This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.
Objectives Recent health policy changes have focused efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care. This was a systematic review of interventions based outside the ED aimed at reducing ED use. Methods This study was designed as a systematic review. We reviewed the literature on interventions in five categories: patient education, creation of additional non-ED capacity, managed care, prehospital diversion, and patient financial incentives. Studies written in English, with interventions administered outside of the ED, and a comparison group where ED use was an outcome, were included. Two independent reviewers screened search results using MEDLINE, Cochrane, OAIster, or Scopus. The following data were abstracted from included studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Quality of individual articles was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. Results Of 39 included studies, 34 were observational and five were randomized controlled trials. Two of five studies on patient education found reductions in ED use ranging from 21% to 80%. Out of 10 studies of additional non-ED capacity, four showed decreases of 9% to 54%, and one a 21% increase. Both studies on prehospital diversion found reductions of 3% to 7%. Of 12 studies on managed care, 10 had decreases ranging from 1% to 46%. Nine out of 10 studies on patient financial incentives found decreases of 3% to 50%, and one a 34% increase. Nineteen studies reported effect on non-ED use with mixed results. Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality. Seven studies included data on cost outcomes. According to the GRADE guidelines, all studies had at least some risk of bias, with four moderate quality, one low quality, and 34 very low quality studies. Conclusions Many studies have explored interventions based outside the ED to reduce ED use in various populations, with mixed evidence. Approximately two-thirds identified here showed reductions in ED use. The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care, while the greatest magnitude of reductions were found in patient education. These findings have implications for insurers and policymakers seeking to reduce ED use.
In patients with gastroesophageal reflux disease (GERD) and erosive esophagitis, treatment with proton pump inhibitors (PPIs) is highly effective. However, in some patients, especially those with nonerosive reflux disease or atypical GERD symptoms, acid-suppressive therapy with PPIs is not as successful. Alginates are medications that work through an alternative mechanism by displacing the postprandial gastric acid pocket. This study performed a systematic review and meta-analysis to examine the benefit of alginate-containing compounds in the treatment of patients with symptoms of GERD. PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through October 2015 for randomized controlled trials comparing alginate-containing compounds to placebo, antacids, histamine-2 receptor antagonists (H2RAs), or PPIs for the treatment of GERD symptoms. Additional studies were identified through a bibliography review. Non-English studies and those with pediatric patients were excluded. Meta-analyses were performed using random-effect models to calculate odds ratios (OR). Heterogeneity between studies was estimated using the I2 statistic. Analyses were stratified by type of comparator. The search strategy yielded 665 studies and 15 (2.3%) met inclusion criteria. Fourteen were included in the meta-analysis (N = 2095 subjects). Alginate-based therapies increased the odds of resolution of GERD symptoms when compared to placebo or antacids (OR: 4.42; 95% CI 2.45-7.97) with a moderate degree of heterogeneity between studies (I2 = 71%, P = .001). Compared to PPIs or H2RAs, alginates appear less effective but the pooled estimate was not statistically significant (OR: 0.58; 95% CI 0.27-1.22). Alginates are more effective than placebo or antacids for treating GERD symptoms.
According to current estimates, more than 54 million Americans live with some type of long lasting condition or disability [1]. While these conditions are diverse and some are due to trauma (e.g., spinal cord injury), many are the result of common chronic diseases such as arthritis, heart disease, emphysema, and multiple sclerosis [2]. In an effort to influence the trajectory of functional limitations, disability, and quality of life in persons with chronic disabling conditions, a number of investigators and clinicians have begun to develop and test innovative interventions to promote the health (rather than control the disease or condition) of persons with chronic disabling conditions [3]. Some interventions have focused on a single behavior such as exercise or stress management, while others have taken a more comprehensive "lifestyle" approach [4,5]. As a group, these interventions clearly reflect the philosophical perspective of the International Classification of Functioning, Disability and Health that individuals with chronic and disabling conditions (e.g. multiple sclerosis, spinal cord injury) are fully capable of being healthy and experiencing a good quality of life [6}. The purpose of this study was to review and evaluate existing evidence supporting the use of wellness/health promotion interventions in persons with chronic disabling conditions. Health Promotion within the Context of Chronic Disabling ConditionsIn the U.S. Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disabilities [7], one of the four broad program statements to be achieved is "Persons with disabilities can promote their own good health by developing and maintaining healthy lifestyles" [7, p2]. Health promotion, activities "motivated by the desire to increase well-being and actualize human potential ' [8, p.7], encompasses a number of self-initiated health behaviors and emphasizes the need to enhance each person's responsibility and commitment to a healthy lifestyle. A variety of health promoting behaviors such as physical activity, stress © 2009 Elsevier Inc. All rights reserved. ** Corresponding Author: Alexa Stuifbergen, The University of Texas at Austin, School of Nursing, 1700 Red River, Austin, TX 78701-1499, Phone: 512-232-4764, Fax: 512-475-8755, astuifbergen@mail.utexas.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. It is important to differentiate conceptually between health promotion/wellness interventions and the disease and symptom management interventions for persons with varied chronic conditions commonly described in the literature. Pen...
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