Oct 222014
 
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Consent, capacity and the right to say no.

Med J Aust. 2014 Oct 20;201(8):486-8

Authors: Snow HA, Fleming BR

Abstract
Competence is a key component in patient consent, whether agreeing to or refusing a treatment. The law surrounding competence can be difficult to understand and interpret. We present a complex case involving a woman refusing life-saving surgical treatment. Initially considered competent by doctors, she was then deemed incompetent by a neuropsychologist, resulting in surgery against her instructions. This raised several questions regarding the notion of competence and the methods by which it is assessed and applied. We outline the legal definitions of competence: that a patient needs to understand, retain and believe the information about the treatment options; be able to weigh the information to reach a decision; and be able to communicate that decision. The assessment of competence is often complex. We discuss the medicolegal issues raised and the legal tests that need to be addressed by clinicians involved in that assessment. Finally, we present the resources and methods available to doctors confronted with difficult or complicated scenarios involving patient competence.

PMID: 25332041 [PubMed - in process]

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Oct 222014
 
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Evaluation of legal capacity by doctors and lawyers: the need for collaborative assessment.

Med J Aust. 2014 Oct 20;201(8):483-5

Authors: Purser KJ, Rosenfeld T

Abstract
Balancing the interests of individual autonomy and protection is an escalating challenge confronting an ageing Australian society. One way this is manifested is in the current ad hoc and unsatisfactory way that capacity is assessed in the context of wills, enduring powers of attorney and advance health directives. The absence of nationally accepted assessment guidelines results in terminological and methodological miscommunication and misunderstanding between legal and medical professionals. Expectations between legal and medical professionals can be clarified to provide satisfactory capacity assessments based on the development of a sound assessment paradigm.

PMID: 25332040 [PubMed - in process]

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Oct 222014
 
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Association Between Hospital Conversions to For-Profit Status and Clinical and Economic Outcomes.

JAMA. 2014 Oct 22;312(16):1644-1652

Authors: Joynt KE, Orav EJ, Jha AK

Abstract
Importance: An increasing number of hospitals have converted to for-profit status, prompting concerns that these hospitals will focus on payer mix and profits, avoiding disadvantaged patients and paying less attention to quality of care.
Objective: To examine characteristics of US acute care hospitals associated with conversion to for-profit status and changes following conversion.
Design, Setting, and Participants: Retrospective cohort study conducted among 237 converting hospitals and 631 matched control hospitals. Participants were 1 843 764 Medicare fee-for-service beneficiaries at converting hospitals and 4 828 138 at control hospitals.
Exposures: Conversion to for-profit status, 2003-2010.
Main Outcomes and Measures: Financial performance measures, quality process measures, mortality rates, Medicare volume, and patient population for the 2 years prior and the 2 years after conversion, excluding the conversion year, assessed using difference-in-difference models.
Results: Hospitals that converted to for-profit status were more often small or medium in size, located in the south, in an urban or suburban location, and were less often teaching institutions. Converting hospitals improved their total margins (ratio of net income to net revenue plus other income) more than controls (2.2% vs 0.4% improvement; difference in differences, 1.8% [ 95% CI, 0.5% to 3.1%]; P = .007). Converting hospitals and controls both improved their process quality metrics (6.0% vs 5.6%; difference in differences, 0.4% [95% CI, -1.1% to 2.0%]; P = .59). Mortality rates did not change at converting hospitals relative to controls for Medicare patients overall (increase of 0.1% vs 0.2%; difference in differences, -0.2% [95% CI, -0.5% to 0.2%], P = .42) or for dual-eligible or disabled patients. There was no change in converting hospitals relative to controls in annual Medicare volume (-111 vs -74 patients; difference in differences, -37 [95% CI, -224 to 150]; P = .70), Disproportionate Share Hospital Index (1.7% vs 0.4%; difference in differences, 1.3% [95% CI, -0.9% to 3.4%], P = .26), the proportion of patients with Medicaid (-0.2% vs 0.4%; difference in differences, -0.6% [95% CI, -2.0% to 0.8%]; P = .38) or the proportion of patients who were black (-0.4% vs -0.1%; difference in differences, -0.3% [95% CI, -1.9% to 1.3%]; P = .72) or Hispanic (0.1% vs -0.1%; difference in differences, 0.2% [95% CI, -0.3% to 0.7%]; P = .50).
Conclusions and Relevance: Hospital conversion to for-profit status was associated with improvements in financial margins but not associated with differences in quality or mortality rates or with the proportion of poor or minority patients receiving care.

PMID: 25335146 [PubMed - as supplied by publisher]

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Oct 222014
 
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Atrial fibrillation and future risk of venous thromboembolism - the Tromsø study.

J Thromb Haemost. 2014 Oct 21;

Authors: Enga KF, Rye-Holmboe I, Hald EM, Løchen ML, Mathiesen EB, Njølstad I, Wilsgaard T, Braekkan SK, Hansen JB

Abstract
AIMS: Whether atrial fibrillation is related to risk of venous thromboembolism (VTE) is not extensively studied. Therefore, we investigated the association between atrial fibrillation and future risk of VTE in a population-based cohort.
METHODS: In total, 29 975 subjects were recruited from three surveys of the Tromsø study and followed from enrolment (1994-95, 2001-02 and 2007-08) through 2010. Incident events of atrial fibrillation and VTE during follow-up were recorded. Information on potential confounders was obtained at baseline. Cox-regression models with atrial fibrillation as time-dependent variable were used to calculate hazard ratios (HR) for VTE with 95% confidence intervals (CI).
RESULTS: During 16 years of median follow-up, 1604 subjects were diagnosed with atrial fibrillation and 614 with incident VTE. The risk of VTE was substantially increased during the first 6 months after diagnosis of atrial fibrillation (HR 8.44, 95% CI: 5.61-12.69), and remained increased throughout the study period (HR: 1.43, 95% CI 1.43-1.99) compared to those without atrial fibrillation. Atrial fibrillation displayed higher risk estimates for pulmonary embolism (HR: 11.84, 6.80-20.63) than for deep vein thrombosis (HR: 6.20, 3.37-11.39), during the first 6 months, and was still associated with pulmonary embolism (HR: 1.96, 95% CI: 1.24-3.10) but not with deep vein thrombosis (HR: 1.08, 95% CI: 0.66-1.75) more than 6 months after diagnosis.
CONCLUSION: Atrial fibrillation was associated with increased risk of VTE, and pulmonary embolism in particular. Our findings support the concept that isolated pulmonary embolism may originate from right atrial thrombi due to atrial fibrillation. This article is protected by copyright. All rights reserved.

PMID: 25330989 [PubMed - as supplied by publisher]

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Oct 222014
 
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Venous thromboembolism in Germany: results of the GermAn VTE registry (GATE-registry).

Int J Clin Pract. 2014 Oct 21;

Authors: Kröger K, Moerchel C, Bus C, Serban M

Abstract
BACKGROUND: Despite the existence of active prophylaxis strategies for patients at risk of venous thromboembolism (VTE), people still suffer from this disease. To establish the setting in which VTE occurs and how it can be prevented, a study was conducted aimed at analysing the circumstances surrounding VTE development.
PATIENTS AND METHODS: In a nationwide study, 629 patients (54% female) with acute deep vein thrombosis (DVT) or pulmonary embolism (PE) were recruited consecutively at 17 centres (78.4% with DVT, 5.1% with PE, 16.5% with both). The physicians completed a standardised questionnaire together with the patients on the day the diagnosis was made, or a few days later. The following items were included: general information, circumstances that could increases VTE risk within the previous 6 weeks, action taken to prevent VTE within the previous 6 weeks, specific VTE risk factors. Patients were defined as being 'in a medical setting' if they had had contact with a physician within the 6-week period prior to VTE diagnosis.
RESULTS: A total of 286 (45.5%) patients were classified in a medical setting, but 343 (54.5%) patients were not. Of those who were not in a medical setting within the last six weeks, 12.0% had returned from a journey and 15.5% had restricted mobility. Of those within a medical setting, only 80 (28.0%) patients had received heparin as prophylaxis. Thus, the largest group of patients with VTE today is not within a medical setting. The next largest group of patients were in a medical setting but received no heparin as prophylaxis. Those with a failed or inadequate use of prophylaxis represented the smallest group.
DISCUSSION: More than 50% of those who have acute VTE are not being reached by our present day VTE prophylaxis strategies.

PMID: 25333964 [PubMed - as supplied by publisher]

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Oct 222014
 
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Differences in Hospital-Associated Multidrug-Resistant Organisms and Clostridium difficile Rates Using 2-Day versus 3-Day Definitions.

Infect Control Hosp Epidemiol. 2014 Nov;35(11):1417-1420

Authors: Gombosev A, Fouad SE, Cui E, Cao C, Terpstra L, Avery TR, Kim D, Meyers H, Cheung M, Huang SS

Abstract
We surveyed infection prevention programs in 16 hospitals for hospital-associated methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, extended-spectrum β-lactamase, and multidrug-resistant Acinetobacter acquisition, as well as hospital-associated MRSA bacteremia and Clostridium difficile infection based on defining events as occurring >2 days versus >3 days after admission. The former resulted in significantly higher median rates, ranging from 6.76% to 45.07% higher.

PMID: 25333439 [PubMed - as supplied by publisher]

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