This research examines the safety and cost effectiveness of an institutional policy on discharge of preterm infants with Apnea of Prematurity (AOP) from the Virginia Commonwealth University Medical Center Newborn Intensive Care Unit (VCUNC NICU) with caffeine therapy and a cardiorespiratory monitor. This practice policy was developed over a decade ago as a cost containment measure in neonatal care and continues to be implemented today despite the lack of a formal evaluation. The secondary objective was to examine through a review of the literature the psychosocial impact of premature birth on the family and the potential effect on the infant's hospital discharge. The evaluation of this policy is based on the conceptual framework of effectiveness, efficiency, and equity in health care. Results were used to generate policy recommendations.This is a retrospective case study of 933 infants admitted to the VCU Medical Center and the community hospital NICU between 1993 and 2002 diagnosed with Apnea of Prematurity. Data was obtained from the Neonatal Information System database at Virginia Commonwealth University Health System (VCUHS), the Virginia Department of Health, and the VCUHS hospital information system. In this mixed methods study, the infants were divided into two groups: 1) those discharged from the hospital on caffeine citrate therapy, and a cardiorespiratory monitor for continued management of apnea; and 2) those that were hospitalized until resolution of apnea. Data was analyzed for differences in mortality and morbidity, hospital readmissions and cost of hospital care from birth to 1 year of age. Interviews were conducted with NICU clinicians to obtain a qualitative perspective on this policy. No significant differences were found in the mortality rate between the two groups (p=.65), and the causes of the four deaths were unrelated to Apnea of Prematurity. Mean hospital costs were approximately $58,000 in both groups. Bronchiolitis was the leading cause for hospital readmission and there was no difference in the rate of hospital readmissions. Based on interviews with NICU clinicians, the policy works well and early discharge is advantageous to the infant and family. Therefore, we find no reason to not continue this policy. Study results support the importance and direction for further research on early discharge of infants with AOP and enhanced epidemiologic surveillance of this population.

No description available.

Hospital readmissions are a major burden for patients with end stage renal disease (ESRD). On average, one in three hospital discharges among patients with ESRD are followed by a readmission within 30 days. Currently, dialysis facilities are held accountable for readmissions via the ESRD Quality Incentive Program standardized readmission ratio (SRR) clinical measure. However, little is known about facility-level factors associated with readmission. Additionally, unlike other standardized measures of quality in the dialysis setting, incident patients within their first 90-days of dialysis are included in the performance calculation. This study analyzed CMS Dialysis Facility Report data from 2013 to 2016 to examine dialysis facility and incident patient factors associated with SRR using multivariate mixed models. Among 5,419 dialysis facilities treating 104,768 incident patients, the mean SRR remained stable across all four study years at 0.99. Factors significantly associated with a lower SRR (p<0.0001) included Western geographic region and higher patient care technician ratios. Several incident patient pre-dialysis nephrology care characteristics were associated with lower SRRs including higher percentages of patients with a fistula present at first dialysis treatment, higher percentages of patients receiving 6-12 months or greater than 12 months of nephrology care prior to dialysis and higher facility average hemoglobin. Factors significantly associated with a higher SRR (p<0.0001) included Northeastern geographic region, higher registered nurse ratios, higher percentage of incident patients, and higher facility average GFR. Understanding facility-level and patient-level factors associated with higher SRRs may inform interventions to reduce 30-day hospital readmission among patients receiving dialysis.

Background: Religious involvement is widespread and may influence patient engagement with their healthcare (patient activation) and health outcomes. This dissertation examined the association between religiosity and patient activation, changes in health-related quality of life (HRQOL), readmissions, and survival after hospitalization for acute coronary syndrome (ACS). Methods: We recruited 2,174 patients hospitalized for ACS in Georgia and Central Massachusetts (2011-2013) in a prospective cohort study. Participants self-reported three items assessing religiosity – strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. Patient activation was measured using the 6-item Patient Activation Measure. Generic HRQOL was assessed with the SF-36®v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated with the Seattle Angina Questionnaire Quality of Life subscale. Unscheduled readmissions were validated from medical records. Mortality status was obtained from national and state vital statistics. Results: After adjustment for several sociodemographic, psychosocial, and clinical variables, reports of strength/comfort from religion and receipt of intercessions were associated with high activation. Praying for one’s health was associated with low activation. Prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL. Neither strength/comfort from religion, petition, nor intercessory prayers were significantly associated with unscheduled 30-day readmissions and two-year all-cause mortality. Conclusions: Most ACS survivors acknowledge religious practices for their health. Religiosity was associated with patient activation and changes in HRQOL. These findings suggest that religiosity may influence patient engagement in their healthcare and recovery after a life-threatening illness, buttressing the need for holistic approach in patient management.

Heart failure (HF) is a serious public health problem associated with high mortality rates, hospital readmissions, and health care costs. Transitional care has emerged as a disease management model used to reduce readmissions for hospital-discharged patients with HF. However, the efficacy of an advanced practice nurse (APN)-led transitional care program (TCP) in readmission reduction is under debate. The practice question for this project examined the extent to which an APN-led TCP was effective in reducing 30-day all-cause readmissions for hospital-discharged HF patients. The logic model was the framework guiding this program evaluation. An analysis of quality improvement HF data from September 2015 to August 2016 was reviewed for one hospital in southern California. The APN-led TCP included 47 patients and had 7 patients with 30-day readmissions. The physicians' group included 298 patients and had 53 patients with 30-day readmissions. The results of chi-square analysis revealed a nonsignificant association between 30-day readmissions and post-discharge care providers [Ï? 2 (1, N = 345) = 0.236, p = 0.627], and the HF 30-day readmission rates were the same between two groups. The APN-led TCP served a large proportion of Medi-Cal patients (48.94%) who had less primary care access, while the majority of patients in the physicians' group were Medicare (51%) who had primary care providers. This project highlights the positive social changes that advanced practice nurses affect via their critical leadership and clinical roles in increasing care access for the low-income population. Further studies on payer sources and readmissions are recommended on the efficacy of APN-led TCP in readmission reduction.

Objectif : Estimer la contribution statistique des caractéristiques des hôpitaux et des caractéristiques liés aux patients sur la probabilité de réadmission des patients qui ont subi une PCNL, une procédure endoscopique à haut risque de morbidité, dans les hôpitaux aux États-Unis en 2014 et évaluer les prédicteurs des taux de réadmissions d’une PCNL. Méthode : Nous avons identifié tous les patients qui ont subi une PCNL dans les hôpitaux aux États-Unis en 2014 (janvier-novembre) en utilisant la banque de données nationale de réadmission (NRD). L’issue d’intérêt était une réadmission non planifiée 30 jours après une PCNL. À l’aide d’un modèle multi-niveaux à effets mixtes, nous avons estimé l’association statistique entre les caractéristiques hospitalières ainsi que les caractéristiques individuelles liés aux patients sur la probabilité de réadmission. Un effet aléatoire associée à l'hôpital a été utilisé pour estimer le taux de réadmission au niveau hospitalier. Un pseudo R-carré a été calculé pour évaluer la contribution de chaque catégorie de variables sur les taux de réadmission. Résultats : Notre échantillon pondérée était constitué de 6 974 personnes ayant subi une PCNL dans 485 hôpitaux aux États-Unis en 2014. Le taux de réadmission à 30 jours était de 8,5 % (IC à 95 % 7,4 – 9,7). Après ajustement, les caractéristiques hospitalières n’étaient pas associées à une probabilité accrue de réadmission. Le sexe féminin était associé à une diminution de la probabilité de réadmission (IC à 95% 0.54 – 0.93). Les hôpitaux individuelles n’ont contribué qu’à une infime partie à la probabilité d’être réadmis de leurs patients. Les caractéristiques liés aux patients expliquaient davantage la variabilité dans la probabilité de réadmission que les caractéristiques hospitalières (pseudo-R2 9.50% vs 0.03%). Conclusion : Le risque d’être réadmis après une PCNL varie énormément entre les hôpitaux. Une fraction minime de cette variabilité peut être expliqué par les caractéristiques hospitalières contrairement aux caractéristiques des patients. Ces résultats soulignent les limites potentielles de l’utilisation des réadmissions comme mesure de la qualité des soins. / Objective: Estimate the relative contribution of hospital and patient factors to readmission after a typical high-risk endoscopic procedure, percutaneous nephrolithotomy (PCNL). Methods: We utilized the Nationwide Readmission Database to identify the patients who underwent PCNL in the United States hospitals in 2014 (January-November). The main outcome was unplanned 30-day readmission following a PCNL. Using a multilevel mixed-effects model, we estimated the statistical association between patient and hospital characteristics and readmission. A hospital-level random effects term was added to estimate hospital-level readmission. To assess the relative contribution of each group of variables on readmission rates, a pseudo-R2 was calculated to assess the contribution of hospital effects to the model of readmission. Results: We identified a weighted sample of 6,974 individuals who underwent PCNL at 485 hospitals in the United States in 2014. The 30-day readmission rate was 8.5% (95% CI 7.4 – 9.7). In our adjusted model, hospital characteristics were not associated with increased likelihood of readmission. Female sex was the only characteristic associated with decreased likelihood of readmission (95% CI 0.54 – 0.93). Individual hospitals contributed marginally to their patients probability of readmission. Patient level characteristics explained far more of the variability in readmissions than hospital characteristics (pseudo-R2 9.50% vs 0.03%). Conclusion: The risk of readmission after a PCNL is highly variable in between hospitals. The statistical contribution of individual hospitals and hospital characteristics to the probability of readmission following a PCNL was minimal compare to patient characteristics. These findings underscore the potential limitations of using 30-day post-discharge readmissions as a hospital-level quality metric.

No description available.

Na atual conjuntura assistencial em saúde mental, em que se prioriza modalidades de tratamento comunitário, o efetivo funcionamento da rede de assistência ao portador de transtorno mental é de vital importância. A região de Ribeirão Preto-SP, durante o processo de desinstitucionalização de pacientes com transtorno mental das últimas décadas, assistiu à diminuição substancial do número de leitos psiquiátricos e à criação de novos serviços comunitários, que mais recentemente parecem não ser suficientes para atender à demanda de internação existente. Nesse contexto, o objetivo deste estudo foi analisar fatores sociodemográficos e clínicos associados à má aderência ao tratamento, às readmissões hospitalares e às necessidades de cuidados não atendidas de pacientes com transtorno mental, pois essas informações juntas podem ser um indicador de qualidade da assistência oferecida. Inovou-se, ao utilizar em um estudo brasileiro, na área da saúde mental, o índice de vulnerabilidade social como uma variável sociodemográfica, e também por se avaliarem as necessidades de cuidados dos pacientes da rede de assistência utilizando a Camberwell Assessment of Needs (CAN), instrumento mundialmente utilizado para esse fim. Foi realizada busca de todos os 933 pacientes psiquiátricos que apresentaram um transtorno mental que foi grave o suficiente para justificar suas primeiras internações nos anos de 2006 e 2007, nos hospitais com leitos psiquiátricos em Ribeirão Preto. Como a busca foi do indivíduo na comunidade, independente do seu vínculo com serviços de saúde, esse desenho conferiu ao estudo uma característica naturalística do que aconteceu aos pacientes na rede assistencial em um período mínimo de quatro anos após a primeira internação. Por meio de entrevista com 333 pacientes, identificou-se taxa de aderência de 59,6%, e os fatores associados à melhor aderência ao tratamento foram: maior faixa etária, inatividade profissional e internação em hospital geral; enquanto o diagnóstico de transtorno relacionado ao uso de substâncias psicoativas associou-se a pior aderência. Em relação à taxa de reinternação, 22,2% dos pacientes foram reinternados no período. A inatividade profissional, a internação índice com 31 dias ou mais e diagnósticos de mania e transtornos psicóticos do tipo esquizofrênico associaram-se positivamente à readmissão hospitalar. Finalmente, a média de necessidades de cuidados não atingidas encontrada foi de 4,5, similar aos resultados de países desenvolvidos. Nesta amostra, as variáveis significativamente associadas com maiores escores na CAN foram: menos anos de estudo, inatividade laboral e o fato de morar com o companheiro. Os dados do presente estudo alcançaram os objetivos propostos e trouxeram informações sobre o perfil dos pacientes que necessitam de mais assistência e devem ser priorizados pelas políticas públicas de saúde. / In the current context of mental health where community mental services are a priority, the effective operation of the health care network for people with mental disorders is essential. During the process of deinstitutionalization of patients with mental disorders over the past decades, the region of Ribeirão Preto SP witnessed a substantial decrease in the number of psychiatric beds and the creation of new community services, which, however, cannot meet the current demands for hospitalization. Therefore, we aimed to analyze the sociodemographic and clinical factors associated to poor treatment adherence, readmissions and unmet needs of patients with mental disorders. Such information, taken together, can provide an indicator of the quality of health care delivered. The use of an index of social vulnerability as a socio-demographic variable in a Brazilian study in the field of mental health is an innovation, as well as the assessment of care needs by patients admitted in the local mental health network through the Camberwell Assessment of Needs (CAN), a tool used worldwide for this purpose. In our search, we identified all the 933 psychiatric patients who had a sufficiently serious mental disorder that justified their first admissions in 2006 and 2007, in hospitals with psychiatric beds in Ribeirão Preto. Since the individuals were contacted in their community, regardless of their attachment to health services, this design conferred to the study a naturalistic feature of what happened to the patients in the health network for a minimum period of 4 years after the first admission. In the interviews of the 333 patients, we identified a rate of adherence to treatment of 59.6%, and the factors associated to better adherence to treatment were older age, professional inactivity and hospitalization in a general hospital, while a diagnosis of disorder related to the use of psychoactive substances was associated to the worst treatment adherence. Regarding the rate of hospital readmission, 22.2% of the patients were readmitted in the period. Inactivity, hospitalization for 31 days or more and diagnoses of mania and psychotic disorders were positively associated with hospital readmission. Finally, the average rate of unmet care needs was 4.5, similar to the results from developed countries. In our sample, the variables significantly associated to higher scores in the CAN were less years of schooling, inactivity and living with a partner. Our data achieved the proposed goals and brought information on the profile of the patients who require more care and should be a priority of the public health policies.

Na atual conjuntura assistencial em saúde mental, em que se prioriza modalidades de tratamento comunitário, o efetivo funcionamento da rede de assistência ao portador de transtorno mental é de vital importância. A região de Ribeirão Preto-SP, durante o processo de desinstitucionalização de pacientes com transtorno mental das últimas décadas, assistiu à diminuição substancial do número de leitos psiquiátricos e à criação de novos serviços comunitários, que mais recentemente parecem não ser suficientes para atender à demanda de internação existente. Nesse contexto, o objetivo deste estudo foi analisar fatores sociodemográficos e clínicos associados à má aderência ao tratamento, às readmissões hospitalares e às necessidades de cuidados não atendidas de pacientes com transtorno mental, pois essas informações juntas podem ser um indicador de qualidade da assistência oferecida. Inovou-se, ao utilizar em um estudo brasileiro, na área da saúde mental, o índice de vulnerabilidade social como uma variável sociodemográfica, e também por se avaliarem as necessidades de cuidados dos pacientes da rede de assistência utilizando a Camberwell Assessment of Needs (CAN), instrumento mundialmente utilizado para esse fim. Foi realizada busca de todos os 933 pacientes psiquiátricos que apresentaram um transtorno mental que foi grave o suficiente para justificar suas primeiras internações nos anos de 2006 e 2007, nos hospitais com leitos psiquiátricos em Ribeirão Preto. Como a busca foi do indivíduo na comunidade, independente do seu vínculo com serviços de saúde, esse desenho conferiu ao estudo uma característica naturalística do que aconteceu aos pacientes na rede assistencial em um período mínimo de quatro anos após a primeira internação. Por meio de entrevista com 333 pacientes, identificou-se taxa de aderência de 59,6%, e os fatores associados à melhor aderência ao tratamento foram: maior faixa etária, inatividade profissional e internação em hospital geral; enquanto o diagnóstico de transtorno relacionado ao uso de substâncias psicoativas associou-se a pior aderência. Em relação à taxa de reinternação, 22,2% dos pacientes foram reinternados no período. A inatividade profissional, a internação índice com 31 dias ou mais e diagnósticos de mania e transtornos psicóticos do tipo esquizofrênico associaram-se positivamente à readmissão hospitalar. Finalmente, a média de necessidades de cuidados não atingidas encontrada foi de 4,5, similar aos resultados de países desenvolvidos. Nesta amostra, as variáveis significativamente associadas com maiores escores na CAN foram: menos anos de estudo, inatividade laboral e o fato de morar com o companheiro. Os dados do presente estudo alcançaram os objetivos propostos e trouxeram informações sobre o perfil dos pacientes que necessitam de mais assistência e devem ser priorizados pelas políticas públicas de saúde. / In the current context of mental health where community mental services are a priority, the effective operation of the health care network for people with mental disorders is essential. During the process of deinstitutionalization of patients with mental disorders over the past decades, the region of Ribeirão Preto SP witnessed a substantial decrease in the number of psychiatric beds and the creation of new community services, which, however, cannot meet the current demands for hospitalization. Therefore, we aimed to analyze the sociodemographic and clinical factors associated to poor treatment adherence, readmissions and unmet needs of patients with mental disorders. Such information, taken together, can provide an indicator of the quality of health care delivered. The use of an index of social vulnerability as a socio-demographic variable in a Brazilian study in the field of mental health is an innovation, as well as the assessment of care needs by patients admitted in the local mental health network through the Camberwell Assessment of Needs (CAN), a tool used worldwide for this purpose. In our search, we identified all the 933 psychiatric patients who had a sufficiently serious mental disorder that justified their first admissions in 2006 and 2007, in hospitals with psychiatric beds in Ribeirão Preto. Since the individuals were contacted in their community, regardless of their attachment to health services, this design conferred to the study a naturalistic feature of what happened to the patients in the health network for a minimum period of 4 years after the first admission. In the interviews of the 333 patients, we identified a rate of adherence to treatment of 59.6%, and the factors associated to better adherence to treatment were older age, professional inactivity and hospitalization in a general hospital, while a diagnosis of disorder related to the use of psychoactive substances was associated to the worst treatment adherence. Regarding the rate of hospital readmission, 22.2% of the patients were readmitted in the period. Inactivity, hospitalization for 31 days or more and diagnoses of mania and psychotic disorders were positively associated with hospital readmission. Finally, the average rate of unmet care needs was 4.5, similar to the results from developed countries. In our sample, the variables significantly associated to higher scores in the CAN were less years of schooling, inactivity and living with a partner. Our data achieved the proposed goals and brought information on the profile of the patients who require more care and should be a priority of the public health policies.

No description available.