Objective To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction.Data sources Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013.Study selection Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included.Data extraction Studies' characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I .Results 48 studies with fair quality, enrolling 1 896 859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1 892 424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70 534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity. ConclusionThis systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility. IntroductionAcute myocardial infarction remains a leading cause of death worldwide.1 Every year, approximately one million people in the United States have an acute myocardial infarction and 400 000 die from coronary heart disease.2 Previous studies have suggested that patients with acute myocardial infarction who present to the hospital during off-hours (weekends and nights) may have higher mortality. [3][4][5][6] Higher mortality during off-hours may be attributed to a lower likelihood of receiving evidence based treatment or timely reperfusion therapies.6 7 Furthermore, the number of hospital staff and their level of expertise may contribute to gaps in the quality of care during off-hours. 4 8 9Because of the high incidence and case fatality of acute myocardial infarction, small increases in the relative risk of mortality during off-hours can translate to important effects in the population.Using data from the National Re...
CONTEXT: The effectiveness of many interventions aimed at reducing the risk of retinopathy has not been well established. OBJECTIVE:To estimate the effectiveness of nutritional interventions, oxygen saturation targeting, blood transfusion management, and infection prevention on the incidence of retinopathy of prematurity (ROP). DATA SOURCES:A comprehensive search of several databases was conducted, including Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through March 2014. STUDY SELECTION:We included studies that evaluated nutritional interventions, management of supplemental oxygen, blood transfusions, or infection reduction and reported the incidence of ROP and mortality in neonates born at <32 weeks. DATA EXTRACTION:We extracted patient characteristics, interventions, and risk of bias indicators. Outcomes of interest were any stage ROP, severe ROP or ROP requiring treatment, and mortality. RESULTS:We identified 67 studies enrolling 21 819 infants. Lower oxygen saturation targets reduced the risk of developing any stage ROP (relative risk [RR] 0.86, 95% confidence interval [CI], 0.77-0.97) and severe ROP or ROP requiring intervention (RR 0.58, 95% CI, 0.45-0.74) but increased mortality (RR 1.15, 95% CI, 1.04-1.29). Aggressive parenteral nutrition reduced the risk of any stage ROP but not severe ROP. Supplementation of vitamin A, E, or inositol and breast milk feeding were beneficial but only in observational studies. Use of transfusion guidelines, erythropoietin, and antifungal agents were not beneficial. LIMITATIONS:Results of observational studies were not replicated in randomized trials. Interventions were heterogeneous across studies. CONCLUSIONS:At the present time, there are no safe interventions supported with high quality evidence to prevent severe ROP.
Effective quality improvement (QI) education should improve patient care, but many curriculum studies do not include clinical measures. The research team evaluated the prevalence of QI curricula with clinical measures and their association with several curricular features. MEDLINE, Embase, CINAHL, and ERIC were searched through December 31, 2013. Study selection and data extraction were completed by pairs of reviewers. Of 99 included studies, 11% were randomized, and 53% evaluated clinically relevant measures; 85% were from the United States. The team found that 49% targeted 2 or more health professions, 80% required a QI project, and 65% included coaching. Studies involving interprofessional learners (odds ratio [OR] = 6.55; 95% confidence interval [CI] = 2.71-15.82), QI projects (OR = 13.60; 95% CI = 2.92-63.29), or coaching (OR = 4.38; 95% CI = 1.79-10.74) were more likely to report clinical measures. A little more than half of the published QI curricula studies included clinical measures; they were more likely to include interprofessional learners, QI projects, and coaching.
Purpose:The hospital discharge summary (HDS) serves as a critical method of patient information transfer between hospitalist and primary care provider (PCP). This study was designed to increase our understanding of PCP preferences for, and perceived deficiencies in, the discharge summary.Methods: We designed a mail survey that was sent to a random sample of 800 American Academy of Family Physicians members nationally. The survey response rate was 59%. We analyzed the availability of summaries at hospital followup, whether all desired information was contained in the summary and whether certain specific items were completed. Provider subgroup analysis was performed.Results: The strongest predictor of discharge summary availability at posthospital followup is direct access to inpatient data. Respondents (27.5%) had a summary available 0% to 40% of the time, 41.4% noted availability 41% to 80% of the time and 31.1% >80% of the time; if a provider had access to inpatient data they tended to have a discharge summary available to them (P < .0001). Providers also described significant content deficits: 26.5% of providers noted the summary contained all information needed 0% to 40% of the time, 48.5% of providers noted this 41% to 80% of the time and only 25% >80% of the time. Specific summary items considered "very important" by providers included medication list (94% of respondents), diagnosis list (89%), and treatment provided (87%).
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