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A research agenda for malaria eradication: health systems and operational research.
Health systems research and development is needed to support the global malaria eradication agenda. In this paper, we (the malERA Consultative Group on Health Systems and Operational Research) focus on the health systems needs of the elimination phase of malaria eradication and consider groupings of countries at different stages along the pathway to elimination. We examine the difference between the last attempt at eradication of malaria and more recent initiatives, and consider the changing health system challenges as countries make progress towards elimination. We review recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. Finally, we identify a number of needs for research and development, including tools for analyzing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.
Asunto(s): Planificación en Salud Comunitaria Investigación sobre Servicios de Salud Malaria/prevención & control Investigación Operativa Investigación Planificación en Salud Comunitaria/economía Planificación en Salud Comunitaria/organización & administración Prestación de Atención de Salud Países en Desarrollo Metas Instituciones de Salud/normas Recursos Humanos en Salud/estadística & datos numéricos Recursos en Salud/provisión & distribución Humanos Malaria/economía Informática Médica/tendencias Evaluación de Programas y Proyectos de Salud Teoría de Sistemas Salud Mundial
Improving effective surgical delivery in humanitarian disasters: lessons from Haiti.
Kathryn Chu and colleagues describe the experiences of Médecins sans Frontières after the 2010 Haiti earthquake, and discuss how to improve delivery of surgery in humanitarian disasters.
Asunto(s): Prestación de Atención de Salud/organización & administración Planificación en Desastres/organización & administración Desastres Servicios Médicos de Urgencia/organización & administración Agencias Voluntarias de Salud/organización & administración Heridas y Traumatismos/cirugía Terremotos Urgencias Médicas Equipos y Suministros/provisión & distribución Haití Recursos Humanos en Salud Humanos Agencias Internacionales/organización & administración Cooperación Internacional
Low demand for nontraditional cookstove technologies.
Biomass combustion with traditional cookstoves causes substantial environmental and health harm. Nontraditional cookstove technologies can be efficacious in reducing this adverse impact, but they are adopted and used at puzzlingly low rates. This study analyzes the determinants of low demand for nontraditional cookstoves in rural Bangladesh by using both stated preference (from a nationally representative survey of rural women) and revealed preference (assessed by conducting a cluster-randomized trial of cookstove prices) approaches. We find consistent evidence across both analyses suggesting that the women in rural Bangladesh do not perceive indoor air pollution as a significant health hazard, prioritize other basic developmental needs over nontraditional cookstoves, and overwhelmingly rely on a free traditional cookstove technology and are therefore not willing to pay much for a new nontraditional cookstove. Efforts to improve health and abate environmental harm by promoting nontraditional cookstoves may be more successful by designing and disseminating nontraditional cookstoves with features valued more highly by users, such as reduction of operating costs, even when those features are not directly related to the cookstoves' health and environmental impacts.
Asunto(s): Satisfacción de los Consumidores/estadística & datos numéricos Culinaria/economía Culinaria/instrumentación Población Rural/estadística & datos numéricos Contaminación del Aire en Interiores/estadística & datos numéricos Bangladesh/epidemiología Biomasa Conservación de los Recursos Naturales Costos y Análisis de Costo Recolección de Datos Países en Desarrollo/estadística & datos numéricos Salud Ambiental Diseño de Equipo Femenino Humanos Tecnología/economía Tecnología/tendencias
Synthesizing epidemiological and economic optima for control of immunizing infections.
Epidemic theory predicts that the vaccination threshold required to interrupt local transmission of an immunizing infection like measles depends only on the basic reproductive number and hence transmission rates. When the search for optimal strategies is expanded to incorporate economic constraints, the optimum for disease control in a single population is determined by relative costs of infection and control, rather than transmission rates. Adding a spatial dimension, which precludes local elimination unless it can be achieved globally, can reduce or increase optimal vaccination levels depending on the balance of costs and benefits. For weakly coupled populations, local optimal strategies agree with the global cost-effective strategy; however, asymmetries in costs can lead to divergent control optima in more strongly coupled systems--in particular, strong regional differences in costs of vaccination can preclude local elimination even when elimination is locally optimal. Under certain conditions, it is locally optimal to share vaccination resources with other populations.
Asunto(s): Control de Enfermedades Transmisibles/economía Control de Enfermedades Transmisibles/estadística & datos numéricos Enfermedades Transmisibles/economía Enfermedades Transmisibles/epidemiología Inmunización/economía Inmunización/estadística & datos numéricos Enfermedades Transmisibles/inmunología Migración Internacional Recursos en Salud/economía Recursos en Salud/estadística & datos numéricos Humanos Internacionalidad Modelos Biológicos Dinámica de Población Vacunación/economía Vacunación/estadística & datos numéricos
Emergence of HIV drug resistance during first- and second-line antiretroviral therapy in resource-limited settings.
INTRODUCTION: Antiretroviral therapy (ART) in resource-limited settings has expanded in the last decade, reaching >8 million individuals and reducing AIDS mortality and morbidity. Continued success of ART programs will require understanding the emergence of HIV drug resistance patterns among individuals in whom treatment has failed and managing ART from both an individual and public health perspective. We review data on the emergence of HIV drug resistance among individuals in whom first-line therapy has failed and clinical and resistance outcomes of those receiving second-line therapy in resource-limited settings. RESULTS: Resistance surveys among patients initiating first-line nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based therapy suggest that 76%-90% of living patients achieve HIV RNA suppression by 12 months after ART initiation. Among patients with detectable HIV RNA at 12 months, HIV drug resistance, primarily due to M184V and NNRTI mutations, has been identified in 60%-72%, although the antiretroviral activity of proposed second-line regimens has been preserved. Complex mutation patterns, including thymidine-analog mutations, K65R, and multinucleoside mutations, are prevalent among cases of treatment failure identified by clinical or immunologic methods. Approximately 22% of patients receiving second-line therapy do not achieve HIV RNA suppression by 6 months, with poor adherence, rather than HIV drug resistance, driving most failures. Major protease inhibitor resistance at the time of second-line failure ranges from 0% to 50%, but studies are limited. CONCLUSIONS: Resistance of HIV to first-line therapy is predictable at 12 months when evaluated by means of HIV RNA monitoring and, when detected, largely preserves second-line therapy options. Optimizing adherence, performing resistance surveillance, and improving treatment monitoring are critical for long-term prevention of drug resistance.
Asunto(s): Antirretrovirales/farmacología Farmacorresistencia Viral Infecciones por VIH/quimioterapia VIH-1/fisiología ARN Viral/metabolismo Antirretrovirales/uso terapéutico Quimioterapia Combinada Infecciones por VIH/virología Inhibidores de la Proteasa VIH/farmacología Inhibidores de la Proteasa VIH/uso terapéutico VIH-1/efectos de drogas VIH-1/genética Recursos en Salud/economía Humanos Mutación Mutación Missense ARN Viral/genética Inhibidores de Transcriptasa Inversa/farmacología Inhibidores de Transcriptasa Inversa/uso terapéutico Insuficiencia del Tratamiento Carga Viral
Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting.
BACKGROUND: Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status. METHODS AND RESULTS: From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001). CONCLUSIONS: Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.
Asunto(s): Puente de Arteria Coronaria/estadística & datos numéricos Recursos en Salud/utilización Medicaid/estadística & datos numéricos Pacientes no Asegurados/estadística & datos numéricos Medicare/estadística & datos numéricos Complicaciones Postoperatorias/mortalidad Anciano Comorbilidad Puente de Arteria Coronaria/economía Grupos Étnicos/estadística & datos numéricos Femenino Recursos en Salud/economía Costos de Hospital/estadística & datos numéricos Mortalidad Hospitalaria Humanos Seguro de Salud/economía Seguro de Salud/estadística & datos numéricos Tiempo de Internación/economía Tiempo de Internación/estadística & datos numéricos Masculino Mediana Edad Complicaciones Postoperatorias/economía Áreas de Pobreza Pronóstico Factores de Riesgo Resultado del Tratamiento Estados Unidos/epidemiología
The clinical and economic impact of genotype testing at first-line antiretroviral therapy failure for HIV-infected patients in South Africa.
BACKGROUND: In resource-limited settings, genotype testing at virologic failure on first-line antiretroviral therapy (ART) may identify patients with wild-type (WT) virus. After adherence counseling, these patients may safely and effectively continue first-line ART, thereby delaying more expensive second-line ART. METHODS: We used the Cost-Effectiveness of Preventing AIDS Complications International model of human immunodeficiency virus (HIV) disease to simulate a South African cohort of HIV-infected adults at first-line ART failure. Two strategies were examined: no genotype vs genotype, assuming availability of protease inhibitor-based second-line ART. Model inputs at first-line ART failure were mean age 38 years, mean CD4 173/µL, and WT virus prevalence 20%; genotype cost was $300 per test and delay to results, 3 months. Outcomes included life expectancy, per-person costs (2010 US dollars), and incremental cost-effectiveness ratios (dollars per years of life saved [YLS]). RESULTS: No genotype had a projected life expectancy of 106.1 months, which with genotype increased to 108.3 months. Per-person discounted lifetime costs were $16 360 and $16 540, respectively. Compared to no genotype, genotype was very cost-effective, by international guidance, at $900/YLS. The cost-effectiveness of genotype was sensitive to prevalence of WT virus (very cost-effective when prevalence ⥠12%), CD4 at first-line ART failure, and ART efficacy. Genotype-associated delays in care ⥠5 months decreased survival and made no genotype the preferred strategy. When the test cost was <$100, genotype became cost-saving. CONCLUSIONS: Genotype resistance testing at first-line ART failure is very cost-effective in South Africa. The cost-effectiveness of this strategy will depend on prevalence of WT virus and timely response to genotype results.
Asunto(s): Síndrome de Inmunodeficiencia Adquirida/prevención & control Fármacos Anti-VIH/uso terapéutico Infecciones por VIH/quimioterapia Síndrome de Inmunodeficiencia Adquirida/genética Adulto Fármacos Anti-VIH/economía Técnicas de Laboratorio Clínico/economía Análisis Costo-Beneficio Genotipo VIH/genética Infecciones por VIH/economía Infecciones por VIH/genética Recursos en Salud/economía Humanos Modelos Teóricos Sudáfrica Insuficiencia del Tratamiento
Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies.
BACKGROUND: Almost 50% of women in low- and middle-income countries (LMICs) don't receive adequate antenatal care. Women's views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies. METHODS AND FINDINGS: Using a predetermined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMICs who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line-of-argument synthesis. We derived policy-relevant hypotheses from the findings. We included 21 papers representing the views of more than 1,230 women from 15 countries. Three key themes were identified: "pregnancy as socially risky and physiologically healthy", "resource use and survival in conditions of extreme poverty", and "not getting it right the first time". The line-of-argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. CONCLUSIONS: Our findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.
Asunto(s): Países en Desarrollo/economía Renta Atención Prenatal/economía Atención Prenatal/utilización Investigación Cualitativa Femenino Salud Recursos en Salud/economía Recursos en Salud/utilización Accesibilidad a los Servicios de Salud/economía Humanos Modelos Teóricos Pobreza Embarazo Análisis de Supervivencia Mujeres
Induction mortality and resource utilization in children treated for acute myeloid leukemia at free-standing pediatric hospitals in the United States.
BACKGROUND: Clinical trials in pediatric acute myeloid leukemia (AML) determine induction regimen standards. However, these studies lack the data necessary to evaluate mortality trends over time and differences in resource utilization between induction regimens. Moreover, these trials likely underreport the clinical toxicities experienced by patients. METHODS: The Pediatric Health Information System database was used to identify children treated for presumed de novo AML between 1999 and 2010. Induction mortality, risk factors for induction mortality, and resource utilization by induction regimen were estimated using standard frequentist statistics, logistic regression, and Poisson regression, respectively. RESULTS: A total of 1686 patients were identified with an overall induction case fatality rate of 5.4% that decreased from 9.8% in 2003 to 2.1% in 2009 (P = .0023). The case fatality rate was 9.0% in the intensively timed DCTER (dexamethasone, cytarabine, thioguanine, etoposide, and rubidomycin [daunomycin]/idarubicin) induction and 3.8% for ADE (cytarabine, daunomycin, and etoposide) induction (adjusted odds ratio = 2.2, 95% confidence interval = 1.1-4.5). Patients treated with intensively timed DCTER regimens had significantly greater antibiotic, red cell/platelet transfusion, analgesic, vasopressor, renal replacement therapy, and radiographic resource utilization than patients treated with ADE regimens. Resource utilization was substantially higher than reported in published pediatric AML clinical trials. CONCLUSIONS: Induction mortality for children with AML decreased significantly as ADE use increased. In addition to higher associated mortality, intensively timed DCTER regimens had a correspondingly higher use of health care resources. Using resource utilization data as a proxy for adverse events, adverse event rates reported on clinical trials substantially underestimated the clinical toxicities of all pediatric AML induction regimens.
Asunto(s): Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos Recursos en Salud/utilización Hospitales Pediátricos/estadística & datos numéricos Quimioterapia de Inducción/métodos Leucemia Mieloide Aguda/quimioterapia Leucemia Mieloide Aguda/mortalidad Adolescente Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico Niño Preescolar Estudios de Cohortes Citarabina/administración & dosificación Citarabina/efectos adversos Daunorrubicina/administración & dosificación Daunorrubicina/efectos adversos Dexametasona/administración & dosificación Dexametasona/efectos adversos Etopósido/administración & dosificación Etopósido/efectos adversos Femenino Humanos Quimioterapia de Inducción/efectos adversos Lactante Leucemia Mieloide Aguda/etnología Modelos Logísticos Masculino Oportunidad Relativa Distribución de Poisson Medición de Riesgo Factores de Riesgo Tioguanina/administración & dosificación Tioguanina/efectos adversos Resultado del Tratamiento Estados Unidos/epidemiología
Health care costs and resource utilization, including patient burden, associated with novel-agent-based treatment versus other therapies for multiple myeloma: findings using real-world claims data.
BACKGROUND: . Treatment of multiple myeloma has dramatically improved with the introduction of bortezomib (BOR), thalidomide (THAL), and lenalidomide (LEN). Studies assessing health care costs, particularly economic burden on patients, are limited. We conducted a claims-based, retrospective analysis of total health care costs as well as patient burden (patient out-of-pocket costs and number of ambulatory/hospital visits) associated with BOR/THAL/LEN treatment versus other therapies (OTHER). METHODS. Treatment episodes starting between January 1, 2005 and September 30, 2010 were identified from the claims database of a large U.S. health plan. Health care costs and utilization were measured during 1 year after initiation and analyzed per treatment episode. Multivariate analyses were used to adjust for patient characteristics, comorbidities, and line of treatment. RESULTS: A total of 4,836 treatment episodes were identified. Mean adjusted total costs were similar between BOR ($112,889) and OTHER ($111,820), but higher with THAL ($129,412) and LEN ($158,428). Mean adjusted patient out-of-pocket costs were also similar for BOR ($3,846) and OTHER ($3,900) but remained higher with THAL ($4,666) and LEN ($4,483). Mean adjusted rates of ambulatory visits were similar across therapies (BOR: 69.67; THAL: 66.31; LEN: 65.60; OTHER: 69.42). CONCLUSIONS: Adjusted analyses of real-world claims data show that total health care costs, as well as patient out-of-pocket costs, are higher with THAL/LEN treatment episodes than with BOR/OTHER therapies. Additionally, similar rates of ambulatory visits suggest that any perceived advantage in patient convenience of the orally administered drugs THAL/LEN is not supported by these data.
Asunto(s): Antineoplásicos/economía Costos de la Atención en Salud Mieloma Múltiple/economía Adulto Antineoplásicos/administración & dosificación Ácidos Borónicos/administración & dosificación Femenino Recursos en Salud/economía Hospitalización/economía Humanos Masculino Mediana Edad Mieloma Múltiple/quimioterapia Mieloma Múltiple/epidemiología Pirazinas/administración & dosificación Estudios Retrospectivos Talidomida/administración & dosificación Talidomida/análogos & derivados
Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.
BACKGROUND: Provisions of the Affordable Care Act that increase hospitals' financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. OBJECTIVES: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. METHOD AND DESIGN: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. RESULTS: Nearly 1 quarter of heart failure index admissions [23.3% (n=39,954)], 19.1% (n=12,131) of myocardial infarction admissions, and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse's workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR)=1.07; confidence interval CI, 1.05-1.09], 6% for pneumonia patients (OR=1.06; CI, 1.03-1.09), and 9% for myocardial infarction patients (OR=1.09; CI, 1.05-1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR=0.93; CI, 0.89-0.97), 6% lower for myocardial infarction (OR=0.94; CI, 0.88-0.98), and 10% lower for pneumonia (OR=0.90; CI, 0.85-0.96) patients. CONCLUSIONS: Improving nurses' work environments and staffing may be effective interventions for preventing readmissions.
Asunto(s): Insuficiencia Cardíaca/enfermería Infarto del Miocardio/enfermería Personal de Enfermería en Hospital/organización & administración Readmisión del Paciente/estadística & datos numéricos Neumonía/enfermería Factores de Edad Anciano Anciano de 80 o más Años Investigación en Enfermería Clínica Educación en Enfermería/estadística & datos numéricos Ambiente Femenino Insuficiencia Cardíaca/epidemiología Hospitales/recursos humanos Hospitales/estadística & datos numéricos Humanos Tiempo de Internación Masculino Medicare/estadística & datos numéricos Infarto del Miocardio/epidemiología Personal de Enfermería en Hospital/estadística & datos numéricos Admisión y Programación de Personal/organización & administración Admisión y Programación de Personal/estadística & datos numéricos Neumonía/epidemiología Calidad de la Atención de Salud/organización & administración Calidad de la Atención de Salud/estadística & datos numéricos Factores Sexuales Estados Unidos Carga de Trabajo/estadística & datos numéricos
Direct health-care costs attributed to hip fractures among seniors: a matched cohort study.
SUMMARY: Using a matched cohort design, we estimated the mean direct attributable cost in the first year after hip fracture in Ontario to be $36,929 among women and $39,479 among men. These estimates translate into an annual $282 million in direct attributable health-care costs in Ontario and $1.1 billion in Canada. INTRODUCTION: Osteoporosis is a major public health concern that results in substantial fracture-related morbidity and mortality. It is well established that hip fractures are the most devastating consequence of osteoporosis, yet the health-care costs attributed to hip fractures in Canada have not been thoroughly evaluated. METHODS: We determined the 1- and 2-year direct attributable costs and cost drivers associated with hip fractures among seniors in comparison to a matched non-hip fracture cohort using health-care administrative data from Ontario (2004-2008). Entry into long-term care and deaths attributable to hip fracture were also determined. RESULTS: We successfully matched 22,418 female (mean age = 83.3 years) and 7,611 male (mean age = 81.3 years) hip fracture patients. The mean attributable cost in the first year after fracture was $36,929 (95 % CI $36,380-37,466) among women and $39,479 (95 % CI $38,311-$40,677) among men. These estimates translate into an annual $282 million in direct attributable health-care costs in Ontario and $1.1 billion in Canada. Primary cost drivers were acute and post-acute institutional care. Approximately 24 % of women and 19 % of men living in the community at the time of fracture entered a long-term care facility, and 22 % of women and 33 % of men died within the first year following hip fracture. Attributable costs remained elevated into the second year ($9,017 among women, $10,347 among men) for patients who survived the first year. CONCLUSIONS: We identified significant health-care costs, entry into long-term care, and mortality attributed to hip fractures. Results may inform health economic analyses and policy decision-making in Canada.
Asunto(s): Costos de la Atención en Salud/estadística & datos numéricos Fracturas de Cadera/economía Fracturas Osteoporóticas/economía Distribución por Edad Anciano Anciano de 80 o más Años Estudios de Cohortes Femenino Recursos en Salud/utilización Investigación sobre Servicios de Salud/métodos Fracturas de Cadera/epidemiología Fracturas de Cadera/terapia Humanos Masculino Ontario/epidemiología Fracturas Osteoporóticas/epidemiología Fracturas Osteoporóticas/terapia Pronóstico Distribución por Sexo Factores Sexuales Análisis de Supervivencia Resultado del Tratamiento
The policy context of patient centered medical homes: perspectives of primary care providers.
BACKGROUND: Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues. RESEARCH DESIGN: Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH. PARTICIPANTS: Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations. KEY RESULTS: We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH. CONCLUSIONS: Providers' motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved.
Asunto(s): Reforma de la Atención de Salud/organización & administración Atención Dirigida al Paciente/organización & administración Atención Primaria de Salud/organización & administración Actitud del Personal de Salud Implementación de Plan de Salud/organización & administración Investigación sobre Servicios de Salud Humanos Michigan Política Organizacional Atención Dirigida al Paciente/recursos humanos Atención Primaria de Salud/recursos humanos Investigación Cualitativa Mecanismo de Reembolso/organización & administración Carga de Trabajo
Open access in the patient-centered medical home: lessons from the Veterans Health Administration.
BACKGROUND: The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care. OBJECTIVE: We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change. DESIGN: A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states. PARTICIPANTS: Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics. APPROACH: We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011. KEY RESULTS: Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge. CONCLUSIONS: Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.
Asunto(s): Prestación de Atención de Salud/organización & administración Accesibilidad a los Servicios de Salud/organización & administración Atención Dirigida al Paciente/organización & administración United States Department of Veterans Affairs/organización & administración Acceso a la Información Continuidad de la Atención al Paciente Prestación de Atención de Salud/recursos humanos Registros Electrónicos de Salud Humanos Modelos Organizacionales Atención Dirigida al Paciente/recursos humanos Proyectos Piloto Atención Primaria de Salud/recursos humanos Atención Primaria de Salud/organización & administración Investigación Cualitativa Estados Unidos
Village health workers in Bihar, India: an untapped resource in the struggle against kala-azar.
INTRODUCTION: In 2005 a visceral leishmaniasis (VL) elimination initiative was launched on the Indian subcontinent; important components of early case finding and treatment are entrusted to the primary health care system (PHC). In an earlier study in Bihar, India, we discovered some major shortcomings in implementation, in particular related to monitoring of treatment and treatment outcomes. These shortcomings could be addressed through involvement of village health workers. In the current study we assessed knowledge, attitude and practice of these village health workers in relation to VL. Main objective was to assess the feasibility of their involvement in VL control. METHODS: We obtained a list of auxiliary nurses/midwives and accredited social health activists for the highly endemic district of Muzaffarpur. We randomly sampled 100 auxiliary nurses and 100 activists, who were visited in their homes for an interview. Questions were asked on knowledge, attitude and practice related to visceral leishmaniasis and to tuberculosis. RESULTS: Auxiliary nurses and activists know the presenting symptoms of visceral leishmaniasis, they know how it is diagnosed but they are not aware of the recommended first-line treatment. Many are already involved in tuberculosis control and are very well aware of the treatment modalities of tuberculosis, but few are involved in control of visceral leishmaniasis control. They are well organised, have strong links to the primary healthcare system and are ready to get more involved in visceral leishmaniasis control. CONCLUSION: To ensure adequate monitoring of visceral leishmaniasis treatment and treatment outcomes, the control programme urgently needs to consider involving auxiliary nurses and activists.
Asunto(s): Antiprotozoarios/uso terapéutico Agentes Comunitarios de Salud/organización & administración Recursos en Salud/organización & administración Control de Insectos/métodos Leishmaniasis Visceral/prevención & control Auxiliares de Enfermería/organización & administración Servicios Rurales de Salud/organización & administración Adulto Escolaridad Femenino Conocimientos, Actitudes y Práctica en Salud Humanos India/epidemiología Control de Insectos/normas Leishmaniasis Visceral/epidemiología Mediana Edad Salud Pública Resultado del Tratamiento
The interplay between CD4 cell count, viral load suppression and duration of antiretroviral therapy on mortality in a resource-limited setting.
OBJECTIVE: To examine the interaction between CD4 cell count, viral load suppression and duration of antiretroviral therapy (ART) on mortality. METHODS: Cohort analysis of HIV-infected patients initiating ART between April 2004 and June 2011 at a large public sector clinic in Johannesburg, South Africa. A log-linear model with Poisson distribution was used to estimate risk of death as a function of the interaction between current CD4 count, current viral load suppression and duration on ART in 12-month intervals. We calculated predicted mortality using estimated coefficients within combinations of predictors. RESULTS: Amongst 14 932 ART patients, 1985 (13.3%) died. Current CD4 was the strongest predictor of death (<50 vs. â¥550 cells/mm(3) - RR: 46.3; 95% CI: 26.8-80), while unsuppressed current viral load vs. suppressed (RR: 1.8; 95% CI: 1.5-2.1) and short duration of ART (0-11.9 vs. 66-71.9 months RR: 1.7; 95% CI: 1.2-2.3) also predicted death. Our interaction model showed that mortality was highest in the first 12 months on treatment across all CD4 and viral load strata. As current CD4 and duration on ART increased and viral load suppression occurred, mortality dropped. CD4 count was the strongest predictor of death. The relative effect of current CD4 count varied strongly by viral load and duration of ART (from 1.3 to 55). Lack of suppression increased the risk of mortality upwards of six-fold depending on time on ART and current CD4. CONCLUSIONS: Our findings show that while CD4 count is the strongest predictor of death, the effect is modified by viral load and the duration of ART. Assessment of risk should take into account all three factors.
Asunto(s): Antirretrovirales/administración & dosificación Linfocitos T CD4-Positivos/inmunología Infecciones por VIH/quimioterapia Infecciones por VIH/mortalidad Carga Viral/fisiología Adolescente Adulto Recuento de Linfocito CD4 Estudios de Cohortes Femenino Recursos en Salud/provisión & distribución Humanos Masculino Mediana Edad Estudios Prospectivos Medición de Riesgo Sudáfrica/epidemiología Factores de Tiempo Adulto Joven
Barriers to community case management of malaria in Saraya, Senegal: training, and supply-chains.
BACKGROUND: Health workers in sub-Saharan Africa can now diagnose and treat malaria in the field, using rapid diagnostic tests and artemisinin-based combination therapy in areas without microscopy and widespread resistance to previously effective drugs. OBJECTIVE: This study evaluates communities' perceptions of a new community case management of malaria programme in the district of Saraya, south-eastern Senegal, the effectiveness of lay health worker trainings, and the availability of rapid diagnostic tests and artemisinin-based combination therapy in the field. METHODS: The study employed qualitative and quantitative methods including focus groups with villagers, and pre- and post-training questionnaires with lay health workers. RESULTS: Communities approved of the community case management programme, but expressed concern about other general barriers to care, particularly transportation challenges. Most lay health workers acquired important skills, but a sizeable minority did not understand the rapid diagnostic test algorithm and were not able to correctly prescribe arteminisin-based combination therapy soon after the training. Further, few women lay health workers participated in the programme. Finally, the study identified stock-outs of rapid tests and anti-malaria medication products in over half of the programme sites two months after the start of the programme, thought due to a regional shortage. CONCLUSION: This study identified barriers to implementation of the community case management of malaria programme in Saraya that include lay health worker training, low numbers of women participants, and generalized stock-outs. These barriers warrant investigation into possible solutions of relevance to community case management generally.
Asunto(s): Manejo de Caso/organización & administración Agentes Comunitarios de Salud/educación Servicios de Salud/recursos humanos Servicios de Salud/provisión & distribución Malaria/diagnóstico Malaria/quimioterapia Adulto Femenino Grupos Focales Conocimientos, Actitudes y Práctica en Salud Humanos Masculino Mediana Edad Cuestionarios Población Rural Senegal
Increased efficiency of endocrine procedures performed in an ambulatory operating room.
BACKGROUND: Thyroid and parathyroid procedures historically have been viewed as inpatient procedures. Because of the advancements in surgical techniques, these procedures were transferred from the inpatient operating room (OR) to the outpatient OR at a single academic institution approximately 7 y ago. The goal of this study was to determine whether this change has decreased turnover times and maximized OR utilization. METHODS: We performed a retrospective review of 707 patients undergoing thyroid (34%) and parathyroid (66%) procedures by a single surgeon at our academic institution between 2005 and 2008. Inpatient and outpatient groups were compared using Student t-test, chi-square test, or the Kruskal-Wallis test where appropriate. Multiple regression analysis was used to determine how patient and hospital factors influenced turnover times. RESULTS: Turnover times were significantly lower in the outpatient OR (mean 18 ± 0.7 min) when compared with the inpatient OR (mean 36 ± 1.4 min) (P < 0.001). When compared by type of procedure, all turnover times remained significantly lower in the outpatient OR. Patients in both ORs were similar in age, gender, and comorbidities. However, inpatients had a higher mean American Society of Anesthesiologists score (2.30 versus 2.13, P < 0.001) and were more likely to have an operative indication of cancer (23.1% versus 9.2%, P < 0.001). Using multiple regression, the inpatient OR remained highly significantly associated with higher turnover times when controlling for these small differences (P < 0.001). CONCLUSIONS: Endocrine procedures performed in the outpatient OR have significantly faster turnover times leading to cost savings and greater OR utilization for hospitals.
Asunto(s): Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos Procedimientos Quirúrgicos Ambulatorios/utilización Evaluación de Procesos y Resultados (Atención de Salud) Enfermedades de las Paratiroides/cirugía Enfermedades de la Tiroides/cirugía Centros Médicos Académicos/economía Centros Médicos Académicos/estadística & datos numéricos Centros Médicos Académicos/utilización Procedimientos Quirúrgicos Ambulatorios/economía Ahorro de Costo Procedimientos Quirúrgicos Endocrinos/economía Procedimientos Quirúrgicos Endocrinos/estadística & datos numéricos Procedimientos Quirúrgicos Endocrinos/utilización Femenino Costos de la Atención en Salud Humanos Pacientes Internos/estadística & datos numéricos Masculino Mediana Edad Pacientes Ambulatorios/estadística & datos numéricos Enfermedades de las Paratiroides/economía Paratiroidectomía/economía Paratiroidectomía/estadística & datos numéricos Análisis de Regresión Estudios Retrospectivos Enfermedades de la Tiroides/economía Tiroidectomía/economía Tiroidectomía/estadística & datos numéricos Revisión de Utilización de Recursos
Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations.
PURPOSE: Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. METHODS: This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. RESULTS: Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. CONCLUSIONS: In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.
Asunto(s): Antibacterianos/uso terapéutico Infecciones Comunitarias Adquiridas/diagnóstico Infecciones Comunitarias Adquiridas/quimioterapia Recursos en Salud Pacientes Internos Neumonía/diagnóstico Neumonía/quimioterapia Adulto Anciano Femenino Humanos Masculino Mediana Edad Guías de Práctica Clínica como Asunto Administración de la Práctica Médica/normas Estudios Retrospectivos Factores de Riesgo Resultado del Tratamiento
Cost and burden of gastroesophageal reflux disease among patients with persistent symptoms despite proton pump inhibitor therapy: an observational study in France.
BACKGROUND: Gastrointestinal reflux disease (GERD) is a common disorder that negatively impacts health-related quality of life (HRQL) and work productivity. Many patients have only a partial response to proton pump inhibitor (PPI) therapy and continue to experience GERD symptoms despite optimized treatment. This observational study aimed to provide information on symptoms, HRQL, resource usage, costs and treatment pathways associated with partial response to PPI therapy in French patients with GERD. METHODS: Patients with partial response to PPI therapy, defined as persistent GERD symptoms â¥3 days/week despite optimized treatment with a PPI, were recruited for this 12-month observational study. GERD symptoms, HRQL, work productivity and resource use were assessed by patient surveys. Costs were calculated based on lost work productivity and resource use. RESULTS: The patient population (n=262; mean age, 54 years; 40% men) carried a significant symptom burden, with 98% of patients having moderate-to-severe GERD symptoms and 65% of patients experiencing daily symptoms at baseline. HRQL and work productivity were significantly impaired, with a greater degree of impairment in patients with higher symptom burden. The mean total cost per patient over the 12-month follow-up period was 5237, of which 4674 (89%) was due to lost work productivity. CONCLUSIONS: Partial response to PPI therapy for GERD is associated with a high symptom burden, significant impairment of HRQL and work productivity, and substantial GERD-related costs.
Asunto(s): Costo de Enfermedad Reflujo Gastroesofágico/quimioterapia Reflujo Gastroesofágico/economía Costos de la Atención en Salud/tendencias Inhibidores de la Bomba de Protones/uso terapéutico Femenino Francia/epidemiología Reflujo Gastroesofágico/epidemiología Costos de la Atención en Salud/estadística & datos numéricos Recursos en Salud/utilización Humanos Estudios Longitudinales Masculino Mediana Edad Calidad de Vida/psicología Estudios Retrospectivos Resultado del Tratamiento Carga de Trabajo/estadística & datos numéricos