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Tsui E. Using Social Media to Disseminate Ophthalmic Information during the #COVID19 Pandemic. Ophthalmology 2020; 127:e75-e78. [PMID: 32502595 PMCID: PMC7265847 DOI: 10.1016/j.ophtha.2020.05.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/20/2023] Open
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Jacobi JV. Payment Theory and the Last Mile Problem. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:474-479. [PMID: 33021174 DOI: 10.1177/1073110520958871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Health reform debate understandably focuses on large system design. We should not omit attention to the "last mile" problem of physician payment theory. Achieving fundamental goals of integrative, patient-centered primary care depends on thoughtful financial support. This commentary describes the nature and importance of innovative primary care payment programs.
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Berlin J. Road to Recovery: COVID-19 Tests, Bends, and Breaks Texas Practices. Tex Med 2020; 116:20-25. [PMID: 32866271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Ricardo Garza, MD, was still walking the tightrope: standing, but unable to withstand another gust of wind. COVID-19 swept away about 35% of the San Antonio solo cardiologist's practice revenue, and that was just what he could calculate as he waited for insurers to process straggling claims. But he had returned to in-office operations without any layoffs. While some practices are surviving - and trying their best to prepare for future threats - others weren't so lucky. On-the-ground experiences align with the Texas Medical Association's Practice Viability Survey in showing COVID-19 was, and still is, a disruptor unlike any other - challenging or torpedoing the viability of various practice types.
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Thiesset HF, Schliep KC, Stokes SM, Valentin VL, Gren LH, Porucznik CA, Huang LC. Opioid Misuse and Dependence Screening Practices Prior to Surgery. J Surg Res 2020; 252:200-205. [PMID: 32283333 PMCID: PMC8668076 DOI: 10.1016/j.jss.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/19/2020] [Accepted: 03/08/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND A majority of surgical patients are prescribed opioids for pain management. Many patients have pre-existing chronic pain managed with opioids and/or opioid use disorders (OUDs), which can complicate perioperative management. Patients who use opioids prior to surgery are at increased risk of developing OUD after surgery. To date, no studies have examined the prevalence of opioid screening and electronic medical record (EMR) documentation prior to surgery. MATERIALS AND METHODS A 40-item survey was administered to 268 patients at their first postoperative care visit at a single tertiary academic center from October 2017 to July 2018. A chart review of a random sample of 100 patients was performed to determine provider opioid screening prevalence in the presurgical setting. Log-binomial models were used to calculate prevalence ratios (PRs) to determine the provider role (surgeon, advanced practice clinicians [APC], surgical trainee) association with opioid screening documentation. Exploratory qualitative interviews were conducted with surgical providers to identify barriers to screening and screening documentation. RESULTS Only 7% of patients were screened preoperatively for opioid use. A total of 38% of patients self-reported that they had used opioids in the past year. Of that group, only 3% had screening by a surgical provider prior to surgery documented in their EMR. Provider role was not associated with likelihood of opioid screening (surgeon versus trainee, PR = 1.2, 95% CI 0.2-8.5) (surgeons versus APCs, PR = 1.05, 95% CI 0.17-8.53). EMRs were discordant with patient survey results for patients with no ICD-10 codes for opioid use. The most common perceived barriers to preoperative screening were insufficient clinic time; logistics of who should screen/not required as part of their clinical workflow; not perceiving screening as a priority; and lack of expertise in the area of chronic opioid use and OUD. CONCLUSIONS Preoperative screening for opioid use is uncommon, and EMRs are often discordant with patient self-reported use. Efforts to increase preoperative screening will need to address barriers screening practices and increasing health system support by incorporating screening into the clinical workflow and adding it to documentation templates.
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Buchanan TR, Johns EA, Massad LS, Dick R, Thaker PH, Hagemann AR, Fuh KC, McCourt CK, Powell MA, Mutch DG, Kuroki LM. A fellow-run clinic achieves similar patient outcomes as faculty clinics: A safe and feasible model for gynecologic oncology fellow education. Gynecol Oncol 2020; 159:209-213. [PMID: 32694061 DOI: 10.1016/j.ygyno.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/11/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Fellow involvement in patient care is important for education, but effect on patient care is unclear. Our aim was to compare patient outcomes in gynecologic oncology attending clinics versus a fellow training clinic at a large academic medical center. METHODS A retrospective review of consecutive gynecologic oncology patients from six attending clinics and one faculty-supervised fellow clinic was used to analyze differences based on patient demographics, cancer characteristics, and practice patterns. Primary outcome was overall survival (OS); secondary outcomes included recurrence-free survival (RFS), postoperative complications and chemotherapy within the last 30 days of life. Survival analyses were performed using Kaplan-Meier curves with log-rank tests. RESULTS Of 159 patients, 76 received care in the attending clinic and 83 in the fellow clinic. Patients in the fellow clinic were younger, less likely to be Caucasian, and more overweight, but cancer site and proportion of advanced stage disease were similar. Both clinics had similar rates of moderate to severe adverse events related to surgery (15% vs. 8%, p = .76), chemotherapy (21% vs. 23%, p = .40), and radiation (14% vs. 17%, p = .73). There was no difference in median RFS in the fellow compared to attending clinic (38 vs. 47 months, p = .78). OS on both univariate (49 months-fellow clinic, 60 months-attending clinic vs. p = .40) and multivariate analysis [hazard ratio 1.3 (0.57, 2.75), P = .58] was not significantly different between groups. CONCLUSIONS A fellow-run gynecologic oncology clinic designed to provide learning opportunities does not compromise patient outcomes and is a safe and feasible option for fellow education.
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Szczapa T, Hożejowski R, Krajewski P. Implementation of less invasive surfactant administration in clinical practice-Experience of a mid-sized country. PLoS One 2020; 15:e0235363. [PMID: 32628732 PMCID: PMC7337349 DOI: 10.1371/journal.pone.0235363] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/13/2020] [Indexed: 11/18/2022] Open
Abstract
Objective There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level. Methods A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform. Results Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated “easy/very easy” vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with “RAM” cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes. Conclusions The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.
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Dotzauer R, Böhm K, Brandt MP, Sparwasser P, Haack M, Frees SK, Kamal MM, Mager R, Jäger W, Höfner T, Tsaur I, Haferkamp A, Borgmann H. Global change of surgical and oncological clinical practice in urology during early COVID-19 pandemic. World J Urol 2020; 39:3139-3145. [PMID: 32623500 PMCID: PMC7335229 DOI: 10.1007/s00345-020-03333-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives While the coronavirus disease 2019 (COVID-19) pandemic captures healthcare resources worldwide, data on the impact of prioritization strategies in urology during pandemic are absent. We aimed to quantitatively assess the global change in surgical and oncological clinical practice in the early COVID-19 pandemic. Methods In this cross-sectional observational study, we designed a 12-item online survey on the global effects of the COVID-19 pandemic on clinical practice in urology. Demographic survey data, change of clinical practice, current performance of procedures, and current commencement of treatment for 5 conditions in medical urological oncology were evaluated. Results 235 urologists from 44 countries responded. Out of them, 93% indicated a change of clinical practice due to COVID-19. In a 4-tiered surgery down-escalation scheme, 44% reported to make first cancellations, 23% secondary cancellations, 20% last cancellations and 13% emergency cases only. Oncological surgeries had low cancellation rates (%): transurethral resection of bladder tumor (27%), radical cystectomy (21–24%), nephroureterectomy (21%), radical nephrectomy (18%), and radical orchiectomy (8%). (Neo)adjuvant/palliative treatment is currently not started by more than half of the urologists. COVID-19 high-risk-countries had higher total cancellation rates for non-oncological procedures (78% vs. 68%, p = 0.01) and were performing oncological treatment for metastatic diseases at a lower rate (35% vs. 48%, p = 0.02). Conclusion The COVID-19 pandemic has affected clinical practice of 93% of urologists worldwide. The impact of implementing surgical prioritization protocols with moderate cancellation rates for oncological surgeries and delay or reduction in (neo)adjuvant/palliative treatment will have to be evaluated after the pandemic. Electronic supplementary material The online version of this article (10.1007/s00345-020-03333-6) contains supplementary material, which is available to authorized users.
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Alterio D, Volpe S, Marvaso G, Turturici I, Ferrari A, Leonardi MC, Lazzari R, Fiore MS, Bufi G, Cattani F, Arrobbio C, Patti F, Casbarra A, Cavallo I, Mastrilli F, Orecchia R, Jereczek‐Fossa BA. Head and neck cancer radiotherapy amid COVID-19 pandemic: Report from Milan, Italy. Head Neck 2020; 42:1482-1490. [PMID: 32557972 PMCID: PMC7323327 DOI: 10.1002/hed.26319] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/20/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Management of head and neck cancers (HNC) in radiation oncology in the coronavirus disease 2019 (COVID-19) era is challenging. Aim of our work is to report organization strategies at a radiation therapy (RT) department in the first European area experiencing the COVID-19 pandemic. METHODS We focused on (a) dedicated procedures for HNC, (b) RT scheduling, and (c) health care professionals' protection applied during the COVID-19 breakdown (from March 1, 2020 to April 30, 2020). RESULTS Applied procedures are reported and discussed. Forty-three patients were treated. Image-guided, intensity modulated RT was performed in all cases. Median overall treatment time was 50 (interquartile range: 47-54.25) days. RT was interrupted/delayed in seven patients (16%) for suspected COVID-19 infection. Two health professionals managing HNC patients were proven as COVID-19 positive. CONCLUSION Adequate and well-timed organization allowed for the optimization of HNC patients balancing at the best of our possibilities patients' care and personnel's safety.
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Finley EP, Schneegans S, Curtis ME, Bebarta VS, Maddry JK, Penney L, McGeary D, Potter JS. Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts. PLoS One 2020; 15:e0234425. [PMID: 32542028 PMCID: PMC7295233 DOI: 10.1371/journal.pone.0234425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 05/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors. OBJECTIVE We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S. DESIGN We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems. PARTICIPANTS Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated. APPROACH Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation. KEY RESULTS Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery. CONCLUSIONS Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.
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Khalfallah M, Makni A, Bouassida M, Bayar R, Abdelkafi S, Ben Amar M, Arfa N, Nouira R. Recommandations of the Tunisian Association of Surgery for the practice of visceral surgery during COVID-19 pandemic. LA TUNISIE MEDICALE 2020; 98:442-445. [PMID: 33479960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The World Health Organization declared on March 11, 2020 that the COVID-19 epidemic has become a pandemic. In Tunisia, the Ministry of Health has recommended enhanced preventive hygiene measures to contain and limit the spread of the virus. Following the entry of Tunisia into phase 4 of the COVID-19 epidemic, the Tunisian Association of Surgery proposed recommendations related to surgical activity. Surgical emergencies must be treated urgently and without delay. Non-tumor pathologies which require surgery in an elective situation and for which the risk of aggravation or complication is considered low shoud be postponed. For digestive tumor pathology, and apart from complicated forms, neoadjuvant treatment is highly recommended in the context of multidisciplinary concertation staff.
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Abstract
Approximately 50% of women experience at least one bone fracture postmenopause. Current screening approaches target anti-fracture interventions to women aged >60 years who satisfy clinical risk and bone mineral density criteria for osteoporosis. Intervention is only recommended in 7-25% of those women screened currently, well short of the 50% who experience fractures. Large screening trials have not shown clinically significant decreases in the total fracture numbers. By contrast, six large clinical trials of anti-resorptive therapies (for example, bisphosphonates) have demonstrated substantial decreases in the number of fractures in women not identified as being at high risk of fracture. This finding suggests that broader use of generic bisphosphonates in women selected by age or fracture risk would result in a reduction in total fracture numbers, a strategy likely to be cost-effective. The utility of the current bone density definition of osteoporosis, which neither corresponds with who suffers fractures nor defines who should be treated, requires reappraisal.
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Jones-Bonofiglio K, Nortjé N. A policy and decision-making framework for South African doctors during the COVID-19 pandemic. S Afr Med J 2020; 110:613-616. [PMID: 32880333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 06/11/2023] Open
Abstract
Faced with a pandemic, doctors around the world are forced to make difficult ethical decisions about clinical, economic and politically charged issues in medicine and healthcare, with little time or resources for support. A decision-making framework is suggested to guide policy and clinical practice to support the needs of healthcare workers, help to allocate scarce resources equitably and promote communication among stakeholders, while drawing on South African doctors' knowledge, culture and experience.
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Pollock K, Setzen M, Svider PF. Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: An invited commentary. Am J Otolaryngol 2020; 41:102490. [PMID: 32307192 PMCID: PMC7159874 DOI: 10.1016/j.amjoto.2020.102490] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic has quickly and radically altered how Otolaryngologists provide patient care in the outpatient setting. Continuity of care with established patients as well as establishment of a professional relationship with new patients is challenging during this Public Health Emergency (PHE). Many geographic areas are under "stay at home" or "shelter in place" directives from state and local governments to avoid COVID-19 exposure risks. Medicare has recently allowed "broad flexibilities to furnish services using remote communications technology to avoid exposure risks to health care providers, patients, and the community." [1] The implementation of telemedicine, or virtual, services, will help the Otolaryngologists provide needed care to patients while mitigating the clinical and financial impact of the pandemic. The significant coding and billing issues related to implementing telemedicine services are discussed to promote acceptance of this technology by the practicing Otolaryngologist. Of particular importance, outpatient visit Current Procedural Terminology® codes (99201-99215) may be used for telehealth visits performed in real-time audio and video.
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Lee JT, Polsky D, Fitzsimmons R, Werner RM. Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations. JAMA Netw Open 2020; 3:e204439. [PMID: 32383749 PMCID: PMC7210481 DOI: 10.1001/jamanetworkopen.2020.4439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The incentive structure of accountable care organizations (ACOs) may lead to participating physician groups selecting fewer vulnerable patients. OBJECTIVE To test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining the ACO. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort consisted of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups from 2010 to 2016. Medicare Shared Savings Program (MSSP) participation was determined using ACO files. Analyses were conducted between January 1, 2019, and February 25, 2020. EXPOSURES Using linear probability models, we conducted difference-in-differences analyses based on the year a physician group joined an ACO to estimate changes in vulnerable patients within ACO-participating groups compared with nonparticipating groups. MAIN OUTCOMES AND MEASURES Whether the patient was black, was dually enrolled in Medicare and Medicaid, and poverty and unemployment rates of the patient's zip code. RESULTS In a cohort of 76 717 physician groups caring for 7 307 130 patients, 16.1% of groups caring for 27.8% of patients participated in an MSSP ACO. Using 2010 characteristics, patients attributed to ACOs from 2012 to 2016, compared with those who were not, were less likely to be black (8.0% [n = 81 698] vs 9.3% [n = 270 924]) or dually enrolled in Medicare and Medicaid (12.8% [n = 130 957] vs 18.2% [n = 528 685]), and lived in zip codes with lower poverty rates (13.8% vs 15.5%); unemployment rates were similar (8.0% vs 8.5%). In the difference-in-differences analysis, there was no statistically significant change associated with ACO participation in the proportions of vulnerable patients attributed to ACO-participating groups compared with nonparticipating groups. After joining an ACO, ACO-participating groups had 0.0 percentage points change (95% CI, -0.1 to 0.1 percentage points; P = .59) for black patients, -0.1 percentage points (95% CI, -0.2 to 0.1 percentage points; P = .32) for patients dually enrolled in Medicare and Medicaid, 0.2 percentage points (95% CI, -3.5 to 4.0 percentage points; P = .91) in poverty rates, and -0.4 percentage points (95% CI, -2.0 to 1.2 percentage points; P = .62) in unemployment rates. CONCLUSIONS AND RELEVANCE In this cohort study, there were no changes in the proportions of vulnerable patients cared for by ACO-participating physician groups after joining an ACO compared with changes among nonparticipating groups.
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Krzystanek M, Matuszczyk M, Krupka-Matuszczyk I, Koźmin-Burzyńska A, Segiet S, Przybyło J. Letter to Editor. Polish recommendations for conducting online visits in psychiatric care. PSYCHIATRIA POLSKA 2020; 54:391-394. [PMID: 32772068 DOI: 10.12740/pp/120067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
no summary.
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Dehmer GJ, Badhwar V, Bermudez EA, Cleveland JC, Cohen MG, D'Agostino RS, Ferguson TB, Hendel RC, Isler ML, Jacobs JP, Jneid H, Katz AS, Maddox TM, Shahian DM. 2020 AHA/ACC Key Data Elements and Definitions for Coronary Revascularization: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Coronary Revascularization). J Am Coll Cardiol 2020; 75:1975-2088. [PMID: 32217040 DOI: 10.1016/j.jacc.2020.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Steward WT, Koester KA, Guzé MA, Kirby VB, Fuller SM, Moran ME, Botta EW, Gaffney S, Heath CD, Bromer S, Shade SB. Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study. PLoS Med 2020; 17:e1003079. [PMID: 32214312 PMCID: PMC7098549 DOI: 10.1371/journal.pmed.1003079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS). METHODS AND FINDINGS Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation. CONCLUSIONS In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks. Urology 2020; 138:37-44. [PMID: 31945379 DOI: 10.1016/j.urology.2019.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve. METHODS Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals. RESULTS We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities. CONCLUSION We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.
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Marsenic O, Rodean J, Richardson T, Swartz S, Claes D, Day JC, Warady B, Neu A. Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative. Pediatr Nephrol 2020; 35:135-143. [PMID: 31654224 DOI: 10.1007/s00467-019-04384-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE. METHODS Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques. RESULTS Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001). CONCLUSIONS Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.
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MESH Headings
- Adolescent
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/etiology
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/standards
- Catheterization, Central Venous/statistics & numerical data
- Central Venous Catheters/adverse effects
- Central Venous Catheters/standards
- Central Venous Catheters/statistics & numerical data
- Child
- Child, Preschool
- Female
- Guideline Adherence/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Intersectoral Collaboration
- Kidney Failure, Chronic/therapy
- Male
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Program Evaluation
- Prospective Studies
- Quality Improvement/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/instrumentation
- Renal Dialysis/standards
- Renal Dialysis/statistics & numerical data
- Sepsis/epidemiology
- Sepsis/etiology
- Standard of Care/organization & administration
- Standard of Care/statistics & numerical data
- Young Adult
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Vreman RA, Mantel-Teeuwisse AK, Hövels AM, Leufkens HGM, Goettsch WG. Differences in Health Technology Assessment Recommendations Among European Jurisdictions: The Role of Practice Variations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:10-16. [PMID: 31952664 DOI: 10.1016/j.jval.2019.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/02/2019] [Accepted: 07/15/2019] [Indexed: 05/25/2023]
Abstract
BACKGROUND Health technology assessment (HTA) plays an important role in reimbursement decision-making in many countries, but recommendations vary widely throughout jurisdictions, even for the same drug. This variation may be due to differences in the weighing of evidence or differences in the processes or procedures, which are known as HTA practices. OBJECTIVE To provide insight into the effects of differences in practices on interpretation of intercountry differences in HTA recommendations for conditionally approved drugs. METHODS HTA recommendations for conditionally approved drugs (N = 27) up until June 2017 from England/Wales, France, Germany, the Netherlands, and Scotland were included. Recommendations and practice characteristics were extracted from these five jurisdictions and this data was validated. The effect of nonsubmissions, resubmissions, and reassessments; cost-effectiveness assessments; and price negotiations on changes in the percentage of negative recommendations and the interpretation of intercountry differences in HTA outcomes were analyzed using Fisher exact tests. RESULTS The inclusion of cost-effectiveness assessments led to significant increases in the proportion of negative recommendations in England/Wales (from 4% to 50%, P<.01) and Scotland (from 21% to 71%, P<.01). The subsequent inclusion of price negotiations led to significant reductions in the proportion of negative recommendations in England/Wales (from 50% to 14%, P<.01), France (from 31% to 3%, P=.012), and Germany (from 34% to 0%, P<.01). Results indicated that the inclusion of nonsubmissions and resubmissions might affect Scottish negative HTA recommendations (from 7% to 21%), but this effect was not significant. No significant effects were observed in the Netherlands, possibly owing to sample size. CONCLUSION Variations in HTA practices between international jurisdictions can have a substantial and significant impact on conclusions about recommendations by HTA bodies, as exemplified in this cohort of conditionally approved products. Studies comparing international HTA recommendations should carefully consider possible practice variations between jurisdictions.
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Kwak J, Wilkey AL, Abdalla M, Joshi R, Roman PEF, Greilich PE. Perioperative Blood Conservation: Guidelines to Practice. Adv Anesth 2019; 37:1-34. [PMID: 31677651 DOI: 10.1016/j.aan.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Scott R, Hawarden A, Russell B, Edmondson RJ. Decision-Making in Gynaecological Oncology Multidisciplinary Team Meetings: A Cross-Sectional, Observational Study of Ovarian Cancer Cases. Oncol Res Treat 2019; 43:70-77. [PMID: 31743932 DOI: 10.1159/000504260] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/16/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Multidisciplinary team (MDT) meetings are widely used across the UK to provide expert decisions and improve cancer outcomes. However, little is known about the underlying mechanisms of MDT decision-making. We investigated how decisions are made regarding the management of advanced ovarian cancer in gynaecological oncology MDT meetings. METHODS A cross-sectional observational study was performed, focussing on 41/ 223 MDT case discussions across six hospitals. The validated MDT-MODe tool was adapted to increase relevance to gynaecological oncology. Case information and contributions from seven disciplines were rated on a five-point Likert scale. Spearman's correlation investigated relationships between factors and an exploratory factor analysis examined the underlying structure of MDT discussion. RESULTS Forty-one MDT decisions were made for patients with FIGO Stage III/IV ovarian cancer. MDT case discussions were structured by four factors: "Clinical Presentation," "Patient Factors," "Chair's Direction" and "Input from Other Specialties." Nurses were often quiet but facilitated discussion of patient factors. Junior doctors were not involved in MDT decision-making. CONCLUSIONS The decision-making process in MDT meetings is driven by four underlying factors, the most significant of which represents patient history, tumour markers, images and radiologist input. Patient factors were underrepresented, and nurses should be empowered to overcome this.
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Krawiec C. Why Residency Programs Should Not Ignore the Electronic Heath Record after Adoption. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2019; 16:1d. [PMID: 31908628 PMCID: PMC6931052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
During residency training, one of the tools residents learn to use is the electronic health record (EHR). The EHR contains up-to-date medical data that are crucial to the care of the patient; thus the provider must know what is pertinent, where to locate it, and how to efficiently document the data for ongoing communication of patient care. Because institutions may have different EHR vendors, EHR workflow study data are often obtained in single institutions, with a limited number of participants and specialties. Increasing our understanding of the subtleties of residents' EHR usage not only can help educators understand how residents use the EHR but also may provide information on another cognitive factor to assess residents' performance. This, however, will only occur when EHR skills are considered an important part of residency training and we ask our EHR vendors to help us develop validated electronic tools to assess EHR performance.
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