Adequação dos exames de radiologia solicitados por um departamento de emergência: um estudo retrospetivo

Imaging tests are essential for diagnosis in the emergency context and convey clinical information that is essential to assess the appropriateness of the tests and improve their interpretation. Therefore, we aimed to analyze the imaging tests requested by the Emergency Department in a district hospital.info:eu-repo/semantics/publishedVersio

Implementation of a Standardized Oral Screening Tool by Pediatric Cardiologists

Background: An examination of procedure cancellations found that the lack of preprocedural oral screening was a preventable cause, for children with congenital heart disease. The purpose of this study was to implement an oral screening tool within the pediatric cardiology clinic, with referral to pediatric dental providers for positive screens. The target population were children age ≥ 6 mo. to \u3c 18 yr. old, being referred for cardiac procedures. Methods: The Quality Implementation Framework method was used for this study design. The multimodal intervention included education, audit and feedback, screening guidelines, environmental support, and interdisciplinary collaboration. Baseline rates for oral screenings were determined by retrospective chart audit from January 2018 to January 2019 (n=211). Adherence to the oral screening tool was the outcome measure. Positive oral screens, resulting in referral to the pediatric dental clinic, were measured as a secondary outcome. Provider compliance rates were used as a process measure. Results: Data collected over 14-weeks showed a 29% increase in documentation of oral screenings prior to referral, as compared to the retrospective chart audit. During the study period 13% of completed screenings were positive (n=5). Provider compliance for the period averaged 70%. Conclusion: A substantial increase in preprocedural oral screenings by pediatric cardiologists was achieved using the Quality Implementation Framework, and targeted interventions

The Group Employed Model as a Foundation for Health Care Delivery Reform

Outlines group employed models, with salaried primary and specialty care physicians and quality of care- and satisfaction-based incentives as high-quality, low-cost alternatives to fee-for-service; elements of success; and implications beyond Medicare

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

Treatment of acute ischemic stroke with recombinant tissue plasminogen activator: practice pattern among neurologists and physicians

Background: Stroke is an abrupt onset of a neurologic deficit due to a focal vascular disease. Treatment guidelines for acute ischemic stroke (AIS) within 4.5 hours of onset are thrombolysis with recombinant tissue plasminogen activator (rtPA). To determine the practice pattern of rtPA in the treatment of acute ischemic stroke among consultants using a questionnaire.Methods: A questionnaire based study was carried out from May to September 2015. Neurologists and physicians from Kolar and Bengaluru were given a questionnaire comprising of 21 questions, regarding the treatment of AIS with rtPA. The data was analyzed using descriptive statistics.Results: A total of 76.9% responded to the questionnaire, of which 18 were neurologists and 82 were physicians. An average of 4-5 AIS patients per month were seen by the doctors. Majority (72%) did not use rtPA, due to delay in patient reaching hospital or non-affordability of the drug. The consultants (66%) opined that rtPA was the best if patient arrived within 4.5 hours of onset of AIS. Only 34% consultants knew the correct score of AIS for administration of rtPA. The usage of penumbral imaging before thrombolysis was agreed by neurologists (58%) and physicians (34%). The IV+IA rtPA thrombolytic therapy produced highest rate of recanalization as expressed by neurologists (84%) and physicians (56%). Majority (80%) felt that use of rtPA beyond 4-6 hours had no beneficial effect. The adverse effects encountered were hypotension and bleeding.Conclusions: Neurologists and physicians opined that treatment with rtPA was effective in patients of AIS within 4.5 hours of onset, but the limitations were late arrival of patient to hospital and drug cost

Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: An overview of systematic reviews

Background: Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials. Objectives: To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care. Methods: We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'. We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview. Main results: We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care. Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important. Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence). The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence). None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications. Authors' conclusions: We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials. We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice. Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions. </p

Home opioid use following cesarean delivery: How many opioid tablets should obstetricians prescribe?

AimTo quantify home opioid use after cesarean delivery and identify factors associated with increased opioid use.MethodsA convenience sample of women discharged by postoperative day 2 following a term cesarean delivery of a singleton fetus from May 2015 to May 2016 were contacted 2 weeks post‐partum and questioned regarding opioid use, pain control and pain expectations.ResultsAmong 141 women included in the analysis, the median number of opioid tablets used was 36 (interquartile range 16–45) and the median number prescribed was 60 (interquartile range 42–65). Logistic regression identified operative time ≥59.5 min and number of opioid tablets prescribed as two factors independently associated with opioid use in the top quartile.ConclusionIn the first 2 weeks post‐partum, 75% of women used 45 or fewer opioid tablets. Operative time over 1 h and increased number of opioid tablets prescribed are factors associated with higher post‐partum opioid use.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/143657/1/jog13579.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/143657/2/jog13579_am.pd

Benzodiazepine and z-hypnotic prescribing from acute psychiatric inpatient discharge to long-term care in the community

Background: Benzodiazepine and z-hypnotic prescribing has slowly decreased over the past 20 years, however long-term chronic prescribing still occurs and is at odds with prescribing guidance. Objectives: To identify the pattern of benzodiazepine and z-hypnotic prescribing in psychiatric inpatients at discharge and 12 months post-discharge. Methods: Retrospective observational longitudinal cohort study of patients admitted to two adult psychiatric wards between June and November 2012 (inclusive) who were discharged with a prescription for a benzodiazepine or z-hypnotic drug. Routinely collected prescription data available from NHS Scotland Prescribing Information System was used to identify and follow community prescribing of benzodiazepine and z-hypnotics for a 12 month period post-discharge. Data were entered in Excel® and further analysed using SPSS 23. Ethical approval was not required for this service evaluation however Caldicott Guardian approval was sought and granted. Results: Eighty patients were admitted during the study period however only those patients with a single admission were included for analysis (n=74). Thirty per cent (22/74) of patients were prescribed a benzodiazepine or z-hypnotics at discharge; 14 of whom received ‘long-term’ benzodiazepine and z-hypnotics i.e. continued use over the 12 month period. Seven patients received a combination of anxiolytics and hypnotics (e.g., diazepam plus temazepam or zopiclone). Long-term use was associated with a non-significant increase in median benzodiazepine or z-hypnotic dose, expressed as diazepam equivalents. Conclusions: One in three patients were prescribed a benzodiazepine or z-hypnotics at discharge with 1 in 5 receiving continuous long-term treatment (prescriptions) for 12 months post-discharge. As chronic long-term B-Z prescribing and use still remains an issue, future strategies using routine patient-level prescribing data may support prescribers to review and minimise inappropriate long-term prescribing