Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy

OBJECTIVE

To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement.

DESIGN

Qualitative descriptive study.

SETTING

Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia.

POPULATION

All obstetric claims and incident notifications occurring within the date range were included for analysis.

METHODS

De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified.

MAIN OUTCOME MEASURES

Rate of claims and notifications, relative frequency of issues, a revised taxonomy.

RESULTS

A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented.

CONCLUSIONS

Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement.

TWEETABLE ABSTRACT

New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.

Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

BACKGROUND

Safely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk.

METHODS

In a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy's primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery.

RESULTS

Patients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775).

CONCLUSIONS

Among patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.

Mental health and behavioural problems in children with XXYY: a comparison with intellectual disabilities

BACKGROUND

The phenotype of children with XXYY has predominantly been defined by comparison to other sex chromosome aneuploidies trisomies affecting male children; however, the intellectual ability of children with XXYY is lower than children with other sex chromosome aneuploidies trisomies. It is not known to what extent the phenotype identified to date is specific to XXYY, rather than a reflection of lower IQ. This study evaluates the mental health and behaviour of children with XXYY, in comparison to children with intellectual disabilities of heterogeneous genetic origin.

METHODS

Fifteen children with XXYY and 30 controls matched for age (4-14 years), sex and intellectual ability were ascertained from the IMAGINE ID study. IMAGINE ID participants have intellectual disabilities due to genetic anomalies confirmed by National Health Service Regional Genetic Centre laboratories. The mental health and behaviour of participants was examined with the Development and Well-being Assessment and the Strengths and Difficulties Questionnaire.

RESULTS

Children with XXYY experienced significantly more frequent and intense temper outbursts than the control group.

CONCLUSION

Our results suggest that temper outbursts may be specifically associated with the XXYY phenotype. These problems have a significant impact on the daily lives of boys with XXYY and their families. It is crucial to ensure that families are well supported to manage these difficulties.

Spaying and urinary incontinence in bitches under UK primary veterinary care: a case-control study

Objectives

To evaluate associations between spaying and urinary incontinence in bitches under primary veterinary care in the UK.

Materials and Methods

A case–control study was nested within the study population of 333,910 bitches, which included all bitches within the VetCompass database with an electronic patient record in 2016 or in both 2015 and 2017. The electronic records were searched automatically for urinary incontinence cases, which were manually reviewed for inclusion. All non‐cases were included as controls. Additional demographic and clinical information was extracted on cases and controls.

Results

The study included 427 incident cases and 1708 controls that were presented between November 1, 2014 and October 31, 2017. Prior spaying was associated with increased odds of urinary incontinence (odds ratio: 3.01; 95% CIs: 2.23 to 4.05). Increased odds of urinary incontinence were additionally associated with increasing age and increasing bodyweight. Age at spay was not associated with urinary incontinence.

Clinical Significance

The findings support spaying as a major risk factor associated with urinary incontinence, but age at spay appears to be of less clinical importance. These results will help assist clinicians in making evidence‐based recommendations on spaying while taking other considerations for urinary incontinence into account.

Evaluation of Random Plasma Cortisol and the Low Dose Corticotropin Test as Indicators of Adrenal Secretory Capacity in Critically Ill Patients: A Prospective Study

It is unclear whether a random plasma cortisol measurement and the corticotropin (ACTH) test adequately reflect glucocorticoid secretory capacity in critical illness. This study aimed to determine whether these tests provide information representative of the 24 hour period.

Plasma cortisol was measured hourly for 24 hours in 21 critically ill septic patients followed by a corticotropin test with 1 μg dose administered intravenously. Serum and urine were analysed for ACTH and free cortisol respectively. Marked hourly variability in plasma cortisol was evident (coefficient of variation 8–30%) with no demonstrable circadian rhythm. The individual mean plasma cortisol concentrations ranged from 286±59 nmol/l to 796± 83 nmol/l. The 24 hour mean plasma cortisol was strongly correlated with both random plasma cortisol (r2 0.9, P<0.0001) and the cortisol response to corticotropin (r2 0.72, P<0.001). Only nine percent of patients increased their plasma cortisol by 250 nmol/l after corticotropin (euadrenal response). However, 35% of non-responders had spontaneous hourly rises >250 nmol/l thus highlighting the limitations of a single point corticotropin test. Urinary free cortisol was elevated (865±937 nmol) in both corticotropin responders and non-responders suggesting elevated plasma free cortisol. No significant relationship was demonstrable between plasma cortisol and ACTH.

We conclude that although random cortisol measurements and the low dose corticotropin tests reliably reflect the 24 hour mean cortisol in critical illness, they do not take into account the pulsatile nature of cortisol secretion. Consequently, there is the potential for erroneous conclusions about adrenal function based on a single measurement. We suggest that caution be exercised when drawing conclusions on the adequacy of adrenal function based on a single random plasma cortisol or the corticotropin test.

Serum Procalcitonin and C-reactive Protein as Markers of Sepsis and Outcome in Patients with Neurotrauma and Subarachnoid Haemorrhage

This prospective study evaluated serum procalcitonin (PCT) and C-reactive protein (CRP) as markers for systemic inflammatory response syndrome (SIRS)/sepsis and mortality in patients with traumatic brain injury and subarachnoid haemorrhage. Sixty-two patients were followed for 7 days. Serum PCT and CRP were measured on days 0, 1, 4, 5, 6 and 7.

Seventy-seven per cent of patients with traumatic brain injury and 83% with subarachnoid haemorrhage developed SIRS or sepsis (P=0.75). Baseline PCT and CRP were elevated in 35% and 55% of patients respectively (P=0.03). There was a statistically non-significant step-wise increase in serum PCT levels from no SIRS (0.4±0.6 ng/ml) to SIRS (3.05±9.3 ng/ml) to sepsis (5.5±12.5 ng/ml). A similar trend was noted in baseline PCT in patients with mild (0.06±0.9 ng/ml), moderate (0.8±0.7 ng/ml) and severe head injury (1.2±1.9 ng/ml). Such a gradation was not observed with serum CRP. There was a non-significant trend towards baseline PCT being a better marker of hospital mortality compared with baseline CRP (ROC-AUC 0.56 vs 0.31 respectively). This is the first prospective study to document the high incidence of SIRS in neurosurgical patients. In our study, serum PCT appeared to correlate with severity of traumatic brain injury and mortality. However, it could not reliably distinguish between SIRS and sepsis in this cohort. This is in part because baseline PCT elevation seemed to correlate with severity of injury. Only a small proportion of patients developed sepsis, thus necessitating a larger sample size to demonstrate the diagnostic usefulness of serum PCT as a marker of sepsis. Further clinical trials with larger sample sizes are required to confirm any potential role of PCT as a sepsis and outcome indicator in patients with head injuries or subarachnoid haemorrhage.

First Observation of P-odd γ Asymmetry in Polarized Neutron Capture on Hydrogen

We report the first observation of the parity-violating gamma-ray asymmetry A_{γ}^{np} in neutron-proton capture using polarized cold neutrons incident on a liquid parahydrogen target at the Spallation Neutron Source at Oak Ridge National Laboratory. A_{γ}^{np} isolates the ΔI=1, ^{3}S_{1}→^{3}P_{1} component of the weak nucleon-nucleon interaction, which is dominated by pion exchange and can be directly related to a single coupling constant in either the DDH meson exchange model or pionless effective field theory. We measured A_{γ}^{np}=[-3.0±1.4(stat)±0.2(syst)]×10^{-8}, which implies a DDH weak πNN coupling of h_{π}^{1}=[2.6±1.2(stat)±0.2(syst)]×10^{-7} and a pionless EFT constant of C^{^{3}S_{1}→^{3}P_{1}}/C_{0}=[-7.4±3.5(stat)±0.5(syst)]×10^{-11}  MeV^{-1}. We describe the experiment, data analysis, systematic uncertainties, and implications of the result.

Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery

BACKGROUND

We reported previously that, in patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive transfusion strategy was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or 28 days after surgery, whichever came first. We now report the clinical outcomes at 6 months after surgery.

METHODS

We randomly assigned 5243 adults undergoing cardiac surgery to a restrictive red-cell transfusion strategy (transfusion if the hemoglobin concentration was <7.5 g per deciliter intraoperatively or postoperatively) or a liberal red-cell transfusion strategy (transfusion if the hemoglobin concentration was <9.5 g per deciliter intraoperatively or postoperatively when the patient was in the intensive care unit [ICU] or was <8.5 g per deciliter when the patient was in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis occurring within 6 months after the initial surgery. An expanded secondary composite outcome included all the components of the primary outcome as well as emergency department visit, hospital readmission, or coronary revascularization occurring within 6 months after the index surgery. The secondary outcomes included the individual components of the two composite outcomes.

RESULTS

At 6 months after surgery, the primary composite outcome had occurred in 402 of 2317 patients (17.4%) in the restrictive-threshold group and in 402 of 2347 patients (17.1%) in the liberal-threshold group (absolute risk difference before rounding, 0.22 percentage points; 95% confidence interval [CI], -1.95 to 2.39; odds ratio, 1.02; 95% CI, 0.87 to 1.18; P=0.006 for noninferiority). Mortality was 6.2% in the restrictive-threshold group and 6.4% in the liberal-threshold group (odds ratio, 0.95; 95% CI, 0.75 to 1.21). There were no significant between-group differences in the secondary outcomes.

CONCLUSIONS

In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy for red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis at 6 months after surgery. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898 .).

Characterization of adult obesity in Florida using the OneFlorida clinical research consortium

INTRODUCTION

With obesity rates and obesity-related healthcare costs increasing, policy makers must understand the scope of obesity across populations.

OBJECTIVE

This study sought to characterize adult obesity using electronic health records (EHRs) available from a statewide clinical data research network, the OneFlorida Clinical Research Consortium, which contains claims and EHR data from over 12 million patients in Florida. The primary aim was to compare EHR-based Florida obesity rates with those rates obtained from the Behavioural Risk Factor Surveillance System (BRFSS).

METHODS

Body mass index from OneFlorida patient data (2012-2016) was used to characterize obesity among adults 20-79 years old. Obesity rates from both OneFlorida and BRFSS (2013) were reported by demographics and by county.

RESULTS

Among the 1,344,015 adults in OneFlorida with EHR data and who met inclusion criteria, the obesity rate was 37.1%. Women had higher obesity rates compared with men. Obesity rates varied within racial/ethnic groups, with the highest rate among African-Americans (45.7%). Obesity rates from OneFlorida were consistently higher than those found in BRFSS (overall 27.8%).

CONCLUSIONS

Utilizing clinical big data available through hospital system and health partner collaborations provides an important view of the extent of obesity. Although these data are available only from healthcare users, they are large in scope, directly measured and are available sooner than commonly used national data sources.

Promoting activity, independence and stability in early dementia and mild cognitive impairment (PrAISED): development of an intervention for people with mild cognitive impairment and dementia

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless, they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is an understanding of how to develop an intervention for people with mild cognitive impairment and dementia to promote their independence, stability, and physical activity.

INTRODUCTION

Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting.

METHODS

We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset.

RESULTS

Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls.

CONCLUSION

We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.

Gene expression of AvBD6-10 in broiler chickens is independent of AvBD6, 9, and 10 peptide potency

The Avian β-defensin (AvBD) gene cluster contains fourteen genes; within this, two groups (AvBD6/7 and AvBD8 -10) encode charged peptides of >+5 (AvBD6/7), indicative of potent microbial killing activities, and ≤+4 (AvBD8-10), suggestive of reduced antimicrobial activities. Chicken broiler gut tissues are constantly exposed to microbes in the form of commensal bacteria. This study examined whether tissue expression patterns of AvBD6-10 reflected microbial exposure and the encoded peptides a functional antimicrobial hierarchy. Gut AvBD6-10 gene expression was observed in hatch to day 21 birds, although the AvBD8-10 profiles were eclipsed by those detected in the liver and kidney tissues. In vitro challenges of chicken CHCC-OU2 cells using the gut commensal Lactobacillus johnsonii (10⁴ CFU) did not significantly affect AvBD8-10 gene expression patterns, although upregulation (P < 0.05) of IL-Iβ gene expression was observed. Similarly, in response to Bacteriodes doreii, IL-Iβ and IL-6 gene upregulation were detected (P < 0.05), but AvBD10 gene expression remained unaffected. These data suggested that AvBD8-10 gene expression was not induced by commensal gut bacteria. Bacterial time-kill assays employing recombinant (r)AvBD6, 9 and 10 peptides (0.5μM - 12μM), indicated an antimicrobial hierarchy, linked to charge, of AvBD6 > AvBD9 > AvBD10 against Escherichia coli, but AvBD10 > AvBD9 > AvBD6 using Enterococcus faecalis. rAvBD10, selected due to its reduced cationic charge was, using CHCC-OU2 cells, investigated for cell proliferation and wound healing properties, but none were observed. These data suggest that in healthy broiler chicken tissues AvBD6/7 and AvBD8-10 gene expression profiles are independent of the in vitro antimicrobial hierarchies of the encoded AvBD6, 9 and 10 peptides.

High molecular weight hyaluronic acid: a two-pronged protectant against infection of the urogenital tract?

OBJECTIVES

Recurrent urinary tract infections are associated with uropathogenic Escherichia coli (UPEC) ascending and infecting the urinary tract. Antibiotics provide only symptomatic relief, not prevent recurrence. Clinical evidence suggests that intravesical glycosaminoglycan therapy, such as hyaluronic acid (HA), helps reduce UTI recurrence. This has been investigated here using in vitro systems modelling the urogenital tract tissues.

METHODS

RT4 bladder cells were preconditioned with high molecular weight HA (> 1500 kDa) at 2 mg mL-1 and challenged with UPEC to analyse barrier protection and bacterial adherence. Untreated and HA-preconditioned VK2 E6/E7 vaginal cells were challenged with E. coli flagellin (50 ng mL-1) to mimic bacterial challenge, and media analysed for lipocalin-2, human β-defensin 2 and interleukin-8 by ELISA. Experiments were repeated after siRNA knockdown of Toll-like receptors 2, 4 and 5, and CD44 to investigate signalling.

RESULTS

Microscopic analyses showed reduced bacterial adherence and urothelial disruption with HA, suggesting that HA functions as a barrier protecting the epithelium from bacterial infection. Cells treated with HA and flagellin simultaneously produced more of the host antimicrobial peptide LCN2 and pro-inflammatory IL-8 (P < 0.05) compared to the no HA/flagellin challenges. Increased gene expression of DEFB4 (P < 0.05), but not the hBD2 peptide, was observed in the HA/flagellin-challenged cells.

CONCLUSION

These data suggest that exogenous HA has potential to protect the urogenital epithelia from UPEC infection via a two-pronged approach that involves the physical enhancement of the epithelial barrier and augmentation of its innate immune response.