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American Journal of Respiratory and... Dec 2014Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care... (Review)
Review
Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.
Topics: Continuity of Patient Care; Cost Control; Critical Care; Cross-Cultural Comparison; Humans
PubMed: 25163008
DOI: 10.1164/rccm.201406-1117PP -
Dermatology Online Journal Jan 2021Completing prior authorizations (PAs) can be a lengthy process, which can delay access to appropriate care. A 2017 American Academy of Dermatology survey highlighted...
BACKGROUND
Completing prior authorizations (PAs) can be a lengthy process, which can delay access to appropriate care. A 2017 American Academy of Dermatology survey highlighted that PAs are common across many dermatologic medication classes. However, little is known regarding the impact of PAs on patient care and resource use.
METHODS
To better characterize the burden of PAs on dermatology practices and their effects on patient care, a survey was conducted in February 2020 among U.S.-based dermatologists (N=3,000) and the Association of Dermatology Administrators/Managers (ADAM) members (N=718).
RESULTS
Respondents reported 24% of patients require PAs. Dermatologists and staff spend a mean of 3.3 hours/day on PAs. Sixty percent of dermatologists reported interrupting patient visits for PAs. Sixty-five percent respondents reported PAs were required for clobetasol, 76% for tretinoin, and 42% for 5-fluorouracil. Respondents noted 45% of PA determinations took beyond one week and 17% took beyond two weeks. Respondents reported 12% of PAs resulted in delaying or abandoning treatment and 17% resulted in less appropriate treatment.
CONCLUSIONS
Prior authorization burden remains high and consumes substantial clinical resources, which may negatively impact patient care. Additionally, they result in prolonged treatment delays and are associated with delaying treatment, abandoning treatment, or using lesser treatment.
Topics: Dermatology; Health Surveys; Humans; Office Management; Patient Care; Prior Authorization; Time Factors; Time-to-Treatment; United States
PubMed: 33560787
DOI: No ID Found -
The Cochrane Database of Systematic... Jan 2009'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.
OBJECTIVES
To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.
SEARCH STRATEGY
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.
SELECTION CRITERIA
Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.
MAIN RESULTS
Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.
AUTHORS' CONCLUSIONS
Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.
Topics: Adult; Home Care Services, Hospital-Based; Hospitalization; Humans; Patient Care; Patient Discharge; Randomized Controlled Trials as Topic
PubMed: 19160179
DOI: 10.1002/14651858.CD000356.pub3 -
Journal of General Internal Medicine Jan 2009Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for... (Review)
Review
BACKGROUND
Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for the physician. While the best of these discussions offer valuable insights into the patient-physician relationship, many of them lack an action component for alleviating the patient's suffering and emphasize the physician's experience of empathy rather than the patient's experience of illness.
METHODS
By examining educational methods, such as reflective writing exercises and the study of literary texts, and by analyzing theoretical approaches to empathy and suggestions for clinical practice, this article considers how to mindfully keep the focus on what the patient is going through.
CONCLUSION
Clinical empathy can be improved by strategies that address (1) the patient's authority in providing first-person accounts of illness and disability, (2) expanding the concept of empathy to include an action component geared toward relieving patients' suffering, and (3) the potential value of extending empathy to include the social context of illness.
Topics: Attitude of Health Personnel; Education, Medical; Empathy; Humans; Patient Care; Patient Satisfaction; Physician-Patient Relations
PubMed: 19015926
DOI: 10.1007/s11606-008-0849-9 -
Journal of Hospital Medicine Dec 2015US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. (Review)
Review
BACKGROUND
US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care.
OBJECTIVE
Describe a model of inpatient care and measure its impact.
DESIGN
A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation.
SETTING AND PATIENTS
Inpatient medical and surgical units in a large academic health center.
INTERVENTION
Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented.
MEASUREMENTS
Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index-adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured.
RESULTS
The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered.
CONCLUSIONS
Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging.
Topics: Hospitalization; Humans; Inpatients; Length of Stay; Patient Care; Patient Care Team; Social Responsibility; Treatment Outcome
PubMed: 26286828
DOI: 10.1002/jhm.2432 -
BMC Medicine Aug 2013Considerable variety in how patients respond to treatments, driven by differences in their geno- and/ or phenotypes, calls for a more tailored approach. This is already... (Review)
Review
Considerable variety in how patients respond to treatments, driven by differences in their geno- and/ or phenotypes, calls for a more tailored approach. This is already happening, and will accelerate with developments in personalized medicine. However, its promise has not always translated into improvements in patient care due to the complexities involved. There are also concerns that advice for tests has been reversed, current tests can be costly, there is fragmentation of funding of care, and companies may seek high prices for new targeted drugs. There is a need to integrate current knowledge from a payer's perspective to provide future guidance. Multiple findings including general considerations; influence of pharmacogenomics on response and toxicity of drug therapies; value of biomarker tests; limitations and costs of tests; and potentially high acquisition costs of new targeted therapies help to give guidance on potential ways forward for all stakeholder groups. Overall, personalized medicine has the potential to revolutionize care. However, current challenges and concerns need to be addressed to enhance its uptake and funding to benefit patients.
Topics: Delivery of Health Care; Feasibility Studies; Forecasting; Humans; Patient Care; Pharmacogenetics; Precision Medicine
PubMed: 23941275
DOI: 10.1186/1741-7015-11-179 -
British Medical Journal (Clinical... Mar 1987
Topics: Aged; Brain Diseases; Brain Injuries; Chronic Disease; Decision Making; Dementia; Ethics; Euthanasia; Euthanasia, Active; Euthanasia, Active, Voluntary; Humans; Life Support Care; Nursing Homes; Patient Care; Quality of Life; Right to Die; Stress, Psychological; Terminal Care; United Kingdom; Value of Life; Wedge Argument
PubMed: 11652497
DOI: 10.1136/bmj.294.6574.767 -
Health Expectations : An International... Aug 2022Compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the...
OBJECTIVE
Compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the globe. Yet, despite the value placed on compassion, the empirical study of compassion remains in its infancy and little is known regarding what compassion 'looks like' to patients. The current study addresses limitations in prior work by asking patients what physicians do that helps them feel cared for.
METHODS
Topic modelling analysis was employed to identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for.
RESULTS
Descriptively, seven meaningful groupings of physician actions experienced as compassion emerged: listening and paying attention (71% of responses), following-up and running tests (11%), continuity and holistic care (8%), respecting preferences (4%), genuine understanding (2%), body language and empathy (2%) and counselling and advocacy (1%).
CONCLUSION
These findings supplement prior work by identifying concrete actions that are experienced as caring by patients. These early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient-physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients.
PUBLIC CONTRIBUTION
This study involves the analysis of data provided by a diverse sample of patients from the general community population of New Zealand.
Topics: Delivery of Health Care; Emotions; Empathy; Health Facilities; Humans; Patient Care; Physician-Patient Relations; Physicians
PubMed: 35661516
DOI: 10.1111/hex.13512 -
Journal of General Internal Medicine Mar 2014Multimorbidity--the presence of multiple chronic conditions in a patient--has a profound impact on health, health care utilization, and associated costs. Definitions of... (Review)
Review
Multimorbidity--the presence of multiple chronic conditions in a patient--has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.
Topics: Chronic Disease; Comorbidity; Humans; Patient Care; Patient Satisfaction; Primary Health Care; Quality of Health Care
PubMed: 24081443
DOI: 10.1007/s11606-013-2616-9 -
Annals of Family Medicine 2010
Topics: Ethics, Medical; Humans; Patient Care; Preventive Medicine
PubMed: 20644181
DOI: 10.1370/afm.1149