The Efficacy of Peripheral Opioid Antagonists in Opioid-Induced Constipation and Postoperative Ileus: A Systematic Review of the Literature.

Opioid-induced constipation has a negative impact on quality of life for patients with chronic pain and can affect more than a third of patients. A related but separate entity is postoperative ileus, which is an abnormal pattern of gastrointestinal motility after surgery. Nonselective μ-opioid receptor antagonists reverse constipation and opioid-induced ileus but cross the blood-brain barrier and may reverse analgesia. Peripherally acting μ-opioid receptor antagonists target the μ-opioid receptor without reversing analgesia. Three such agents are US Food and Drug Administration approved. We reviewed the literature for randomized controlled trials that studied the efficacy of alvimopan, methylnaltrexone, and naloxegol in treating either opioid-induced constipation or postoperative ileus. Peripherally acting μ-opioid receptor antagonists may be effective in treating both opioid-induced bowel dysfunction and postoperative ileus, but definitive conclusions are not possible because of study inconsistency and the relatively low quality of evidence. Comparisons of agents are difficult because of heterogeneous end points and no head-to-head studies

The main methodological issues in costing health care services: A literature review

The Healthbasket project seeks to offer evidence on the basket of services offered by the health system in nine member states, and the costs and prices associated with those services. A specific objective of the project is “to identify what are the existing possibilities for and limitation to [cost] comparison and recommend the minimum data required to furnish meaningful international comparison in the future.” To that end, work programme WP7 assesses the costing methodologies for inpatient and outpatient health services at the micro-level. The aim of the WP7 subproject is to provide a comprehensive review best practice in cost assessment by examining the scientific literature on methodologies for calculating health service costs. This review examines published scientific literature about the methodologies used to estimate the costs associated with the delivery of a particular service at the micro-level in both in-patient and out-patient settings. In addition, the review summarises the scientific literature on methodologies used in international comparative studies of health service costs at the micro-level, including in-patient and outpatient settings.

Marshfield Clinic: Health Information Technology Paves the Way for Population Health Management

Highlights Fund-defined attributes of an ideal care delivery system and best practices, including an internal electronic health record, primary care teams, physician quality metrics and mentors, and standardized care processes for chronic care management

A Grounded Theory of Patient Flow Management within the Emergency Department

Background: Emergency department (ED) crowding is an urgent threat to patient safety and negatively impacts healthcare staff and institutions. Patient flow researchers have employed a range of methods to address this crisis, including an increase in the use of operations research and operations management strategies. However, identified patient flow solutions are inadequate. Research describing the complexities of patient flow processes and investigating the work and contributions of ED nurses is needed. Purposes: The purposes of this study were to explore how ED nurses perform patient flow management and to develop a constructivist grounded theory of patient flow management within the ED. Methods: A conceptual foundation for patient flow management was first established using evolutionary concept analysis and expanded concept analysis approaches. This study then employed constructivist grounded theory and situational analysis methodologies to examine the work of ED nurses. Data was collected through 29 focus groups and interviews with 27 participants and 64 hours of participant observations across four EDs. Data analysis relied on coding, constant comparative analysis, and memo-writing to identify emergent themes and develop a substantive theory. Findings: Concept analyses defined patient flow management as the application of ED experience, holistic perspectives, dynamic data, and complex considerations of multiple priorities by ED nurses to promote patient safety within their scope of responsibility. The study offers three main contributions: a theoretical model of the work of ED patient flow management, a theoretical framework to describe holistic considerations of factors that impact departmental capacity and nurse engagement in patient flow management, and a grounded theory of patient flow management capacity and engagement that describes how ED nurses adapt patient flow management strategies according to patient burden. Conclusion: This study offers a new conceptual and theoretical foundation to understand the work of patient flow management. This novel perspective centralizes the work of ED nurses as active agents in patient flow processes and describes their strategies and contributions to meet patient care needs. Several practical considerations are offered to engage and support nurses in their roles as patient flow managers, improve patient flow processes, and further investigate ED nurse patient flow management

Exit block in emergency departments: a rapid evidence review.

BACKGROUND: Exit block (or access block) occurs when 'patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame'. Exit block is an increasing challenge for Emergency Departments (EDs) worldwide and has been recognised as a major factor in leading to departmental crowding. This paper aims to identify empirical evidence, highlighting causes, effects and strategies to limit exit block. METHODS: A computerised literature search was conducted of English language empirical evidence published between 2008 and 2014 using a combination of terms relating to exit block in ED. RESULTS: 233 references were identified following the computerised search. Of these, 32 empirical articles of varying scientific quality were identified as relevant and results were presented under a number of headings. The majority of studies presented data relating to the impact of exit block on departments, patients and staff. A smaller number of articles evaluated interventions designed to reduce exit block. Evidence suggests that exit block is more likely to occur in more densely populated areas and less likely to occur in paediatric settings. Bed occupancy appears to be associated with exit block. Evidence supporting the impact of initiatives pointed towards increasing workforce and inpatient bed resources within the hospital setting to reduce block. CONCLUSIONS: Further evidence is needed, especially within the NHS setting to increase the understanding around factors that cause exit block, and interventions that are shown to relieve it without compromising patient outcomes

Effectiveness and cost effectiveness of pharmacist input at the ward level: a systematic review and meta-analysis

Background Pharmacists play important role in ensuring timely care delivery at the ward level. The optimal level of pharmacist input, however, is not clearly defined. Objective To systematically review the evidence that assessed the outcomes of ward pharmacist input for people admitted with acute or emergent illness. Methods The protocol and search strategies were developed with input from clinicians. Medline, EMBASE, Centre for Reviews and Dissemination, The Cochrane Library, NHS Economic Evaluations, Health Technology Assessment and Health Economic Evaluations databases were searched. Inclusion criteria specified the population as adults and young people (age >16 years) who are admitted to hospital with suspected or confirmed acute or emergent illness. Only randomised controlled trials (RCTs) published in English were eligible for inclusion in the effectiveness review. Economic studies were limited to full economic evaluations and comparative cost analysis. Included studies were quality-assessed. Data were extracted, summarised. and meta-analysed, where appropriate. Results Eighteen RCTs and 7 economic studies were included. The RCTs were from USA (n=3), Sweden (n=2), Belgium (n=2), China (n=2), Australia (n=2), Denmark (n=2), Northern Ireland, Norway, Canada, UK and Netherlands. The economic studies were from UK (n=2), Sweden (n=2), Belgium and Netherlands. The results showed that regular pharmacist input was most cost effective. It reduced length-of-stay (mean= -1.74 days [95% CI: -2.76, -0.72], and increased patient and/or carer satisfaction (Relative Risk (RR) =1.49 [1.09, 2.03] at discharge). At £20,000 per quality-adjusted life-year (QALY)-gained cost-effectiveness threshold, it was either cost-saving or cost-effective (Incremental Cost Effectiveness Ratio (ICER) =£632/ QALY-gained). No evidence was found for 7-day pharmacist presence. Conclusions Pharmacist inclusion in the ward multidisciplinary team improves patient safety and satisfaction and is cost-effective when regularly provided throughout the ward stay. Research is needed to determine whether the provision of 7-day service is cost-effective.Peer reviewe

Hospital Acquired Infections in Patients Admitted to the ICU: Impact on Length of Stay, Mortality, and Cost

Objective: To explore the clinical and financial impact of hospital-acquired infections (HAIs) in patients admitted to the Intensive Care Unit (ICU) using statewide representative databases for Washington (WA), New Jersey (NJ), Florida (FL) and New York (NY). Specifically, the following questions will be addressed: 1) Is there an association between HAIs and hospital Length of Stay (LOS) in patients who have an ICU stay ?, 2) Is there an association between HAIs and hospital mortality in patients who have an ICU stay ?, 3) Is there an association between HAIs and hospital cost in patients who have an ICU stay ?, 4) Does the association of HAIs to LOS, mortality and costs vary by type of HAI (as identified by diagnosis related codes) in patients who have ICU stay ?, and 5) Does the association of HAIs to LOS, mortality and cost vary by sex (male or female) in patients who have ICU stay? Methods: Multi-state hospital billing data retrospective cohort study using Healthcare Cost and Utilization Project (HCUP) statewide databases for WA, FL, NJ and NY. Results: HAIs have significant association to clinical and financial indicators within the ICU: LOS increases by a factor of 2.49 times (22.94 days vs. 9.20 days), mortality increases by a factor of 7.149 times, and total adjusted cost increases by a factor of 3.02 times ($68,503 vs.$22,659). Discussion: Certain states such as WA report higher HAI infection rates than others (NY, NJ and FL). It needs to be determined if this is due to higher transparency of reporting and/or under reporting in other states. Some of the larger differences in infection rates could be due to disease severity of patients with HAIs in ICU and non-ICU. Infection control measures need to target HAIs that are more prevalent and costly in the ICU

Transitions of Care: Raising Awareness and Improving Identification of the Social Determinants of Health

Problem: Hospital readmission rates have steadily climbed in the United States and the cost of unplanned readmissions can be detrimental. It has been identified that greater discharge preparation and quality care coordination greatly impacts the patient’s plan of care and reduces the risk of unplanned 30-day readmissions. Transition programs help reduce the psychosocial barriers that prevent patients from being able to self-manage their conditions outside the acute setting and help patients effectively navigate the through the continuum of care. Context: Research has shown that when the social determinants of health (SDOH) barriers are identified appropriately and early-on, this can decrease a patient’s risk of unplanned readmission. Audit results show opportunities for improvement in the program through development of a screening tool that will help clinicians appropriately identify psychosocial issues and increase educational awareness of the Transition Program (TP) as well as SDOH. Interventions: Several interventions were done to help increase low-elevated transitional support level referrals to TP: development of a psychosocial assessment tool, in-service meeting to review the referral process of the TP, and staff education to raise awareness and importance of identifying SDOH in patient care outcomes. Measures: Using HealthConnect and EPIC data to track weekly number of referral cases. Monitor if the development and implementation of the tool has increased the number of lowelevated TSL referrals to the Transition Program. Results: There was a 25% increase in low TSL referrals. Clinicians reported increased awareness and knowledge about SDOH and Transition Program interventions. Conclusions: Readmission and identifying SDOH barriers is a complex challenge to healthcare and requires interdisciplinary team collaboration and multimodal interventions

Understanding the role of physicians within the managerial structure of Russian hospitals.

This article examines the role of physicians within the managerial structure of Russian hospitals. A comparative qualitative methodology with a structured assessment framework is used to conduct case studies that allow for international comparison. The research is exploratory in nature and comprises 63 individual interviews and 49 focus groups with key informants in 15 hospitals, complemented by document analysis. The material was collected between February and April 2017 in five different regions of the Russian Federation. The results reveal three major problems of hospital management in the Russian Federation. First, hospitals exhibit a leaky system of coordination with a lack of structures for horizontal exchange of information within the hospitals (meso-level). Second, at the macro-level, the governance system includes implementation gaps, lacking mechanisms for coordination between hospitals that may reinforce existing inequalities in service provision. Third, there is little evidence of a learning culture, and consequently, a risk that the same mistakes could be made repeatedly. We argue for a new approach to governing hospitals that can guide implementation of structures and processes that allow systematic and coherent coordination within and among Russian hospitals, based on modern approaches to accountability and organisational learning