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Rapin J, Gendron S, Mabire C, Dubois CA. Feedback on clinical team performance: how does it work, in what contexts, for whom, and for what changes? A critical realist qualitative multiple case study. BMC Health Serv Res 2023; 23:410. [PMID: 37106466 PMCID: PMC10136404 DOI: 10.1186/s12913-023-09402-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Feedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non-human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings. METHODS This critical realist qualitative multiple case study included three heterogeneous cases and 98 professionals from a university-affiliated tertiary care hospital. Five data collection methods were used: participant observation, document retrieval, focus groups, semi-structured interviews, and questionnaires. Intra- and inter-case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel. RESULTS Despite the use of a single implementation model throughout the institution, results differed on contextual decision-making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes. CONCLUSIONS This critical realist qualitative multiple case study offers an in-depth explanation of feedback on clinical team performance as a complex and open-ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback.
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Harris W, Skuse K, Sharp C, Molyneux M, Crouch N. From coding to clinical nurse specialist: how a review of coding practice enabled hysteroscopy nurse development. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:372-377. [PMID: 37083380 DOI: 10.12968/bjon.2023.32.8.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Clinical coding, the method by which departments are reimbursed for providing services to patients, is widely mispractised within the NHS. Improving clinical coding accuracy therefore offers an opportunity to increase departmental income, guide efficient resource allocation and enable staff development. The authors audited the clinical coding in outpatient hysteroscopy clinics at their institution and found that coding errors were both prevalent and correctable. By implementing simple changes in coding procedure, and without any additional administrative cost, they significantly improved coding accuracy and achieved an increase in total annual tariffs. Although not applicable in a block contract, this will become highly relevant in a restoration of the Payment by Results tariff system. Nurse development is a key objective of the NHS Long Term Plan but can be hindered by staff costs, which require departmental funding. In the authors' institution, improved clinical coding accuracy directly led to a departmental restructuring, funded the development of a new hysteroscopy nurse development and improved care delivery. Coding errors are not unique to the authors' trust, yet simple amendments led to meaningful changes. Therefore, careful auditing and implemented change are needed to raise national clinical coding standards, to enable clinical restructuring, staff development, and provide more efficient, patient-centred care.
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Calle Rubio M, López-Campos JL, Miravitlles M, Soler Cataluña JJ, Alcázar Navarrete B, Fuentes Ferrer ME, Rodríguez Hermosa JL. Variations in Chronic Obstructive Pulmonary Disease Outpatient Care in Respiratory Clinics: Results From the 2021 EPOCONSUL Audit. Arch Bronconeumol 2023; 59:295-304. [PMID: 36858911 DOI: 10.1016/j.arbres.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION The aim of our work has been to describe the results of the clinical audit carried out in 2021 and to compare the results with 2015 EPOCONSUL audit. METHODS EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021, and January 31, 2022. RESULTS A total of 45 hospitals participated in the 2021 audit and 4.225 clinical records of patients were evaluated. Clinical phenotype according to the Spanish National Guidelines for COPD care (GesEPOC) was reported in 63.1% of the audited patients, and the COPD type assessment for the Global initiative for chronic Obstructive Lung Disease (GOLD) was present in 38.3%. There was an improved compliance with clinical practice guideline (CPG) recommendations in the 2021 audit with respect to the 2015 audit. There was an increase in the proportion of cases with alfa-1-antitrypsin serum level testing available (audit 1: 18.9%; audit 2: 38.7%, p<0.001) and 6-min walk test carried out (audit 1: 24%; audit 2: 45.2%, p<0.001). However, these significant variations adherence to CPG recommendations were not reached for the clinical evaluation and therapeutic intervention category when adjusting for patient and resource variables. CONCLUSIONS The 2021 EPOCONSUL audit showed increased adherence to recommendations although they seem to be related to the availability of resources for care. These results should be taken into account in order to establish improvements in resources to achieve a better quality of care.
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Wong JZW, Park PSW, Frost T, Stephens K, Newk-Fon Hey Tow FK, Garcia PG, Senanayake C, Choi PMC. Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study. BMJ Open 2023; 13:e067816. [PMID: 36697041 PMCID: PMC9884893 DOI: 10.1136/bmjopen-2022-067816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN Continuous observation workflow time study. SETTING AND PARTICIPANTS Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.
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Sharma DVG, Gonzalez DAEM. Clinical audit of the Consultation-Liaison psychiatric service of a metropolitan hospital. Australas Psychiatry 2023; 31:209-212. [PMID: 36657114 DOI: 10.1177/10398562231153006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The primary objective of this study was to use clinical indicators to track changes in efficiency of a Consultation-Liaison service as part of a clinical audit cycle. METHODS This was a clinical audit cycle. The auditing phase involved measuring the efficiency of the service. The 'intervention' was simply the team's awareness and involvement in tracking these statistics. Subsequently, these indicators were re-audited. RESULTS In the initial audit cycle, 315 referrals to the C-L service were audited over a 3 month period, showing a 24 hour time-to-seen rate of 80% and a 36 hour time-to-seen rate of 89.2%. Upon re-auditing of 112 referrals following our intervention, 24 hr timeliness had risen to 92% and 36 hr timeliness had risen to 96.4%. CONCLUSION The measuring of clinical indicators of efficiency in C-L may give service improvement personnel a reflection of the functionality of a C-L service. By involving team members in the measuring and tracking of these indicators, we may be able to boost overall clinical efficiency and outcomes.
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Yakubu A, Briggs E, Hacking S, Akudjedu TN. Clinical audit and research in radiography practice: An exploration of the English landscape. Radiography (Lond) 2023; 29:200-206. [PMID: 36481787 DOI: 10.1016/j.radi.2022.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Research and clinical audit are central to the quality improvement (QI) process in healthcare; whereas research produces new knowledge, clinical audit establishes if practice is meeting set standards. Thus, radiographers have responsibility to engaging in these QI activities. This study aimed to explore radiographers' understanding, attitudes and level of involvement in clinical research and audit across England. METHODS A cross-sectional survey using an online questionnaire for data collection over a 6-week period was employed. The questionnaire consisted of open and closed ended questions. Participants were recruited through social media. The quantitative data obtained was analysed using Statistical Package for Social Sciences (SPSS) Version 26 (IBM Inc, Armonk, NY) whilst content analysis was used to analyse the free-response data. RESULTS A total of 100 valid responses were obtained after exclusion of 45 partial and/or incomplete responses. Radiographers showed a positive attitude towards involvement in research and audit with overall mean score of 3.85 (SD 0.80) and 4.01 (SD 0.80), respectively. Of the respondents, 35.7% (n = 35/98) were currently involved in clinical audit projects whilst 78.6% (n = 77/98) have previously been involved. Radiographers with postgraduate degrees were significantly more likely to have initiated research, 61.5% (n = 16/26) (p = 0.01) and to have previously been involved with research, 80.8% (n = 21/26) (p = 0.02). A significant association between radiographers' role and implementation of changes, following an audit (p = 0.03) was noted. Similarly, a significant association was noted between radiographers' role and initiation of research (p = 0.05). CONCLUSION Clinical radiographers in England showed a positive attitude towards research and audit. However, this did not translate into actual participation in research and audit activities. IMPLICATIONS FOR PRACTICE The need to stimulate clinical radiographers' interest in clinical audit and research is highlighted. Additionally, the findings support the rationale for managers to give more support including protected time to radiographers to engage in QI activities.
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Pande A, Ghosh S. The Hawthorne Effect: Quality and Outcomes in Neurosurgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:207-216. [PMID: 37548741 DOI: 10.1007/978-3-030-12887-6_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.
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Osaghae SO. Quest to Improve Management of Prostate Cancer in West Africa: Development of a Clinical Audit Tool. West Afr J Med 2022; 39:1205-1208. [PMID: 36455254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
In 2010 and during the following decade, two guidelines were published for the management of prostate cancer in West Africa. A key recommendation of the guidelines was the need for the development of a Clinical Audit Tool which should help surgeons and institutions to identify the gaps between the recommended standards and current practice. In this paper, a Clinical Audit Tool, WAPCAT, was developed to facilitate and implement the audit process for the management of Prostate cancer in a West African healthcare institution.
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Serfioti D, Murphy D, Greenberg N, Williamson V. Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review. BMJ Mil Health 2022:e002155. [PMID: 36442888 DOI: 10.1136/military-2022-002155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood. METHODS This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates. RESULTS 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger. CONCLUSIONS The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.
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Maluleke K, Musekiwa A, Mashamba-Thompson TP. Study protocol for developing a novel approach for improving supply chain management for SARS-CoV-2 point of care diagnostic services in resource-limited settings: a case study of Mopani District in Limpopo province, South Africa. BMJ Open 2022; 12:e062509. [PMID: 36424106 PMCID: PMC9693879 DOI: 10.1136/bmjopen-2022-062509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Recent evidence shows that point-of-care (POC) testing is a more feasible alternative for diagnosis of COVID-19 in settings that have poor access to laboratory diagnostic services. Equitable access to POC testing can be optimised through well-established supply chain management (SCM) systems. The proposed study aims to develop a novel approach for improving SCM for COVID-19 POC diagnostic services in resource-limited settings with poor access to laboratory diagnostic services, using Mopani District in Limpopo Province, South Africa as a study setting. METHODS AND ANALYSIS This study was guided by results of the scoping review. Following the scoping review, we propose a mixed-methods study, which will be implemented in three phases. First, we will perform a geospatial analysis to investigate the spatial distribution of COVID-19 testing services. Second, we will perform an audit of POC diagnostic services including its supply chain to evaluate the effect of SCM on accessibility of COVID-19 POC diagnostic services and reveal SCM barriers and enablers of accessibility of COVID-19 POC diagnostic services. Third, we will perform a nominal group technique to collaborate with key stakeholders in co-creation of a novel approach for improving SCM systems for COVID-19 POC diagnostic services. For the geospatial analysis, we will employ the ArcGIS Software. For the analysis of quantitative and qualitative data that will be generated from the audit and nominal group discussion, we will employ Stata software and NVivo software, respectively. ETHICS AND DISSEMINATION This study has been ethically reviewed and approved by two institutional review boards: University of Pretoria Faculty of Health Sciences Research Ethics Committee (approval number 655/2021) and Limpopo Department of Health Research Ethics Committee (approval number LP-2021-12-007). The results of this study will be disseminated through national and international presentations and peer-reviewed publications.
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Wahba AJ, Cromwell DA, Hutchinson PJ, Mathew RK, Phillips N. Mortality as an indicator of quality of neurosurgical care in England: a retrospective cohort study. BMJ Open 2022; 12:e067409. [PMID: 36332948 PMCID: PMC9639111 DOI: 10.1136/bmjopen-2022-067409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Postoperative mortality is a widely used quality indicator, but it may be unreliable when procedure numbers and/or mortality rates are low, due to insufficient statistical power. The objective was to investigate the statistical validity of postoperative 30-day mortality as a quality metric for neurosurgical practice across healthcare providers. DESIGN Retrospective cohort study. SETTING Hospital Episode Statistics data from all neurosurgical units in England. PARTICIPANTS Patients who underwent neurosurgical procedures between April 2013 and March 2018. Procedures were grouped using the National Neurosurgical Audit Programme classification. OUTCOMES MEASURED National 30-day postoperative mortality rates were calculated for elective and non-elective neurosurgical procedural groups. The study estimated the proportion of neurosurgeons and NHS trusts in England that performed sufficient procedures in 3-year and 5-year periods to detect unusual performance (defined as double the national rate of mortality). The actual difference in mortality rates that could be reliably detected based on procedure volumes of neurosurgeons and units over a 5-year period was modelled. RESULTS The 30-day mortality rates for all elective and non-elective procedures were 0.4% and 6.1%, respectively. Only one neurosurgeon in England achieved the minimum sample size (n=2402) of elective cases in 5 years needed to detect if their mortality rate was double the national average. All neurosurgical units achieved the minimum sample sizes for both elective (n=2402) and non-elective (n=149) procedures. In several neurosurgical subspecialties, approximately 80% of units (or more) achieved the minimum sample sizes needed to detect if their mortality rate was double the national rate, including elective neuro-oncology (baseline mortality rate=2.3%), non-elective neuro-oncology (rate=5.7%), neurovascular (rate=6.7%) and trauma (rate=11%). CONCLUSION Postoperative mortality lacks statistical power as a measure of individual neurosurgeon performance. Neurosurgical units in England performed sufficient procedure numbers overall and in several subspecialty areas to support the use of mortality as a quality indicator.
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Khalfan MA, Sasi P, Mugusi S. Factors influencing receipt of an antibiotic prescription among insured patients in Tanzania: a cross-sectional study. BMJ Open 2022; 12:e062147. [PMID: 36332955 PMCID: PMC9639089 DOI: 10.1136/bmjopen-2022-062147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES There are limited data on factors influencing antibiotic prescription among insured patients. We assessed for correlates of an antibiotic prescription among insured patients. DESIGN A cross-sectional study. SETTING The study was conducted at the National Health Insurance Fund offices, Dar es Salaam, Tanzania. DATA SOURCE We captured data from the claim forms, containing inpatient and outpatient treatment information for insured patients, for the month of September 2019. OUTCOME VARIABLE Receipt of an antibiotic prescription. EXPOSURE VARIABLES Age, sex, diagnosis, prescriber qualification, health facility level, ownership and department were exposure variables. Predictors of receipt of an antibiotic prescription were determined by Poisson regression analysis. RESULTS Of 993 analysed patients, the mean (±SD) age was 36.3 (±23.2) years, 581 (58.5%) were females and 535 (53.9%) were adults. The prevalence of antibiotic prescription was 46.4% (95% CI 42.8% to 50.0%). Strong predictors of an antibiotic prescription were being a child (1.7, 95% CI 1.3 to 2.2); acute upper respiratory tract infection (URTI) of multiple and unspecified sites (1.6, 95% CI 1.3 to 1.4); chronic rhinitis, nasopharyngitis and pharyngitis (4.0, 95% CI 2.4 to 6.4); being attended by a clinical officer (1.9, 95% CI 1.2 to 3.0); attending a health centre (1.5, 95% CI 1.1 to 2.0); attending a public facility (1.2, 95% CI 1.0 to 1.4) and visiting an inpatient department (2.0, 95% CI 1.2 to 3.4). CONCLUSIONS Among insured patients, being a child, acute URTI, being attended by a clinical officer or dental therapist, being attended by an assistant medical/dental officer, attending a health centre or a district hospital, attending a public health facility and visiting an inpatient department predicted an antibiotic prescription. Incorporation of these findings in revisions or establishment of targeted antimicrobial stewardship programmes may lead to better antibiotic prescribing practices that are critical for combating antibiotic resistance.
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Sridharan K, Al Banna R, Husain A. Therapeutic audit of patients on warfarin in an anticoagulation clinic of a tertiary care hospital. LA CLINICA TERAPEUTICA 2022; 173:579-584. [PMID: 36373458 DOI: 10.7417/ct.2022.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Studies have reported huge variations in the prescribing practice of warfarin. We carried out a clinical audit of warfarin use in an anticoagulation clinic of a tertiary care hospital. METHODS Patients receiving warfarin for at least 6 months were recruited and the following details were collected: demographics (age, body weight and gender); diagnoses; concomitant drugs. We calcula-ted CHA₂DS₂-VASc, HASBLED and SAMe-TT2R2 scores for each study participant. Statins, proton pump inhibitors, carbamazepine and amiodarone were the concomitant drugs identified with potential drug interaction with warfarin in patients. RESULTS Two hundred and three patients were recruited. Almost one-third of the study population had poor anticoagulation status. CHA₂DS₂-VASc and HASBLED scores were the significant predictors of appropriate anticoagulation. Poor anticoagulation status was observed more commonly in the first 6 months following which improvements were seen. Nearly half-of the time abnormal PT-INR was observed to be either between 2 to 2.4 (for patients with heart valve replacements) or 1.5 to 1.9 (for other indications). Significant number of patients without any potentially interacting drugs was observed with higher risk of supra-therapeutic PT-INR. CONCLUSION We observed a similar proportion of patients with adequate anticoagulation in our study participants as reported in other populations; and have identified categories at risk for poor anticoagulation. It is the need of the hour to develop in-house algorithm in compliance to international standards for dose titration of warfarin.
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JBI series paper 3: The importance of people, process, evidence, and technology in pragmatic, healthcare provider-led evidence implementation. J Clin Epidemiol 2022; 150:203-209. [PMID: 35462048 DOI: 10.1016/j.jclinepi.2022.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/16/2021] [Accepted: 04/09/2022] [Indexed: 12/16/2022]
Abstract
In this paper, we describe and discuss evidence implementation as a venture in global human collaboration within the framework of "people, process, evidence, and technology" as a roadmap for navigating implementation. At its core implementation is not a technological, or theoretical process, it is a human process. That health professionals central to implementation activities may not have had formal training in implementation, highlights the need for processes and programs that can be integrated within healthcare organization structures. Audit with feedback is an accessible implementation approach that includes the capacity to embed theory, frameworks, and bottom-up change processes to improve the quality of care. In this third paper in the JBI series, we discuss how four overarching principals necessary for sustainability (Culture, Capacity, Communication, and Collaboration) are combined with evidence, technology, and resources for evidence-based practice change. This approach has been successfully used across hundreds of evidence implementation projects around the globe for over 15 years. We present healthcare practitioner-led evidence-based practice improvement as sustainable and achievable in collaborative environments such as the global JBI network as a primary interest of the practicing professions and provide an overview of the JBI approach to evidence implementation.
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Včeva A, Zubčić Ž, Mihalj H, Maleš J, Mendeš T, Šestak A. Pretreatment hearing grades and hearing recovery outcomes after primary hyperbaric oxygen treatment in patients with idiopathic sudden sensorineural hearing loss. Diving Hyperb Med 2022; 52:191-196. [PMID: 36100930 PMCID: PMC9722339 DOI: 10.28920/dhm52.3.191-196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/30/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Previous studies suggest the effectiveness of hyperbaric oxygen treatment (HBOT) in idiopathic sudden sensorineural hearing loss (ISSNHL) but it is mostly used as an adjuvant and salvage treatment. This study evaluated the effect of primary HBOT according to pretreatment hearing grades and hearing recovery outcomes using modified Siegel's criteria in patients with ISSNHL. METHODS Fifty-nine ISSNHL patients treated with only HBOT were included. A pure-tone audiogram was recorded before and after a course of HBOT (90 min at 203 kPa daily for 20 days). Using the modified Siegel's criteria, patients were divided into groups according to hearing threshold before and after treatment. RESULTS Hearing thresholds were significantly lower after HBOT compared to pre-treatment values across all patients (P < 0.001) with a median value of recovery of 22.5 dB (interquartile range 12.5-33.7 dB). Significantly lower hearing threshold values were recorded at 500, 1,000, 2,000, and 4,000 Hz after treatment (P < 0.001). The greatest recovery was at 1,000 Hz, (change in median threshold = 32 dB) but without a significant difference compared to other frequencies (P = 0.10). CONCLUSIONS HBOT is a legitimate choice as the primary treatment for ISSNHL, especially if it is readily accessible, and if there are contraindications for corticosteroid therapy.
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Chew CC, Ibrahim HA, Balan VK, Abd-Aziz NA, Puah HM, Hss AS. Growth management and prevalence of underweight of indigenous children (Orang Asli) in Peninsular Malaysia: a clinical audit. BMC Pediatr 2022; 22:481. [PMID: 35948912 PMCID: PMC9364563 DOI: 10.1186/s12887-022-03532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Most indigenous people (Orang Asli in Peninsular Malaysia) live in poverty, and their children are at risk of growth problems due to nutrition deficiency. Routine health and growth assessments are essential to identify these children. This clinical audit aimed to determine the growth management of indigenous children and the prevalence of underweight among these children in Perak state, Malaysia. Methods A clinical audit was conducted in 2016 after obtaining consensus from stakeholders for audit criteria, forms, and procedures. All weight-for-age growth charts of Orang Asli children aged 2 and below were sampled for retrospective audit. This audit excluded children who required special needs. Growth charts were examined against audit criteria: (i) quality of growth chart plotting (charts were not plotted, incompletely plotted, or incorrectly plotted), (ii) presence of underweight, and (iii) appropriateness of action taken (appropriate or inappropriate action) according to local standard operating policies. Eligible auditors were first trained using simulated growth charts. Results Out of 1329 growth charts audited, 797 (60%) growth charts were correctly plotted, 527 (39.7%) were incompletely or incorrectly plotted, and five (0.3%) were not plotted. Overall, 40.0% of the growth chart was plotted incorrectly or completely not plotted. 550 (41.4%) children were found to be underweight, and 71.5% of them received inappropriate care management. Where growth charts were correctly plotted, 283 children were identified with underweight problems, and 194 (68.6%) of them received inappropriate care. For growth charts that were plotted incompletely or incorrectly, 267 children were identified as having underweight problems, and 199 (74.5%) received inappropriate care. The growth status of 265 (19.9%) children was unable to be determined due to incomplete plotting. Conclusion Approximately 40% of indigenous Orang Asli children aged 2 years and under were underweight, and most of them received inappropriate care.
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Bidaisee S, Hernandez Cruz PP, Mencia MM. Reasons for day of surgery cancellation of orthopaedic cases following a major earthquake in Trinidad and Tobago. J Perioper Pract 2022; 32:320-325. [PMID: 35574718 DOI: 10.1177/17504589211045228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An earthquake in 2018 resulted in irreparable damage to the Port of Spain General Hospital, Trinidad and Tobago, and severely affected orthopaedic services. This study investigates the rate and reasons for cancellation on the day of surgery of orthopaedic cases during the post-earthquake period. We prospectively collected data on all cases scheduled to undergo surgery during the study period. Information was gathered on patient demographics, the number and reasons for cancellation. Data were analysed using Analyse-it for Microsoft Excel 5.40 (Analyse-it Software Ltd). Our results show that 43 patients were cancelled, resulting in a 44.3% cancellation rate. Patients who had their surgery cancelled were older, with a higher American Society of Anesthesiologists class compared with patients whose surgery was not cancelled. Hospital-related factors were found to be responsible for the majority of cancellations. Placed in context, our findings suggest that limited operating time due to the earthquake-induced hospital damage was the principal reason for the high rate of surgery cancellations.
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Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review. BMC Nurs 2022; 21:84. [PMID: 35410289 PMCID: PMC9004102 DOI: 10.1186/s12912-022-00863-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difficulties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes. Methods We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identified, using an extraction tool derived from person-centered care literature. The five-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process. Results The residents’ life stories were identified in 16% of the reviewed records. There were variations in the identified nursing diagnoses related to person-centered information, across all the five categories. There were variations in comprehensiveness within all five categories, and inclusion and occupation had the least comprehensive information. Conclusion Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents’ perspectives and experiences in their planning and evaluation of care. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-022-00863-9.
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Hobden B, Turon H, Fakes K, Cameron E, Sanson-Fisher R. Systems-level audit and feedback interventions to improve oncology care: a scoping review. Transl Behav Med 2022; 12:654-662. [PMID: 35192712 DOI: 10.1093/tbm/ibab164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Audit and feedback is commonly used as a method of both monitoring and attempting to improve the quality of healthcare. No review has examined the literature on systems-level audit and feedback strategies to improve the quality of oncology care. This scoping review examines the number, care focus (technical, nontechnical, or both) and methodological quality of published intervention studies which have used systems-level audit and feedback intended to improve the quality of care delivered in oncology treatment centers. Medline, Embase, PsycINFO, and the Cochrane database were searched, from inception to March 2021, for intervention studies which examined the effectiveness of systems-level audit and feedback in improving care for cancer patients. Studies which met the Effective Practice and Organization of Care (EPOC) minimum design criteria were then assessed using the EPOC risk of bias tool. Study characteristics and outcomes were extracted for those meeting methodological criteria. A narrative approach was used to synthesize the results. A total of 32 intervention studies met the inclusion criteria, of which 53% focused on technical aspects of care, 31% focused on nontechnical and 16% focused on both. Four of the included 32 studies met the EPOC minimum design criteria (13%). Most studies had a before-after study design (75%; n = 24) and methodological quality of the final four studies was moderate. Audit and feedback studies involving oncology treatment centers have primarily focused on technical care aspects. The low number and moderate methodological quality of the studies make it difficult to draw clear inferences about the effectiveness of systems-level audit and feedback. Furthermore, high-quality audit and feedback interventions are required across technical and nontechnical aspects of care to quantify the effectiveness of strategies for improving cancer care and ensure healthcare resources are being optimized.
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George NE, Shukkoor AA, Joseph N, Palanimuthu R, Kaliappan T, Gopalan R. Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome. Egypt Heart J 2022; 74:4. [PMID: 35020077 PMCID: PMC8755862 DOI: 10.1186/s43044-021-00237-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. RESULTS The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month. CONCLUSIONS The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.
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Arroll B, Mulcahy CF, Roskvist RP, Mount V. Emoqol 100, an ultra ultra-brief mood case-finding tool: A diagnostic accuracy study. J Family Med Prim Care 2021; 10:3590-3594. [PMID: 34934651 PMCID: PMC8653449 DOI: 10.4103/jfmpc.jfmpc_40_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 06/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Case-finding for low mood in primary care can be time-consuming using current depression inventories. Aim: To assess the diagnostic accuracy, of a single verbally administered question on the emotional quality of life (Emoqol 100), for low mood in patients with symptoms of distress in an ambulatory care setting. Design and setting: Eligible patients were consecutive patients seen by one of the authors over 13 months with possible distress/low mood. The index test was the verbally asked Emoqol 100, which is the patient's emotional quality of life now, with 100 being perfect emotional health and 0 being the worst imaginable. The reference standard is the written version of the PHQ-9 with a cut point of ≥10. Methods: A retrospective audit of consecutive consultations in a single primary care clinic. Results: One hundred two patients were seen during the study period, of which 76 met the eligibility criteria for this audit, and there were 215 test results. For a cut point of <50 on the Emoqol 100 and the PHQ-9 ≥10 the sensitivity was 47% (95% CI 39-54), and the specificity was 93% (95% CI 86-100). The positive predictive value was 95%, and the negative predictive value was 37%. Conclusion: This is the first accuracy estimation of the Emoqol 100. It appears to have a high specificity which means when it is positive (<50) it is a good estimate of a high PHQ-9, i.e. a mood issue probably exists. The test will be helpful for busy primary care clinicians as it takes less than 15 seconds to verbally administer.
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Madhusudan N, Lewis T, Kunicki A, Hardie J, Macleod I, Marsland D. The introduction of the trauma triage clinic at a district general hospital: safety and efficacy during the first year of implementation. Ann R Coll Surg Engl 2021; 104:340-345. [PMID: 34939841 DOI: 10.1308/rcsann.2021.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Previously published work has shown that there are no missed injuries following the introduction of a trauma triage clinic (TTC). This study aimed to assess both the safety and efficacy of the TTC model in a district general hospital in the United Kingdom. We aimed to assess the rate of missed 'high-risk' injuries, including posterior shoulder dislocations, talar injuries, Lisfranc injuries and complex carpal instability. METHODS Data were collected retrospectively between November 2017 and October 2018 (inclusive). During this time, 3,721 patients were reviewed (mean age 38 years, SD 25.5, range 1-103 years). Case notes and x-rays were reviewed for all patients. Compliance was assessed against British Orthopaedic Association Standards for Trauma (BOAST 7) guidelines for fracture clinic services. The standard for adherence to guidelines was 100%. RESULTS Thirty-two of 3,721 patients had a missed injury during the study period, and 66% of these injuries were high risk. TTC was effective in reducing the number of patients seen in the fracture clinic, with 23% of patients discharged directly from the TTC. Eighty-nine per cent of patients were reviewed in clinic within 72 hours of presentation, with a median time to review of 2 days. CONCLUSION This study has shown that TTC is efficient in reducing the burden of patients seen in the fracture clinic, but it is not as safe as reported previously. Although the prevalence of missed injuries is low, hospitals introducing a TTC model should consider departmental processes to help accurately identify and triage high-risk injuries.
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Tannou T, Menand E, Veillard D, Contreras JB, Slekovec C, Daucourt V, Somme D, Corvol A. Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits. BMC Geriatr 2021; 21:705. [PMID: 34911444 PMCID: PMC8672546 DOI: 10.1186/s12877-021-02619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 11/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. Methods In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. Results The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. Discussion The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.
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Dal Cero M, Rodríguez-Santiago J, Miró M, Castro S, Miranda C, Santamaría M, Gobbini Y, Garsot E, Pujadas M, Luna A, Momblán D, Balagué C, Aldeano A, Olona C, Molinas J, Pulido L, Sánchez-Cano JJ, Güell M, Salazar D, Gimeno M, Grande L, Pera M. Evaluation of data quality in the Spanish EURECCA Esophagogastric Cancer Registry. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:3081-3087. [PMID: 33933340 DOI: 10.1016/j.ejso.2021.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/27/2021] [Accepted: 04/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although the number of nationwide clinical registries in upper gastrointestinal cancer is increasing, few of them perform regular clinical audits. The Spanish EURECCA Esophagogastric Cancer Registry (SEEGCR) was launched in 2013. The aim of this study was to assess the reliability of the data in terms of completeness and accuracy. METHODS Patients who were registered (2014-2017) in the online SEEGCR and underwent esophagectomy or gastrectomy with curative intent were selected for auditing. Independent teams of surgeons visited each center between July 2018 and December 2019 and checked the reliability of data entered into the registry. Completeness was established by comparing the cases reported in the registry with those provided by the Medical Documentation Service of each center. Twenty percent of randomly selected cases per hospital were checked during on-site visits for testing the accuracy of data (27 items per patient file). Correlation between the quality of the data and the hospital volume was also assessed. RESULTS Some 1839 patients from 19 centers were included in the registry. The mean completeness rate in the whole series was 97.8% (range 82.8-100%). For the accuracy, 462 (25.1%) cases were checked. Out of 12,312 items, 10,905 were available for verification, resulting in a perfect agreement of 95% (87.1-98.7%). There were 509 (4.7%) incorrect and 35 (0.3%) missing entries. No correlation between hospital volume and the rate of completeness and accuracy was observed. CONCLUSIONS Our results indicate that the SEEGCR contains reliable data.
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Otero Puime Á, Gutiérrez-Misis A, Toledo-Bartolomé D, Sáez-López P, Gómez-Campelo P, Ojeda-Thies C, Mazzucchelli R, González-Montalvo JI. [The Spanish National Hip Fractures Registry (RNFC) and the Minimum Basic Data Set (CMBD) are useful for research on hip fractures: comparison of two registries.]. Rev Esp Salud Publica 2021; 95:e202111195. [PMID: 34821224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/26/2021] [Indexed: 06/13/2023] Open
Abstract
OBJECTIVE National hip fracture registries have been established in several countries and recent publications show that the care process has been audited inspecting the representativeness according to quality standards. The aim of this study was to analyse if the Spanish National Hip Fracture Registry (RNFC) represents the Spanish population aged 75 and older admitted for hip fractures, and to compare its results regarding the care process with the national average, according to the National Inpatient register (Minimum Basic Dataset, CMBD). METHODS The 2017-2018 National Minimum Basic Dataset (Conjunto Mínimo Básico de Datos, CMBD) was used as reference. For analysis, we included 83,110 cases from the CMBD and 21,130 from the RNFC. Eight common variables of both registries were selected for comparison. RESULTS No significant differences were observed in the patient-related common variables (age, sex, type of fracture and fracture side), but statistically significant differences were found in the variables describing the care process (proportion of patients operated, deceased, surgical procedures and postoperative length of stay). CONCLUSIONS The RNFC, designed as a convenience sample, is also representative of the population of patients aged 75 and older treated for hip fractures in Spain. However, there is a participation bias related to the professionals and the hospitals interested in voluntarily participating in a quality improvement program, which would explain the better results observed in the care process, compared to the national average as collected by the CMBD.
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