RESUMO
BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.
Assuntos
Amputação Cirúrgica/tendências , Acessibilidade aos Serviços de Saúde/tendências , Patient Protection and Affordable Care Act/tendências , Doença Arterial Periférica/cirurgia , Avaliação de Processos em Cuidados de Saúde/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Amputação Cirúrgica/legislação & jurisprudência , Arkansas/epidemiologia , Bases de Dados Factuais , Feminino , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Cobertura do Seguro/legislação & jurisprudência , Cobertura do Seguro/tendências , Salvamento de Membro/legislação & jurisprudência , Salvamento de Membro/tendências , Masculino , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/legislação & jurisprudência , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Avaliação de Processos em Cuidados de Saúde/legislação & jurisprudência , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/legislação & jurisprudênciaRESUMO
BACKGROUND: Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. METHODS AND RESULTS: We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. CONCLUSIONS: Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use.
Assuntos
Ponte de Artéria Coronária/tendências , Estenose Coronária/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Intervenção Coronária Percutânea/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , United States Department of Veterans Affairs , Idoso , Angiografia Coronária/tendências , Ponte de Artéria Coronária/estatística & dados numéricos , Estenose Coronária/diagnóstico por imagem , Ecocardiografia sob Estresse/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/estatística & dados numéricos , Valor Preditivo dos Testes , Avaliação de Programas e Projetos de Saúde , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Vasodilatadores/administração & dosagemRESUMO
This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country's PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/tendências , Países em Desenvolvimento , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Transfusão de Sangue/economia , Brasil , China , Comportamento Cooperativo , Países em Desenvolvimento/economia , Inglaterra , Custos de Cuidados de Saúde/tendências , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/economia , Humanos , Cooperação Internacional , Avaliação das Necessidades/tendências , Segurança do Paciente , Padrões de Prática Médica/economia , Avaliação de Processos em Cuidados de Saúde/economia , Avaliação de Programas e Projetos de Saúde , Fatores de Risco , Fatores de Tempo , Reação Transfusional , Resultado do Tratamento , UgandaRESUMO
Introdução: Devido à necessidade da redução de custos com as hospitalizações e à busca de uma reorientação no modelo atual de assistência à saúde, o Hospital São Sebastião Mártir de Venâncio Aires (RS), juntamente com a Secretaria Municipal de Saúde, instituiu o programa de Assistência Domiciliar, como uma tentativa para reorganização do sistema atual de saúde. Objetivo: Sendo assim, é de suma importância descrever a satisfação dos usuários deste programa. Métodos: Para isso, um entrevistador aplicou um questionário aos usuários, com questões fechadas, em relação ao tempo dos atendimentos, ao relacionamento com a equipe, aos recursos e à disponibilidade da equipe, aos resultados da assistência e em relação à satisfação de uma forma geral. As respostas foram fornecidas através da escala de Lickert, por meio de cinco atributos, envolvendo concordância plena e discordância plena, frente a uma afirmação. A análise dos dados envolveu cálculo das médias dos dados demográficos dos pacientes e dos escores encontrados e teste t de Student (P < 0,05), comparando a satisfação entre os cuidadores e os pacientes. Resultados: Foram entrevistados 56 usuários da Assistência Domiciliar, sendo 15 pacientes (26,8%) e 41 cuidadores (73,2%). Os resultados quanto às questões referentes à assistência domiciliar e ao desempenho da equipe demonstraram satisfação dos usuários em praticamente todas as afirmações, não havendo diferença estatística entre os grupos. A menor média dos atributos foi encontrada no que tange ao contato com a equipe, quando necessário, com média de 3,16 entre os cuidadores e 3,55 entre os pacientes. Conclusão: Foi verificado um alto grau de satisfação do programa de Assistência Domiciliar do Hospital São Sebastião Mártir entre os seus pacientes e cuidadores, sendo assim possível verificar sua aceitação positiva entre os usuários.
Background: Due to both cost reduction with hospitalizations and reorientation in the current model of health care, the São Sebastião Mártir Hospital (SSMH) from Venâncio Aires (RS/Brazil), along with its local health department, instituted a Home Care program. This is an attempt to reorganize the current system implemented recently in the city of Venâncio Aires. Aim: At this point, it is of utmost importance to describe users satisfaction. Methods: With this aim, an interviewer applied a questionnaire to users by adopting closed questions, in relation to: a) the time of home care visits; b) the relationship with the health-support team; c) the resources and the availability of the team; d) the results of the assistance; and e) overall satisfaction. Answers were measured using the Lickert scale, which encompasses five attributes, such as full agreement and full discordance related to an affirmation. The analysis of the data involved the averaging of the samples demographic data, and calculation of scores and t Student test results (P < 0,05), in order to compare the satisfaction between care-takers and patients. Results: Fifty six users of the Home Care program were interviewed; there were fifteen (26.8%) patients and forty one (73.2%) care-takers. Analysis of the data showed a high level of user satisfaction in almost all questions, without statistically significant difference between groups. The lowest level of satisfaction was found in regards to making contact with the health-care team in situations of need. In this category, care-takers averaged 3,16 and patients 3,55. Conclusion: A high index of satisfaction between SSMH and patients and care-takers was demonstrated.
Assuntos
Avaliação de Processos em Cuidados de Saúde/organização & administração , Avaliação de Processos em Cuidados de Saúde/tendências , Avaliação de Processos em Cuidados de Saúde , Pesquisa sobre Serviços de Saúde , Serviços de Assistência Domiciliar/organização & administração , Serviços de Assistência Domiciliar/tendências , Serviços de Assistência Domiciliar , Avaliação de Desempenho Profissional , Inquéritos e Questionários , Comportamento do ConsumidorRESUMO
This was a descriptive, exploratory, documental study of trends that aimed to analyze process indicators in the Program for Humanization of Prenatal Care and Childbirth in Ceará State, Brazil, from 2001 to 2006. The authors analyzed data from 312,507 pregnant women. In 2001, the year the program was implemented in the State, the system tabulated data for three of the seven process indicators; beginning in 2002, all indicators were tabulated. Total enrollment of pregnant women was the only indicator that increased every year until 2006, while the other indicators increased from 2002 until 2005, but declined from 2005 to 2006. When combining the completion of six prenatal visits with a postpartum visit, routine laboratory tests, or both, the percentages declined. Tetanus immunization reached the highest percentage in 2002 (68.34%), decreasing to 60.86% in 2006. The combination of six prenatal visits, a postpartum visit, laboratory tests, tetanus immunization, and HIV test was the indicator with the lowest percentage for the State (15.67%), although it was higher than the national average. Even considering flaws in the use of the Prenatal Care Information System, it is unacceptable that prenatal care still lacks complete coverage for such basic elements as routine laboratory tests and tetanus immunization.
Assuntos
Indicadores Básicos de Saúde , Serviços de Saúde Materna , Programas Nacionais de Saúde , Cuidado Pós-Natal , Cuidado Pré-Natal , Avaliação de Processos em Cuidados de Saúde/tendências , Brasil , Feminino , Humanos , Imunização , Gravidez , Avaliação de Processos em Cuidados de Saúde/estatística & dados numéricos , Toxoide Tetânico/imunologiaRESUMO
BACKGROUND AND PURPOSE: This study describes the large variations in outcome after stroke between countries that participated in the International Stroke Trial and seeks to define whether they could be explained by variations in case mix or by other factors. METHODS: We analyzed data from the 15 116 patients recruited in Argentina, Australia, Italy, the Netherlands, Norway, Poland, Sweden, Switzerland, and the United Kingdom: We compared crude case fatality and the proportion of patients dead or dependent at 6 months; we used logistic regression to adjust for age, sex, atrial fibrillation, systolic blood pressure, level of consciousness, and number of neurological deficits. We used the frequency of prerandomization head CT scan and prescription of aspirin at discharge to indicate quality of care. RESULTS: The differences in outcome (all treatment groups combined) between the "best" and "worst" countries were very large for death (171 cases per 1000 patients) and for death or dependency (375 cases per 1000 patients). The differences were somewhat smaller after adjustment for case mix (160 and 311 cases per 1000 patients, respectively). Process of care may have accounted for some but not all of the residual variation in outcome. CONCLUSIONS: Adjustment for case mix explained only some of the variation in outcome between countries. The residual differences in outcome were too large to be explained by variations in care and most likely reflect differences in unmeasured baseline factors. These findings demonstrate the need to achieve balance of treatment and control within each country in multinational randomized controlled stroke trials and the need for caution in the interpretation of nonrandomized comparisons of outcome after stroke between countries.
Assuntos
Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Acidente Vascular Cerebral/mortalidade , Idoso , Argentina/epidemiologia , Aspirina/uso terapêutico , Austrália/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Heparina/uso terapêutico , Humanos , Modelos Logísticos , Masculino , Modelos Estatísticos , Avaliação de Resultados em Cuidados de Saúde/tendências , Polônia/epidemiologia , Valor Preditivo dos Testes , Avaliação de Processos em Cuidados de Saúde/estatística & dados numéricos , Avaliação de Processos em Cuidados de Saúde/tendências , Prognóstico , Qualidade da Assistência à Saúde , Curva ROC , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Taxa de Sobrevida/tendências , Reino Unido/epidemiologiaRESUMO
Fundamento.- Los objetivos del presente estudio fueron: 1.- Conocer el cumplimiento del tratamiento ambulatorio de la Hipertensión Arterial. 2.- Determinar los factores que contribuyen al incumplimiento del tratamiento. Métodos.- Con estos fines se evaluó un total de 316 pacientes con diagnóstico de hipertensión arterial en tratamiento ambulatorio, durante los meses de junio a diciembre de 1992, como un estudio descriptivo, retrospectivo. Resultados.- Sólo 18 pacientes (6 por ciento) cumplieron tratamiento integral (no farmacológico y farmacológico); el tratamiento farmacológico regular fue cumplido por 172 pacientes (54 por ciento) y el motivo del tratamiento farmacológico irregular se debió a factores personales en el 78 por ciento de los pacientes (se siente bien, descuido, falta de tiempo). Conclusiones.- Los resultados de este estudio demuestra que hay una pobre información y aceptaión del tratamiento integral de la hipertensión arterial.