The American journal of medicine
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Comparative effectiveness research (CER) holds the promise of improving patient-centered care and increasing value in the healthcare system. Achieving these goals, however, depends on effectively implementing the findings of CER. In this article, we draw on lessons from implementation research and our experience in the Veterans Administration (VA) healthcare system to offer recommendations about what is needed to support implementation of CER. ⋯ Implementation efforts must take into account the nature of the evidence, the type of change being implemented, the clinical context in which the findings are being applied, and the specific barriers and facilitators to implementing new practices. The experience of the VA illustrates the importance of taking a systems approach that aligns numerous elements of the healthcare system--guidelines, decision support, performance measures, financial incentives, coverage and benefits policy, and health information technology--to support implementation:. We illustrate these principles with an example of implementing a new model of evidence-based depression care.
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Elevations in cardiac troponin have prognostic importance in critically ill patients. However, there are no data addressing the independent association between troponin levels and mortality, adjusted for the severity of the underlying disease, in patients hospitalized for acute respiratory disorders. We investigated whether troponin T (cTnT) elevations are independently associated with in-hospital mortality in patients in the intensive care unit (ICU) admitted for severe and acute respiratory conditions. After adjusting for the severity of disease measured by the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III prognostic system, we evaluated short-term (30 days) and long-term (3 years) mortality. ⋯ In patients admitted to the ICU for respiratory disorders, cTnT elevations are independently associated with in-hospital, short-term and long-term mortality.
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Bariatric surgery is recognized as the treatment of choice for class III obesity (body mass index ≥40) and has been increasingly recommended for obese patients. Prior research has suggested an excess of deaths due to suicide following bariatric surgery, but few large long-term follow-up studies exist. We examined postbariatric surgery suicides by time since operation, sex, age, and suicide death rates as compared with US suicide rates. ⋯ Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.