Yes / Routine administrative data have been used to show that patients admitted to hospitals over the weekend appear to have a higher mortality compared to weekday admissions. Such data do not take the severity of sickness of a patient on admission into account. Our aim was to incorporate a standardized vital signs physiological-based measure of sickness known as the National Early Warning Score to investigate if weekend admissions are: sicker as measured by their index National Early Warning Score; have an increased mortality; and experience longer delays in the recording of their index National Early Warning Score. Methods: We extracted details of all adult emergency medical admissions during 2014 from hospital databases and linked these with electronic National Early Warning Score data in four acute hospitals. We analysed 47,117 emergency admissions after excluding 1657 records, where National Early Warning Score was missing or the first (index) National Early Warning Score was recorded outside ±24 h of the admission time. Results: Emergency medical admissions at the weekend had higher index National Early Warning Score (weekend: 2.53 vs. weekday: 2.30, p

Sepse é causa comum de óbito, e vários fatores prognósticos têm sido identificados. Entretanto, é possível que a rota do paciente séptico no hospital também tenha efeito sobre o prognóstico. Nosso objetivo foi verificar se a rota do paciente séptico antes da admissão na UTI tem efeito sobre a letalidade hospitalar. Métodos Foi realizado um estudo de coorte retrospectiva com 489 pacientes com sepse grave ou choque séptico (idade >=18 anos), internados na Unidade de Terapia Intensiva. Analisamos se a rota está associada a mortalidade hospitalar usando modelo de regressão de Cox com variância robusta. Resultados Dos 489 pacientes, 207 (42,3%) foram diagnosticados com sepse na Unidade de Pronto Atendimento (UPA), 185 (37,8%) em unidade de internação clínica ou cirúrgica (Clínica Médica Cirúrgica - CMC), 56 (13,3%) em Unidade Semi-Intensiva (USI) e 32 (6,5%) em Unidade Terapia Intensiva.(UTI). A maioria (56,6%) dos pacientes era do sexo masculino, a idade média foi de 66,3 anos, 39,8% tinham APACHE II de 25 ou mais, e 77,5% tinham o diagnóstico de choque séptico. A letalidade foi 41,9%. Na análise multivariada com ajuste para diversos fatores prognósticos, incluindo tempo de internação hospitalar antes da admissão na UTI, não houve diferença estatisticamente significativa no risco de óbito entre pacientes com sepse grave diagnosticada na UPA ou CMC (risco relativo [RR] 1,36; intervalo de confiança [IC] 95% 1,00 a 1,83). Porém, o risco de óbito hospitalar foi maior nos pacientes em que a sepse grave foi diagnosticada na USI ou UTI (RR 1,64; IC 95% 1,20 a 2,25). Conclusão A mortalidade dos pacientes com sepse grave ou choque séptico atendidos na CMC é similar à de pacientes com sepse diagnosticada na UPA. Entretanto, o risco de óbito hospitalar foi maior nos pacientes que desenvolveram sepse na USI ou UTI / Sepsis is a common cause of death. Several predictors of hospital mortality have been identified. However, it is possible that the route the septic patient takes within the hospital may also affect endpoints. Thus, our main objective was to verify whether the routes of septic patients before being admitted to ICU affect their in-hospital mortality. Methods Retrospective cohort study of 489 patients with severe sepsis or septic shock (age >= 18 years) admitted to the Intensive Care Unit. We analyzed the impact of route on in-hospital mortality using Cox regression with robust variance. Results Of 489 patients, 207 (42.3%) presented with severe sepsis in the ED, 185 (37.8%) were diagnosed with severe sepsis in the ward, 56 (13.3%) in the step down unit and 32 (6.5%) in the ICU. The mortality rate was 41.9%. The mean age was 66.3 years, and 56.6% were men. APACHE II scores were >25 in 39.8% of patients, and 77.5% were diagnosed with septic shock. In the multivariate analysis, with adjustment for several prognostic factors including length of hospital stay before ICU admission, there was no statistically significant difference in the risk of death between patients who had severe sepsis diagnosed in the ED compared to CMC (relative risk [RR] 1,36; IC 95% 1,00 a 1,83). However, the risk of death was increased in patients who had severe sepsis diagnosed in the step-down unit or ICU (RR 1,64; IC 95% 1,20 a 2,25). Conclusion Patients who have severe sepsis or septic shock diagnosed in the CMC have in-hospital mortality similar to those who present with severe sepsis or septic shock in the ED. However, patients who develop severe sepsis in the step-down unit or ICU have higher mortality

Estudos de morbidade por causas externas são escassos em virtude da dificuldade de obtenção de dados para sua realização. Ainda mais escassos são aqueles que examinam a gravidade do trauma com vistas a determinar sua magnitude e repercussão na assistência aos que sofreram os agravos. O estudo apresenta a análise descritiva retrospectiva sobre a morbi-mortalidade hospitalar por causas externas com o uso de medidas objetivas para avaliação da gravidade do trauma e probabilidade de sobrevida. Os índices utilizados para mensurar a gravidade do trauma foram o sistema Abbreviated Injury Scale (AIS) /Injury Severity Score (ISS) e o Revised Trauma Score(RTS). Para calcular a probabilidade de sobrevida (Ps), usou-se o TRauma and Injury Severity Score (TRISS). A população do estudo foi constituída por 1.781 pacientes de causas externas internados no Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no ano de 1998. Do total de pacientes, 30,15% foram internados em decorrência de acidente de transporte, 24,32% por agressões e 17,24% por quedas. A população foi constituída, predominantemente, por pacientes do sexo masculino e jovens entre 15 e 39 anos. Entre os pacientes, 43,34% foram provenientes da cena do evento e 39,08% transferidos de outros hospitais. O atendimento pré-hospitalar foi realizado em tempo médio de 49 minutos à maioria daqueles que vieram diretos da cena do evento. A mortalidade hospitalar foi 12,63%, e nas primeiras 24 horas morreram 64,01%. A maioria das causas externas foi classificada em trauma contuso (61,42%), seguido de penetrante (23,24%). A mensuração da gravidade da lesão foi possível para 1.542 (86,58%) pacientes de acordo com o Manual AIS e resultou em 4.918 lesões decorrentes, predominantemente, de trauma contuso (75,79%), mais freqüentes na região da cabeça (28,12%) seguida da face (22,00%). A média de lesões por paciente foi 3,19. Em relação à gravidade, verificou-se que lesões leves (AIS 1) foram freqüentes na face (45,03%) e as lesões sérias (AIS 3), graves (AIS 4) e críticas (AIS 5) foram mais freqüentes na região da cabeça, 43,21%, 75,00% e 69,82%, respectivamente. A gravidade do trauma (ISS) com base na gravidade das lesões (AIS), foi calculada para 1.527 (99,02%) pacientes. A maioria (65,75%) foi classificada com escores ISS <16. No grupo de sobreviventes, predominaram os escores ISS <16 (76,32%) e, no grupo de óbitos, os escores ISS >16 (96,40%), indicativos de trauma importante. A média do ISS em trauma contuso foi 13,08 e em penetrante, 11,97. A gravidade do trauma na fase pré-hospitalar verificada por meio do RTStriagem foi possível para 228 (49,14%) pacientes. Entre os sobreviventes, 94,93% obtiveram escore 12, indicativo de condição fisiológica inalterada e 93,75% dos óbitos obtiveram escore zero, ausência de resposta fisiológica. O TRISS calculado para uma amostra de 241 pacientes, revelou dez casos de morte inesperada ou evitável pela metodologia PREliminary outcome-based evaluation(PRE). Além disso, os valores da estatística Z e W tanto para trauma contuso quanto penetrante, indicaram que os resultados da amostra foram estatisticamente diferentes em relação à população do Major Trauma Outcome Study. Ajustados os coeficientes do TRISS para a amostra deste estudo, observou-se por meio do método PRE que em trauma contuso, ocorreram cinco mortes inesperadas ou evitáveis e uma sobrevida inesperada. Em trauma penetrante, ocorreu uma morte inesperada ou evitável e não houve casos de sobrevida inesperada. Espera-se que este estudo ofereça subsídios para ações preventivas e melhoria da qualidade da assistência aos pacientes hospitalizados em decorrência das causas externas. / Studies on morbidity resulting from external causes are scarce, due to the difficulty of gathering data for this purpose. Even scarcer are those studies analysing injury severity´s magnitude and consequences in relation to the care of trauma patients. This study presents a retrospective descriptive analysis of hospital morbidity and mortality due to external causes by applying objective measurements of injury severity and survival probability. The indexes used to measure injury severity consisted of the \"Abbreviated Injury Scale\" (AIS), the \"Injury Severity Score\" (ISS), and the \" Revised Trauma Score\" (RTS). So as to calculate probability of survival (Ps), the \"Trauma and Injury Severity Score\" (TRISS) was applied. The target population in this study consisted of 1,781 external-cause inpatients at the Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo in 1998. Out of those patients, 30.15% were hospitalized as a result of transportation accidents, 24.32% of aggression and 17.24% of falls. This population mainly included young male-sex patients aged 15-39. Among these, 43.34% came from the injury scene and 39.08% were transfered from other hospitals. Prehospital time took 49 minutes in average for the majority of field patients. Hospital mortality reached 12.63%, out of which cases 64.01% died within the first 24 hours. Most external-cause types were classified as blunt trauma (61.42%), followed by penetrating trauma (23.24%). According to the AIS Manual, injury severity was possible for 1,542 (86.58%) patients; data showed 4,918 injuries of predominant blunt trauma ( 75.79%), being it most frequent in the head (28.12%), and followed by that on the face (22.00%). Average injury per patient was of 3.19. In relation to severity it was verified that minor injuries (AIS 1) were frequent on the face (45.03%) and the serious ones (AIS 3), the severe ones (AIS 4) and the critical ones (AIS 5) were more frequent in the head: 43.21%, 75.00% and 69.82%, respectively. Injury Severity Score was calculated for 1,527 (99.02%) patients. The majority (65.75%) was classified with scores ISS <16. For the survival group scores ISS <16 predominated (76.32%) and in the death group scores reached ISS >16 (96.40%), indicating major trauma. Average ISS in blunt trauma was 13.08 and 11.97 in penetrating trauma. Injury severity in prehospital care, verified through RTS - in a triage of 228 (49.14%) patients - showed that 94.93% of survivors obtained score 12, indicating unaltered physiological condition, and that 93.75% of deaths obtained score zero, lack of physiological response. TRISS, calculated for 241 patients, indicated 10 unexpected deaths through PREliminary outcome-base evaluation (PRE) methodology. Furthermore, \"Z\" and \"W\" statistics, for both blunt and penetrating trauma, pointed out that sample results differed in relation to the \"Major Trauma Outcome Study\" ´s population. Once TRISS coefficients were adjusted to the sample in this study, it was observed, through the PRE method, that in blunt trauma five unexpected deaths and one unexpected survival occurred. There was one unexpected death in penetrating trauma. It is hoped that this study may offer means for preventive actions and assurance of the quality of care for inpatients due to external causes.

Estudos de morbidade por causas externas são escassos em virtude da dificuldade de obtenção de dados para sua realização. Ainda mais escassos são aqueles que examinam a gravidade do trauma com vistas a determinar sua magnitude e repercussão na assistência aos que sofreram os agravos. O estudo apresenta a análise descritiva retrospectiva sobre a morbi-mortalidade hospitalar por causas externas com o uso de medidas objetivas para avaliação da gravidade do trauma e probabilidade de sobrevida. Os índices utilizados para mensurar a gravidade do trauma foram o sistema Abbreviated Injury Scale (AIS) /Injury Severity Score (ISS) e o Revised Trauma Score(RTS). Para calcular a probabilidade de sobrevida (Ps), usou-se o TRauma and Injury Severity Score (TRISS). A população do estudo foi constituída por 1.781 pacientes de causas externas internados no Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no ano de 1998. Do total de pacientes, 30,15% foram internados em decorrência de acidente de transporte, 24,32% por agressões e 17,24% por quedas. A população foi constituída, predominantemente, por pacientes do sexo masculino e jovens entre 15 e 39 anos. Entre os pacientes, 43,34% foram provenientes da cena do evento e 39,08% transferidos de outros hospitais. O atendimento pré-hospitalar foi realizado em tempo médio de 49 minutos à maioria daqueles que vieram diretos da cena do evento. A mortalidade hospitalar foi 12,63%, e nas primeiras 24 horas morreram 64,01%. A maioria das causas externas foi classificada em trauma contuso (61,42%), seguido de penetrante (23,24%). A mensuração da gravidade da lesão foi possível para 1.542 (86,58%) pacientes de acordo com o Manual AIS e resultou em 4.918 lesões decorrentes, predominantemente, de trauma contuso (75,79%), mais freqüentes na região da cabeça (28,12%) seguida da face (22,00%). A média de lesões por paciente foi 3,19. Em relação à gravidade, verificou-se que lesões leves (AIS 1) foram freqüentes na face (45,03%) e as lesões sérias (AIS 3), graves (AIS 4) e críticas (AIS 5) foram mais freqüentes na região da cabeça, 43,21%, 75,00% e 69,82%, respectivamente. A gravidade do trauma (ISS) com base na gravidade das lesões (AIS), foi calculada para 1.527 (99,02%) pacientes. A maioria (65,75%) foi classificada com escores ISS <16. No grupo de sobreviventes, predominaram os escores ISS <16 (76,32%) e, no grupo de óbitos, os escores ISS >16 (96,40%), indicativos de trauma importante. A média do ISS em trauma contuso foi 13,08 e em penetrante, 11,97. A gravidade do trauma na fase pré-hospitalar verificada por meio do RTStriagem foi possível para 228 (49,14%) pacientes. Entre os sobreviventes, 94,93% obtiveram escore 12, indicativo de condição fisiológica inalterada e 93,75% dos óbitos obtiveram escore zero, ausência de resposta fisiológica. O TRISS calculado para uma amostra de 241 pacientes, revelou dez casos de morte inesperada ou evitável pela metodologia PREliminary outcome-based evaluation(PRE). Além disso, os valores da estatística Z e W tanto para trauma contuso quanto penetrante, indicaram que os resultados da amostra foram estatisticamente diferentes em relação à população do Major Trauma Outcome Study. Ajustados os coeficientes do TRISS para a amostra deste estudo, observou-se por meio do método PRE que em trauma contuso, ocorreram cinco mortes inesperadas ou evitáveis e uma sobrevida inesperada. Em trauma penetrante, ocorreu uma morte inesperada ou evitável e não houve casos de sobrevida inesperada. Espera-se que este estudo ofereça subsídios para ações preventivas e melhoria da qualidade da assistência aos pacientes hospitalizados em decorrência das causas externas. / Studies on morbidity resulting from external causes are scarce, due to the difficulty of gathering data for this purpose. Even scarcer are those studies analysing injury severity´s magnitude and consequences in relation to the care of trauma patients. This study presents a retrospective descriptive analysis of hospital morbidity and mortality due to external causes by applying objective measurements of injury severity and survival probability. The indexes used to measure injury severity consisted of the \"Abbreviated Injury Scale\" (AIS), the \"Injury Severity Score\" (ISS), and the \" Revised Trauma Score\" (RTS). So as to calculate probability of survival (Ps), the \"Trauma and Injury Severity Score\" (TRISS) was applied. The target population in this study consisted of 1,781 external-cause inpatients at the Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo in 1998. Out of those patients, 30.15% were hospitalized as a result of transportation accidents, 24.32% of aggression and 17.24% of falls. This population mainly included young male-sex patients aged 15-39. Among these, 43.34% came from the injury scene and 39.08% were transfered from other hospitals. Prehospital time took 49 minutes in average for the majority of field patients. Hospital mortality reached 12.63%, out of which cases 64.01% died within the first 24 hours. Most external-cause types were classified as blunt trauma (61.42%), followed by penetrating trauma (23.24%). According to the AIS Manual, injury severity was possible for 1,542 (86.58%) patients; data showed 4,918 injuries of predominant blunt trauma ( 75.79%), being it most frequent in the head (28.12%), and followed by that on the face (22.00%). Average injury per patient was of 3.19. In relation to severity it was verified that minor injuries (AIS 1) were frequent on the face (45.03%) and the serious ones (AIS 3), the severe ones (AIS 4) and the critical ones (AIS 5) were more frequent in the head: 43.21%, 75.00% and 69.82%, respectively. Injury Severity Score was calculated for 1,527 (99.02%) patients. The majority (65.75%) was classified with scores ISS <16. For the survival group scores ISS <16 predominated (76.32%) and in the death group scores reached ISS >16 (96.40%), indicating major trauma. Average ISS in blunt trauma was 13.08 and 11.97 in penetrating trauma. Injury severity in prehospital care, verified through RTS - in a triage of 228 (49.14%) patients - showed that 94.93% of survivors obtained score 12, indicating unaltered physiological condition, and that 93.75% of deaths obtained score zero, lack of physiological response. TRISS, calculated for 241 patients, indicated 10 unexpected deaths through PREliminary outcome-base evaluation (PRE) methodology. Furthermore, \"Z\" and \"W\" statistics, for both blunt and penetrating trauma, pointed out that sample results differed in relation to the \"Major Trauma Outcome Study\" ´s population. Once TRISS coefficients were adjusted to the sample in this study, it was observed, through the PRE method, that in blunt trauma five unexpected deaths and one unexpected survival occurred. There was one unexpected death in penetrating trauma. It is hoped that this study may offer means for preventive actions and assurance of the quality of care for inpatients due to external causes.

Sepse é causa comum de óbito, e vários fatores prognósticos têm sido identificados. Entretanto, é possível que a rota do paciente séptico no hospital também tenha efeito sobre o prognóstico. Nosso objetivo foi verificar se a rota do paciente séptico antes da admissão na UTI tem efeito sobre a letalidade hospitalar. Métodos Foi realizado um estudo de coorte retrospectiva com 489 pacientes com sepse grave ou choque séptico (idade >=18 anos), internados na Unidade de Terapia Intensiva. Analisamos se a rota está associada a mortalidade hospitalar usando modelo de regressão de Cox com variância robusta. Resultados Dos 489 pacientes, 207 (42,3%) foram diagnosticados com sepse na Unidade de Pronto Atendimento (UPA), 185 (37,8%) em unidade de internação clínica ou cirúrgica (Clínica Médica Cirúrgica - CMC), 56 (13,3%) em Unidade Semi-Intensiva (USI) e 32 (6,5%) em Unidade Terapia Intensiva.(UTI). A maioria (56,6%) dos pacientes era do sexo masculino, a idade média foi de 66,3 anos, 39,8% tinham APACHE II de 25 ou mais, e 77,5% tinham o diagnóstico de choque séptico. A letalidade foi 41,9%. Na análise multivariada com ajuste para diversos fatores prognósticos, incluindo tempo de internação hospitalar antes da admissão na UTI, não houve diferença estatisticamente significativa no risco de óbito entre pacientes com sepse grave diagnosticada na UPA ou CMC (risco relativo [RR] 1,36; intervalo de confiança [IC] 95% 1,00 a 1,83). Porém, o risco de óbito hospitalar foi maior nos pacientes em que a sepse grave foi diagnosticada na USI ou UTI (RR 1,64; IC 95% 1,20 a 2,25). Conclusão A mortalidade dos pacientes com sepse grave ou choque séptico atendidos na CMC é similar à de pacientes com sepse diagnosticada na UPA. Entretanto, o risco de óbito hospitalar foi maior nos pacientes que desenvolveram sepse na USI ou UTI / Sepsis is a common cause of death. Several predictors of hospital mortality have been identified. However, it is possible that the route the septic patient takes within the hospital may also affect endpoints. Thus, our main objective was to verify whether the routes of septic patients before being admitted to ICU affect their in-hospital mortality. Methods Retrospective cohort study of 489 patients with severe sepsis or septic shock (age >= 18 years) admitted to the Intensive Care Unit. We analyzed the impact of route on in-hospital mortality using Cox regression with robust variance. Results Of 489 patients, 207 (42.3%) presented with severe sepsis in the ED, 185 (37.8%) were diagnosed with severe sepsis in the ward, 56 (13.3%) in the step down unit and 32 (6.5%) in the ICU. The mortality rate was 41.9%. The mean age was 66.3 years, and 56.6% were men. APACHE II scores were >25 in 39.8% of patients, and 77.5% were diagnosed with septic shock. In the multivariate analysis, with adjustment for several prognostic factors including length of hospital stay before ICU admission, there was no statistically significant difference in the risk of death between patients who had severe sepsis diagnosed in the ED compared to CMC (relative risk [RR] 1,36; IC 95% 1,00 a 1,83). However, the risk of death was increased in patients who had severe sepsis diagnosed in the step-down unit or ICU (RR 1,64; IC 95% 1,20 a 2,25). Conclusion Patients who have severe sepsis or septic shock diagnosed in the CMC have in-hospital mortality similar to those who present with severe sepsis or septic shock in the ED. However, patients who develop severe sepsis in the step-down unit or ICU have higher mortality

Introducción: La intervención coronaria percutánea primaria durante las 24 primeras horas de inicio del dolor torácico reduce la mortalidad por infarto de miocardio con ST elevado (IMA STE). El objetivo del estudio fue evaluar la mortalidad intrahospitalaria a 30 días según el tiempo puerta-balón y el tiempo total de isquemia en pacientes con IAM STE sometidos a intervención coronaria percutánea (ICP) primaria en un hospital de referencia. Métodos: Estudio retrospectivo de cohorte de pacientes con IMA STE sometidos a ICP primaria en un hospital de referencia de Lima, Perú. Analizamos la asociación entre el tiempo total de isquemia menor a 12 horas y tiempo puerta balón menor a 90 minutos con mortalidad a 30 días, mediante Regresión de Cox, ajustado por otros factores. Resultados: Durante el periodo 2010-2014, 296 sujetos con IMA STE fueron sometidos a ICP primaria. El 82,4% fueron varones y la media de edad fue 66,5 años ±11,8. La mortalidad intrahospitalaria a 30 días fue 8,11%. El 82,43% tuvo un tiempo total de isquemia menor a 12 horas y el 33,11% un tiempo puerta-balón menor a 90 minutos. No se encontró asociación entre ambos tiempos y mortalidad intrahospitalaria. El paro cardiaco (HR: 2,9 IC 95% 1,09-7,72), shock cardiogénico al ingreso (HR: 7,06 IC 95% 2,84-17,59) y un flujo TIMI menor a 3 post ICP (HR: 4,21 IC 95% 1,73-10,19) se asociaban a mayor mortalidad. Conclusión: No hubo asociación entre los tiempos estudiados con la mortalidad intrahospitalaria. Se sugieren intervenciones para disminuir los tiempos en esta población. / Introduction: Primary percutaneous coronary intervention reduces mortality in patients with ST elevated myocardial infarction (STE MI). The objective was to evaluate the 30 days in-hospital mortality according to door-to-balloon time and total ischemic time in patients treated with primary PCI. Methods: A retrospective cohort study was performed including patients with STE MI who underwent primary PCI at a national reference hospital in Lima, Peru. A Cox Regression analysis was performed for door-to-balloon time less than 90 minutes and total ischemic time less than 12 hours as predictors and in-hospital mortality as outcome. Results: During 2010’2014, 296 STE MI patients underewent PCI. From them, 82,4% were male. The mean age was 66,5 ±11,8 years. The 30-day mortality was 8,11%. The proportion of patients with total ischemic time less than 12 hours and door-to-balloon time was 82,43% and 33,11% respectively. No association between these intervals and 30-day mortality was found. Cardiac arrest (HR: 2,9 95%CI 1,09-7,72), cardiogenic shock at the admission (HR: 7,06; 95%CI: 2,84- 17,59) and TIMI flow less than 3 after primary PCI (HR: 4,21; 95%CI: 1,73-10,19) were associated with higher 30-day mortality.. Conclusion: No association between mortality and lower total ischemia time or door to ballon time mortality was found. A significant delay was observed in hospital arrival and performing revascularization.

No description available.

[pt] A pandemia da COVID-19 infectou uma grande quantidade de indivíduos e provocou elevado número de óbitos no mundo. No Brasil, reforçou disparidades regionais no sistema de saúde e provocou elevada mortalidade hospitalar. Isto chamou a atenção para um estresse no sistema de saúde e levantou a hipótese de que o acesso desigual poderia afetar a mortalidade hospitalar na pandemia. Assim, este estudo utilizou a metodologia da Design Science Research (DSR) junto ao ciclo de vida de Ciência de Dados para identificar como o acesso ao sistema de saúde impacta na mortalidade hospitalar. O acesso ao sistema de saúde é um conceito complexo e carente de uma definição consensual, o que motivou a elaboração de uma descrição que englobasse suas múltiplas características. Uma análise qualitativa da interação entre as camadas do acesso apontou a acessibilidade como esfera central. Portanto, este trabalho utilizou dados públicos do Sistema Integrado de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) para entender como a acessibilidade impactou na mortalidade hospitalar por COVID-19 no Brasil no ano epidemiológico de 2020 ao avaliar as diferenças entre aqueles que foram internados em seus municípios de residência e os que tiveram que se deslocar para outras cidades. Os resultados mostraram que 26 por cento dos pacientes hospitalizados neste período foram internados em um município diferente do que residem. Além disso, existiu um grande deslocamento de municípios da periferia das capitais em direção às capitais. Estas periferias apresentavam elevada mortalidade hospitalar e baixo nível de recursos no sistema de saúde, o que pode ter motivado a evasão. Além disso, a partir de um modelo de regressão logística de efeitos mistos, verificou-se que aqueles que deixaram seus municípios de moradia apresentaram maior chance de óbito do que aqueles que ficaram. Isto mostrou que uma deficiência na acessibilidade impactou a mortalidade hospitalar de forma negativa. / [en] The COVID-19 pandemic infected many individuals and caused a high number of deaths around the world. In Brazil, it highlighted the regional healthcare disparities and caused high in-hospital mortality. This drew attention to the system s burden and raised the question that uneven access could affect in-hospital mortality during the pandemic. Therefore, this study used the Design Science Research (DSR) methodology paired with the Data Science life cycle to identify how the healthcare access affects in-hospital mortality. Access is a complex concept, lacking a consensual definition, which motivated us to create a conceptualization that encompasses its multiple characteristics. A qualitative analysis of the interaction among the layers of this new definition pointed to accessibility as the main issue. Thus, this work used public data from the Sistema Integrado de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) to better understand how it affected the in-hospital mortality among COVID-19 inpatients in Brazil during the epidemiological year of 2020. This was conducted by evaluating the differences between those hospitalized in their city of residence and those that had to go to other cities. Results showed that, in this period, 26 per cent of inpatients were not hospitalized in their city of residence. Also, there was a noticeable flux of patients from towns on the periphery of the state capitals to the capitals. These peripheries presented higher in-hospital mortality and a lower level of healthcare resources, which may have motivated the movement. Besides, the development of a mixed effects logistic regression model evidenced that inpatients that left their cities of residence had a higher chance of death than those that stayed. This showed that a deficiency in accessibility caused a negative impact in in-hospital mortality.

No / Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy. / E. LPQuiC Collaborator Group

L’objectif de cette thèse était d’investiguer différents choix méthodologiques, en particulier le choix du délai et la prise en compte des causes médicales de décès, dans l’élaboration des indicateurs de mortalité post-hospitalière visant à refléter la qualité des soins.Dans une première phase, les données médico-administratives hospitalières des bénéficiaires du Régime Général (RG) de l’Assurance Maladie décédés dans l'année suivant une hospitalisation en 2008 ou 2009 ont été appariées aux causes de décès (base du CépiDc). Le taux d’appariement était de 96,4%.Dans une deuxième phase les séjours pour lesquels la cause initiale de décès pouvait être qualifiée d'indépendante du diagnostic principal du séjour ont été repérés à l'aide d'un algorithme et d'un logiciel s'appuyant sur des standards internationaux. Dans une troisième phase, le modèle le plus souvent utilisé à l'international pour évaluer la mortalité intra-hospitalière (modèle « de Jarman ») a été reproduit et utilisé pour construire des indicateurs de mortalité par établissement à 30, 60, 90, 180 et 365 jours post-admission, pour l'année 2009 (12 322 831 séjours PMSI-MCO des bénéficiaires du RG).L’indicateur de mortalité intra-hospitalière s’est révélé biaisé par les pratiques de sortie des établissements (caractérisées par la durée moyenne de séjour et le taux de transfert vers d’autres établissements). Les indicateurs à 60 ou 90 jours post-admission doivent être préférés à l’indicateur à 30 jours car ils ont l’avantage d’inclure presque tous les décès intra-hospitaliers, limitant notamment les incitations à maintenir les patients en vie jusqu’à la fin de la période de suivi et/ou à cesser de leur dédier des ressources une fois ce terme atteint. L’utilisation des causes de décès en supprimant les décès indépendants change de façon négligeable les indicateurs de mortalité globale par établissement, toutefois elle pourrait être utile pour des indicateurs spécifiques, limités à certaines pathologies ou procédures.Des réserves quant à la pertinence de ces indicateurs ont été décrites (limites du modèle et des variables d'ajustement, hétérogénéité de la qualité du codage entre les établissements), mettant en évidence la nécessité de recherches complémentaires, en particulier sur leur capacité à refléter la qualité des soins et sur l’impact de leur diffusion publique. A ce jour, l’interprétation des indicateurs de mortalité par établissement nécessite la plus grande prudence. / The main objective of this PhD work was to investigate different methodological options for the elaboration of post hospital mortality indicators aiming at reflecting quality of care, in particular to identify the most relevant timeframes and to assess the contribution of the causes of death information.In a first phase, the hospital discharge data of the French General health insurance scheme beneficiaries who died during the year following an hospital stay in 2008 or 2009 were linked to the cause of death register. The matching rate was 96.4%.In a second phase, the hospital stays for which the underlying cause of death could be qualified as independent from the main diagnosis were identified with an algorithm and a software relying on international standards.In a third phase, the method most widely used to assess in-hospital mortality (Dr Foster Unit method) was reproduced and used to construct hospital mortality indicators at 30, 60, 90, 180 et 365 days post-admission, on year 2009 (12 322 831 acute-care stays)..As in other countries, in-hospital mortality revealed biased by discharge patterns in the French data: hospitals : short length-of-stay or high transfer-out rates for comparable casemix tend to have lower in-hospital mortality. The 60-day and 90-day indicators should be preferred to the 30-day indicator, because they reflect a larger part of in-hospital mortality, and are less subject to the incentives either to maintain patients alive until the end of the follow-up window or to shift resources away when this length of stay is reached. The contribution of the causes of death seems negligible in the context of hospital-wide indicators, but it could prove its utility in future health services research about specific indicators limited to selected conditions or procedures.However, reservations about the relevance of hospital-wide mortality indicators aiming at assessing quality of care are described (limits of the statistical model and adjustment variables available, heterogeneity of the coding quality between hospitals). Further research is needed, in particular on the capacity of these indicators to reflect quality of care and on the impact of their public reporting. To date, the use of hospital-wide mortality indicators needs to be extremely cautious.