RESUMEN
PURPOSE: International guidelines adopt risk stratification approach to manage patients with low-risk febrile neutropenia patients. We developed this out-patient program using shared-care model with professional input and patient empowerment, so as to reduce patients' psychological burden from hospitalization and to improve the cost-effectiveness of management. METHOD: This is a prospective cohort study to compare the efficacy and safeness of the out-patient program when compared with traditional in-patient care. Patients with solid tumors, developed febrile neutropenia with Multinational Association of Supportive Care in Cancer score of at least 21, and good performance status were included. After initial assessment and the first dose of oral antibiotics, patients were observed in the ambulatory center. Stable patients were discharged home after 4 h of observation and nurse counseling. Patients' condition and clinical progress were regularly reviewed by specialist nurses within the following week by telephone and nurse clinic follow-up. The primary objective of the study is success rate, which defined as the resolution of fever and infection, without hospitalization or any change in antibiotics. RESULTS: From September 2014 to December 2016, a total of 38 patients were enrolled. Majority were female with breast cancer (97%). Two patients required hospitalization due to persistent fever. The success rate of the out-patient program was not significantly different from the historical in-patient cohort (94.9 versus 97.4%, p = 0.053). No mortality was observed. Patients' compliance to the program was 100%, to telephone follow-up, nurse clinic visits, and daily temperature record. CONCLUSION: Out-patient management of patients with low-risk febrile neutropenia is effective and safe through implementation of a structured protocol with joint inputs and engagement from clinicians, oncology nurses, and patients.
Asunto(s)
Neutropenia Febril/tratamiento farmacológico , Neutropenia Febril/enfermería , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermeras y Enfermeros , Pacientes Ambulatorios , Estudios ProspectivosRESUMEN
This study updates previous estimates of US spending on mental health and substance use disorders through 2014. The results reveal that the long-term trend of greater insurance financing of mental health care continued in recent years. The share of total mental health treatment expenditures financed by private insurance, Medicare, and Medicaid increased from 44 percent in 1986 to 68 percent in 2014. In contrast, the share of spending for substance use disorder treatment financed by private insurance, Medicare, and Medicaid was 45 percent in 1986 and 46 percent in 2014. From 2004 to 2013, a growing percentage of adults received mental health treatment (12.6 percent and 14.6 percent, respectively), albeit only because of the increased use of psychiatric medications. In the same period, only 1.2-1.3 percent of adults received substance use disorder treatment in inpatient, outpatient, or residential settings, although the use of medications to treat substance use disorders increased rapidly.
Asunto(s)
Gastos en Salud/estadística & datos numéricos , Seguro de Salud/tendencias , Servicios de Salud Mental/economía , Servicios de Salud Mental/tendencias , Trastornos Relacionados con Sustancias/economía , Financiación Gubernamental/economía , Humanos , Seguro de Salud/economía , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Trastornos Mentales/tratamiento farmacológico , Estados UnidosRESUMEN
BACKGROUND: Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff. METHODS: In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used. RESULTS: All units reported establishing unit-based teams, of which >90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative. CONCLUSIONS: Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.
Asunto(s)
Enfermeras Administradoras , Personal de Enfermería en Hospital/organización & administración , Cultura Organizacional , Atención al Paciente/normas , Mejoramiento de la Calidad/organización & administración , Conducta Cooperativa , Humanos , Liderazgo , Evaluación de Procesos, Atención de Salud , Estados UnidosRESUMEN
Spending on mental and substance use disorders will likely grow more slowly than all health spending through 2020. We project that spending on mental and substance use disorders, as a share of all health spending, will fall from 7.4 percent in 2009 ($172 billion out of $2.3 trillion) to 6.5 percent in 2020 ($281 billion out of $4.3 trillion). This trend is the projected result of reduced spending on mental health drugs because of patent expirations, the low likelihood of innovative drugs entering the market, and a slowdown in spending growth for hospital treatment. By 2020 the expansion of coverage to previously uninsured Americans under the Affordable Care Act (ACA), combined with the projected slowdown in Medicare provider payment rates under the ACA and the Budget Control Act of 2011, are expected to add 2.7 percent to behavioral health spending, compared to spending without these changes.
Asunto(s)
Gastos en Salud/tendencias , Trastornos Mentales/economía , Trastornos Relacionados con Sustancias/economía , Predicción , Humanos , Medicare/economía , Trastornos Mentales/terapia , Modelos Estadísticos , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
As the U.S. health care system grapples with strained hospital emergency department (ED) capacity in some areas, primary care clinician shortages and rising health care costs, urgent care centers have emerged as an alternative care setting that may help improve access and contain costs. Growing to 9,000 locations in recent years, urgent care centers provide walk-in care for illnesses and injuries that need immediate attention but don't rise to the level of an emergency. Though their impact on overall health care access and costs remains unclear, hospitals and health plans are optimistic about the potential of urgent care centers to improve access and reduce ED visits, according to a new qualitative study by the Center for Studying Health System Change (HSC) for the National Institute for Health Care Reform. Across the six communities studied--Detroit; Jacksonville, Fla.; Minneapolis; Phoenix; Raleigh-Durham, N.C.; and San Francisco--respondents indicated that growth of urgent care centers is driven heavily by consumer demand for convenient access to care. At the same time, hospitals view urgent care centers as a way to gain patients, while health plans see opportunities to contain costs by steering patients away from costly emergency department visits. Although some providers believe urgent care centers disrupt coordination and continuity of care, others believe these concerns may be overstated, given urgent care's focus on episodic and simple conditions rather than chronic and complex cases. Looking ahead, health coverage expansions under national health reform may lead to greater capacity strains on both primary and emergency care, spurring even more growth of urgent care centers.
Asunto(s)
Instituciones de Atención Ambulatoria/tendencias , Servicios Médicos de Urgencia/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/tendencias , Necesidades y Demandas de Servicios de Salud/tendencias , Instituciones de Atención Ambulatoria/economía , Continuidad de la Atención al Paciente , Control de Costos , Servicio de Urgencia en Hospital/economía , Predicción , Reforma de la Atención de Salud/economía , Accesibilidad a los Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud/economía , Humanos , Cobertura del Seguro/economía , Estados UnidosRESUMEN
The Affordable Care Act permanently slows the growth in Medicare hospital prices. To better understand the effects of those price cuts, we used data from ten states for the period 1995-2009 to examine the market-level relationship between Medicare prices and hospital utilization among the elderly. Regression analyses indicate that a 10 percent reduction in the Medicare price was associated with a 4.6 percent reduction in discharges among the elderly. This volume response to price cuts appears to be accomplished through hospitals' reduction in their numbers of staffed beds. They did not leave beds empty; instead, they reduced their scale of operations. Based on our results, we conclude that the Affordable Care Act will help reduce inpatient hospital utilization in the future. From a federal budgetary standpoint, lower utilization is good news, but the implications for patient care and health outcomes are not yet clear.
Asunto(s)
Precios de Hospital , Hospitalización/economía , Medicare , Anciano , Hospitalización/estadística & datos numéricos , Hospitalización/tendencias , Humanos , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems. Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult. While some stakeholders, such as hospitals and local emergency medical services, consistently work together, other important groups--for example, primary care clinicians and nursing homes--typically do not participate in emergency-preparedness coalitions, according to a new qualitative study of 10 U.S. communities by the Center for Studying Health System Change (HSC). Challenges to developing and sustaining community coalitions may reflect the structure of preparedness activities, which are typically administered by designated staff in hospitals or large medical practices. There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing coalitions or building preparedness into activities providers already are pursuing. Moreover, rather than defining and measuring processes associated with collaboration--such as coalition membership or development of certain planning documents--policy makers might consider defining the outcomes expected of a successful collaboration in the event of a disaster, without regard to the specific form that collaboration takes.
Asunto(s)
Atención a la Salud/organización & administración , Planificación en Desastres/métodos , Urgencias Médicas , Motivación , Evaluación de Procesos y Resultados en Atención de Salud , Asignación de Recursos/métodos , Conducta Cooperativa , Agencias Gubernamentales , Encuestas de Atención de la Salud , Instituciones de Salud , Humanos , Asociaciones de Práctica Independiente/organización & administración , Subtipo H1N1 del Virus de la Influenza A , Gripe Humana/epidemiología , Organizaciones , Pandemias , Servicios de Salud Rural , Capacidad de Reacción/organización & administración , Estados UnidosRESUMEN
Over the past decade, large employers increasingly have bypassed traditional health insurance for their workers, opting instead to assume the financial risk of enrollees' medical care through self-insurance. Because self-insurance arrangements may offer advantages--such as lower costs, exemption from most state insurance regulation and greater flexibility in benefit design--they are especially attractive to large firms with enough employees to spread risk adequately to avoid the financial fallout from potentially catastrophic medical costs of some employees. Recently, with rising health care costs and changing market dynamics, more small firms--100 or fewer workers--are interested in self-insuring health benefits, according to a new qualitative study from the Center for Studying Health System Change (HSC). Self-insured firms typically use a third-party administrator (TPA) to process medical claims and provide access to provider networks. Firms also often purchase stop-loss insurance to cover medical costs exceeding a predefined amount. Increasingly competitive markets for TPA services and stop-loss insurance are making self-insurance attractive to more employers. The 2010 national health reform law imposes new requirements and taxes on health insurance that may spur more small firms to consider self-insurance. In turn, if more small firms opt to self-insure, certain health reform goals, such as strengthening consumer protections and making the small-group health insurance market more viable, may be undermined. Specifically, adverse selection--attracting sicker-than-average people--is a potential issue for the insurance exchanges created by reform.
Asunto(s)
Planes de Asistencia Médica para Empleados/economía , Reforma de la Atención de Salud/economía , Cobertura del Seguro/economía , Seguro de Salud/economía , Patient Protection and Affordable Care Act , Gestión de Riesgos/economía , Pequeña Empresa/economía , Regulación Gubernamental , Planes de Asistencia Médica para Empleados/legislación & jurisprudencia , Costos de la Atención en Salud/tendencias , Reforma de la Atención de Salud/legislación & jurisprudencia , Humanos , Cobertura del Seguro/legislación & jurisprudencia , Seguro de Salud/legislación & jurisprudencia , Sector Privado/economía , Sector Privado/legislación & jurisprudencia , Gestión de Riesgos/métodos , Pequeña Empresa/legislación & jurisprudencia , Estados UnidosRESUMEN
In the constant attention paid to what drives health care costs, only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Interviews in twelve US communities indicated that so-called must-have hospital systems and large physician groups--providers that health plans must include in their networks so that they are attractive to employers and consumers--can exert considerable market power to obtain steep payment rates from insurers. Other factors, such as offering an important, unique service or access in a particular geographic area, can contribute to provider leverage as well. Even in markets with dominant health plans, insurers generally have not been aggressive in constraining rate increases, perhaps because the insurers can simply pass along the costs to employers and their workers. Although government intervention--through rate setting or antitrust enforcement--has its place, our findings suggest a range of market and regulatory approaches should be examined in any attempt to address the consequences of growing provider market clout.
Asunto(s)
Atención a la Salud/economía , Reembolso de Seguro de Salud/economía , Negociación , Formulación de Políticas , Estados UnidosRESUMEN
We investigated nurses' time spent in documentation as it relates to the use of electronic charting. A cross-sectional analysis was completed using time and motion data collected during a nursing process improvement initiative for 105 units in 55 hospitals. Ordinary least squares regression with a cluster adjustment revealed very little difference in time spent in documentation with or without the use of electronic medical records or computerized nursing notes. Nurses spent 19% of their time completing documentation, regardless of electronic charting usage, compared with all other categories of care. These findings suggest that integrated electronic medical records and computerized nursing notes do not appear to increase the time nurses spend documenting.
Asunto(s)
Registros Electrónicos de Salud/organización & administración , Proceso de Enfermería/organización & administración , Registros de Enfermería , Personal de Enfermería en Hospital/organización & administración , Estudios de Tiempo y Movimiento , HumanosRESUMEN
Approaches in assessment of process improvements by nurses are a timely issue, given a growing focus on changes in care delivery. Nineteen semistructured phone interviews with nurse managers whose units participated in a process improvement intervention were completed. The most prominent among assessment strategies was observation. Other strategies included quantitative data measurement, informal and formal feedback, and auditing processes. Understanding how nurses are evaluating interventions may contribute to improved measurement in the future.
Asunto(s)
Actitud del Personal de Salud , Enfermeras Administradoras/psicología , Proceso de Enfermería/normas , Evaluación de Procesos, Atención de Salud , Humanos , Investigación en Evaluación de EnfermeríaAsunto(s)
Difusión de Innovaciones , Reestructuración Hospitalaria/organización & administración , Personal de Enfermería en Hospital , Gestión de la Calidad Total/organización & administración , Actitud del Personal de Salud , California , Toma de Decisiones en la Organización , Ambiente de Instituciones de Salud/organización & administración , Conocimientos, Actitudes y Práctica en Salud , Humanos , Enfermeras Administradoras/organización & administración , Enfermeras Administradoras/psicología , Investigación en Evaluación de Enfermería , Investigación Metodológica en Enfermería , Personal de Enfermería en Hospital/educación , Personal de Enfermería en Hospital/organización & administración , Personal de Enfermería en Hospital/psicología , Innovación Organizacional , Evaluación de Resultado en la Atención de Salud , Atención Dirigida al Paciente/organización & administración , Proyectos Piloto , Evaluación de Programas y Proyectos de Salud , Encuestas y CuestionariosAsunto(s)
Actitud del Personal de Salud , Liderazgo , Enfermeras Administradoras , Rol de la Enfermera/psicología , Desarrollo de Programa/métodos , Gestión de la Calidad Total/organización & administración , California , Directores de Hospitales/organización & administración , Directores de Hospitales/psicología , Difusión de Innovaciones , Retroalimentación Psicológica , Humanos , Relaciones Interprofesionales , Enfermeras Administradoras/organización & administración , Enfermeras Administradoras/psicología , Investigación Metodológica en Enfermería , Personal de Enfermería en Hospital/educación , Personal de Enfermería en Hospital/organización & administración , Personal de Enfermería en Hospital/psicología , Proyectos Piloto , Técnicas de Planificación , Competencia Profesional , Apoyo Social , Encuestas y CuestionariosAsunto(s)
Actitud del Personal de Salud , Unidades Hospitalarias/organización & administración , Rol de la Enfermera , Personal de Enfermería en Hospital , Gestión de la Calidad Total/organización & administración , Toma de Decisiones en la Organización , Difusión de Innovaciones , Humanos , Modelos de Enfermería , Rol de la Enfermera/psicología , Investigación en Evaluación de Enfermería , Investigación Metodológica en Enfermería , Personal de Enfermería en Hospital/organización & administración , Personal de Enfermería en Hospital/psicología , Innovación Organizacional , Evaluación de Procesos y Resultados en Atención de Salud/organización & administración , Proyectos Piloto , Autonomía Profesional , Comité de Profesionales/organización & administración , Desarrollo de Programa , Investigación Cualitativa , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Through an initiative called Transforming Care at the Bedside (TCAB), the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement have created an innovative bottom-up framework for redesigning the work environment on medical-surgical units. The specific purpose of this study, conducted by the University of California Los Angeles/RAND evaluation team, was to examine the number of innovations tested and the association of the volume of tests made and changes in a summary measurement of self-reported vitality at the 13 participating hospitals. The findings of this evaluation yielded several important implications for nurse leaders.
Asunto(s)
Personal de Enfermería en Hospital/organización & administración , Atención Dirigida al Paciente/organización & administración , Administración de Personal en Hospitales/métodos , Garantía de la Calidad de Atención de Salud/métodos , Desarrollo de Personal , Eficiencia Organizacional , Unidades Hospitalarias/organización & administración , Humanos , Cultura Organizacional , Innovación Organizacional , Estados Unidos , Recursos HumanosRESUMEN
Healthcare administrators increasingly face the challenge of how to spread innovation throughout their organizations. The authors present the results of an evaluation of the efforts of 3 major hospital systems to internally disseminate nursing unit change among medical-surgical units. The findings show that all 3 organizations carefully planned, coordinated, and implemented a spread process; none left dissemination to chance. Although clear differences were evident in the way they engineered their spread, many similarities also were found.