient groups and applying risk adjustment
Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database
Introduction: This report describes the case mix and outcomes of patients with oesophageal cancer admitted to adult critical care units following elective oesophageal surgery in England, Wales and Northern Ireland.
Methods: Admissions to critical care following elective oesophageal surgery for malignancy were identified using data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. Information on admissions between December 1995 and September 2007 were extracted and the association between in-hospital mortality and patient characteristics on admission to critical care was assessed using multiple logistic regression analysis. The performance of three prognostic models (Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and the ICNARC physiology score) was also evaluated.
Results: Between 1995 and 2007, there were 7227 admissions to 181 critical care units following oesophageal surgery for malignancy. Overall mortality in critical care was 4.4% and in-hospital mortality was 11%, although both declined steadily over time. Eight hundred and seventy-three (12.2%) patients were readmitted to critical care, most commonly for respiratory complications (49%) and surgical complications (25%). Readmitted patients had a critical care unit mortality of 24.7% and in-hospital mortality of 33.9%. Overall in-hospital mortality was associated with patient age, and various physiological measurements on admission to critical care (partial pressure of arterial oxygen (PaO2):fraction of inspired oxygen (FiO2) ratio, lowest arterial pH, mechanical ventilation, serum albumin, urea and creatinine). The three prognostic models evaluated performed poorly in measures of discrimination, calibration and goodness of fit.
Conclusions: Surgery for oesophageal malignancy continues to be associated with significant morbidity and mortality. Age and organ dysfunction in the early postoperative period are associated with an increased risk of death. Postoperative serum albumin is confirmed as an additional prognostic factor. More work is required to determine how this knowledge may improve clinical management
Cultivation of DRG system in the Czech Health Care Service environment
Využití systému Diagnosis-Related Groups (DRG) v úhradách akutní lůžkové péče je jedním z nejdiskutovanějších témat českého zdravotnictví. Cílem této práce je návrh možných změn tohoto mechanismu a jejich diskuze. Nejprve je komplexně zhodnocen současný stav a postupná kultivace úhrad akutní lůžkové péče a systému DRG v ČR, situace v ČR je zasazena do kontextu jiných zemí EU. Problematika úhrad je hodnocena i u konkrétních nemocnic. U třech poskytovatelů je nejprve na základě polostrukturovaných rozhovorů provedena analýza využívaného úhradového mechanismu v letech 2012-2018. Následně je provedeno porovnání aktuálních sazeb s náklady těchto zařízení kalkulovanými pomocí metody Activity-Based Costing. Analyzovány jsou i výnosy od jednotlivých plátců péče a jejich souvislost s case mix indexem. Výstupem práce je diskuze možných změn úhrad z pohledu plátců i poskytovatelů péče, společně s možným vlivem přesunu pojištěnců.Utilization of an acute inpatient care payment mechanism based on Diagnosis-Related Groups (DRG) is one of the most discussed topics of the Czech health care system. The aim of the thesis is to design possible improvements of the mechanism and to discuss them subsequently. Firstly, current state and gradual cultivation of acute inpatient care payments and DRG system is comprehensively reviewed. The situation in the Czech Republic is put in context of other EU member states. The issue of payments is also evaluated for specific hospitals. Using a method of half-structured interviews, the analysis of a payment mechanism is conducted on case of three health care providers for period of 2012 to 2018. Next, current rates are compared with costs of the hospitals calculated with the Activity-Based Costing method. Also, revenues raised by individual payers of care and the relationship of the revenues with the case mix index are analyzed. The outcome of the thesis is the discussion on possible changes of the payments from the perspective of the providers of health care as well as payers and potential influence of fluctuation of insured individuals
Use of cumulative mortality data in patients with acute myocardial infarction for early detection of variation in clinical practice: observational study
OBJECTIVES: Use of cumulative mortality adjusted for
case mix in patients with acute myocardial infarction
for early detection of variation in clinical practice.
DESIGN: Observational study.
SETTING: 20 hospitals across the former Yorkshire
region.
PARTICIPANTS: All 2153 consecutive patients with
confirmed acute myocardial infarction identified
during three months.
MAIN OUTCOME MEASURES: Variable lifeadjusted
displays showing cumulative differences between
observed and expected mortality of patients; expected
mortality calculated from risk model based on
admission characteristics of age, heart rate, and
systolic blood pressure.
RESULTS: The performance of two individual hospitals
over three months was examined as an example. One,
the smallest district hospital in the region, had a series
of 30 consecutive patients but had five more deaths
than predicted. The variable lifeadjusted display
showed minimal variation from that predicted for the
first 15 patients followed by a run of unexpectedly
high mortality. The second example was the main
tertiary referral centre for the region, which admitted
188 consecutive patients. The display showed a period
of apparently poor performance followed by
substantial improvement, where the plot rose steadily
from a cumulative net lives saved of - 4 to 7. These
variations in patient outcome are unlikely to have
been revealed during conventional audit practice.
CONCLUSIONS: Variable lifeadjusted display has been
integrated into surgical care as a graphical display of
riskadjusted survival for individual surgeons or centres.
In combination with a simple risk model, it may have a
role in monitoring performance and outcome in
patients with acute myocardial infarction
Results from the Scottish national HAI prevalence survey
A national point prevalence survey was undertaken over the period of one calendar year in Scotland from October 2005 to October 2006. The prevalence of healthcare-associated infection (HAI) was 9.5% in acute hospitals and 7.3% in non-acute hospitals. The highest prevalence of HAI in acute hospital inpatients was found in the following specialties: care of the elderly (11.9%), surgery (11.2%), medicine (9.6%) and orthopaedics (9.2%). The lowest prevalence was found in obstetrics (0.9%). The most common types of HAI in acute hospital inpatients were: urinary tract infections (17.9% of all HAI), surgical site infections (15.9%) and gastrointestinal infections (15.4%). In non-acute hospitals one in ten inpatients in two specialties (combined) medicine (11.4%) and care of the elderly (7.8%) was found to have HAI, and one in 20 inpatients in psychiatry (5.0%) had HAI. In non-acute hospital patients, urinary tract infections were frequent (28.1% of all HAI) and similarly skin and soft tissue infection (26.8% of all HAI). When combined, these two HAI types affected 4% of all the inpatients in non-acute hospitals. This is the first survey of its kind in Scotland and describes the burden of HAI at a national level
Bundling Payment for Episodes of Hospital Care: Issues and Recommendations for the New Pilot Program in Medicare
Outlines the 2010 healthcare reform's provision to launch a pilot project for bundling Medicare payments around hospitalization episodes of care, the rationale for hospital episode bundling, and guidance on designing an effective pilot program
Physician-owned specialized facilities: focused factories or destructive competition?: a systematic review.
Multiple studies have investigated the business case of physician-owned specialized facilities (specialized hospitals and ambulatory surgery centers). However literature lacks integration. Building on the theoretical insights of disruptive innovation, a systematic review was conducted to assess the evidence base of these innovative delivery models. The Institute of Medicine’s quality framework (safe, effective, equitable, efficient, patient-centered and accessible care) was applied in order to evaluate the performance of such facilities. In addition the corresponding impact on full-service general hospitals was assessed. Database searches yielded 6,108 candidate articles of which 47 studies fulfilled the inclusion criteria. Overall the quality of the included studies was satisfactory. Our results show that little evidence exists in support of competitive advantages in favor of specialized facilities. Moreover even if competitive advantages exist, it is equally important to reflect on the corresponding impact on full service-general hospitals. The development of specialized facilities should therefore be monitored carefully
Taxonomic classification of planning decisions in health care: a review of the state of the art in OR/MS
We provide a structured overview of the typical decisions to be made in resource capacity planning and control in health care, and a review of relevant OR/MS articles for each planning decision. The contribution of this paper is twofold. First, to position the planning decisions, a taxonomy is presented. This taxonomy provides health care managers and OR/MS researchers with a method to identify, break down and classify planning and control decisions. Second, following the taxonomy, for six health care services, we provide an exhaustive specification of planning and control decisions in resource capacity planning and control. For each planning and control decision, we structurally review the key OR/MS articles and the OR/MS methods and techniques that are applied in the literature to support decision making
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