Small volume vacuum phlebotomy tubes: a controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit

BACKGROUND

Patients admitted to intensive care units (ICUs) undergo multiple blood tests. Small volume vacuum phlebotomy tubes (SVTs) provide an important blood conservation measure. SVTs reduce summative blood loss and may reduce odds of transfusion. We aimed to determine whether low volume blood sampling using SVTs for routine diagnostic purposes translates to decreased fall in haemoglobin concentration, and examine downstream effects on anaemia and need for transfusion during ICU admission.

STUDY DESIGN AND METHODS

A single-centre, controlled before-and-after study, evaluating a unit-wide changeover from conventional volume vacuum phlebotomy tubes (CVTs) to SVTs on April 2015. All ICU patients admitted for > 48 hours during the 12 months before and after the intervention were included in multivariate and univariate analysis. Groups were stratified into short admissions (2-7 days) and long admissions (> 7 days).

RESULTS

A total of 318 patients were analysed. For short admissions, SVTs decreased fall in haemoglobin concentration (unstandardized coefficient, -6.7; P = 0.001) and episodes of severe anaemia (odds ratio, 0.37, P = 0.02). There were no changes to haemoglobin concentration in long admissions. No effects on need for transfusion were observed (short admissions, P = 0.05; long admissions, P = 0.11). SVTs reduced daily sampling volumes by 50% with no increase in laboratory error (short admissions, P = 0.61; long admissions, P = 0.98). A moderate correlation existed between blood draws and fall in haemoglobin concentration (short admissions, r = 0.5; long admissions, r = 0.32).

CONCLUSION

SVTs reduce sampling volume without increasing laboratory error. Follow-on effects include reduced fall in haemoglobin concentration and severe anaemia. These correlations are absent in long admissions.

Impact of Functional Capacity Evaluation on Patient-Reported Functional Ability: An Exploratory Diagnostic Before-After Study

Introduction Work capacity in patients with orthopedic trauma and long-lasting inactivity is significantly reduced. Functional capacity evaluation (FCE) is a diagnostic approach for developing recommendations for a return to work and further occupational rehabilitation when the ability to carry out previous job demands is uncertain. However, FCE may also have direct effects on the patients' appraisal of their functional ability. Our study therefore evaluated the change in patient-reported functional ability after the performance of an FCE. Methods We performed a diagnostic before-after study in 161 consecutively recruited patients with trauma who were referred for FCE at the end of an interdisciplinary inpatient rehabilitation program in Austria. Patients completed the Spinal Function Sort to assess patient-reported functional ability both prior to the FCE and after completing it. Results Patient-reported functional ability (0-200 points) improved by 14.8 points (95% CI 11.3-18.2). The number of participants who rated their functional ability below their functional capacity as observed by the FCE decreased from 82.6 to 64.6% by about 18 percentage points. Conclusions The performance of the FCE in patients with trauma was associated with an improvement of patient-reported functional ability. The performance of an FCE in trauma rehabilitation may possibly have a direct therapeutic effect on the patient by allowing a more realistic appraisal of the ability to perform relevant work activities.

Immediate effects of kinesiology tape on the pain and gait function in older adults with knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a degenerative disease that not only causes knee pain in older adults, but also has an adverse effect on walking. Therefore, intervention for older patients with OA is important. To investigate the immediate effects of kinesiology taping (KT) on the pain and gait function of the older adults with knee OA.

METHODS

This study enrolled 10 older adults individuals living in the community who were diagnosed with knee OA. All participants were assessed for knee pain, walking ability, and balance before and after application of knee KT. Knee pain was assessed in resting and walking conditions using the visual analog scale. Walking and balance were assessed using a 10-m walking test and a timed up and go test.

RESULTS

In the present study, KT significantly improved gait and balance with reduction in knee pain during walking than non-KT (P < .05).

CONCLUSIONS

This study demonstrated that knee KT has a positive effect on pain reduction and walking and balance ability of the older adults with OA. Therefore, this study suggests that KT can be used as an intervention to relieve knee pain and aid walking and balance ability in the older adult.

The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation: A pilot before-after study

This study demonstrated a training program of the suction-assisted laryngoscopy assisted decontamination (S.A.L.A.D.) technique for emergency medical technician paramedic (EMT-P). The effectiveness of the training program on the improvements of skills and confidence in managing soiled airway was evaluated.In this pilot before-after study, 41 EMT-P participated in a training program which consisted of 1 training course and 3 evaluation scenarios. The training course included lectures, demonstration, and practice and focused on how to perform endotracheal intubation in soiled airway with the S.A.L.A.D technique. The first scenario was performed on standard airway mannequin head with clean airway (control scenario). The second scenario (pre-training scenario) and the third scenario (post-training scenario) were performed in airway with simulated massive vomiting. The post-training scenario was applied immediately after the training course. All trainees were requested to perform endotracheal intubation for 3 times in each scenario. The "pass" of a scenario was defined as more than twice successful intubation in a scenario. The intubation time, count of successful intubation, pass rate, and the confidence in endotracheal intubation were evaluated.The intubation time in the post-training scenario was significantly shorter than that in the pre-training scenario (P = .031). The pass rate of the control, pre-training, and post-training scenario was 100%, 82.9%, and 92.7%, respectively. The proportion of trainees reporting confident or very confident in endotracheal intubation in soiled airway increased from 22.0% to 97.6% after the training program. Kaplan-Meier analysis revealed that the adjusted hazard ratio of successful intubation for post-training versus pre-training scenario was 2.13 (95% confidence interval of 1.57-2.91).The S.A.L.A.D. technique training could efficiently help EMT-P performing endotracheal intubation during massive vomiting simulation.

Fatal crashes in the 5 years after recreational marijuana legalization in Colorado and Washington

Colorado and Washington legalized recreational marijuana in 2012, but the effects of legalization on motor vehicle crashes remains unknown. Using Fatality Analysis Reporting System data, we performed difference-in-differences (DD) analyses comparing changes in fatal crash rates in Washington, Colorado and nine control states with stable anti-marijuana laws or medical marijuana laws over the five years before and after recreational marijuana legalization. In separate analyses, we evaluated fatal crash rates before and after commercial marijuana dispensaries began operating in 2014. In the five years after legalization, fatal crash rates increased more in Colorado and Washington than would be expected had they continued to parallel crash rates in the control states (+1.2 crashes/billion vehicle miles traveled, CI: -0.6 to 2.1, p = 0.087), but not significantly so. The effect was more pronounced and statistically significant after the opening of commercial dispensaries (+1.8 crashes/billion vehicle miles traveled, CI: +0.4 to +3.7, p = 0.020). These data provide evidence of the need for policy strategies to mitigate increasing crash risks as more states legalize recreational marijuana.

A full Bayes approach for traffic conflict-based before-after safety evaluation using extreme value theory

A full Bayes approach is proposed for traffic conflict-based before-after safety evaluations using extreme value theory. The approach combines traffic conflicts of different sites and periods and develops a uniform generalized extreme value (GEV) model for the treatment effect estimation. Moreover, a hierarchical Bayesian structure is used to link possible covariates to GEV parameters and to account for unobserved heterogeneity among different sites. The proposed approach was applied to evaluate the safety benefits of a left-turn bay extension project in the City of Surrey, Canada, in which traffic conflicts were collected from 3 treatment sites and 3 matched control sites before and after the treatment. A series of models were developed considering different combinations of covariates and their link to different GEV model parameters. Based on the best fitted model, the treatment effects were analyzed quantitatively using the odds ratio (OR) method as well as qualitatively by comparing the shapes of GEV distributions. The results show that there are significant reduction in the expected number of crashes (i.e., OR = 0.409). In addition, there are apparent changes in the shape of GEV distributions for the treatment sites, where GEV distributions shift further away from the risk of crash area after the treatment. Both of these results indicate significant safety improvements after the left-turn bay extension.

Plasma miR-32 levels in non-small cell lung cancer patients receiving platinum-based chemotherapy can predict the effectiveness and prognosis of chemotherapy

BACKGROUND

Previous studies have shown that microRNA-32 (miRNA-32) is an exosome microRNA that affects the proliferation and metastasis of non-small cell lung cancer (NSCLC) cells. In this study, our goal was to assess the expression of plasma microRNA-32 and its potential as a biomarker to predict the tumor response and survival of patients with NSCLC undergoing platinum-based chemotherapy.

METHODS

Plasma microRNA-32 levels before and after 1 cycle of platinum-based chemotherapy in 43 patients with NSCLC were measured using a quantitative real-time polymerase chain reaction assay (qPCR). In addition, the demographic and survival data of the patients were collected for analysis.

RESULTS

A significant correlation was observed between the changes in microRNA-32 levels before and after 1 chemotherapy cycle and the treatment response (P = .035). In addition, Kaplan-Meier analysis showed that the level of microRNA-32 after 1 chemotherapy cycle was significantly correlated with the prognosis of patients. The median progression-free survival (P = .025) and overall survival (P = .015) of patients with high microRNA-32 levels (≥7.73) after 1 chemotherapy cycle was 9 and 21 months, respectively. In contrast, the median survival of patients with low microRNA-32 levels (<7.73) was 5 and 10 months, respectively.

CONCLUSIONS

The plasma levels of microRNA-32 correlated with the efficacy of platinum-based chemotherapy and survival, indicating that microRNA-32 may be useful for predicting the effectiveness of platinum-based chemotherapy and prognosis in NSCLC.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Operative treatment of displaced midshaft clavicle fractures: has randomised control trial evidence changed practice patterns?

OBJECTIVES

To determine if level 1 evidence from a landmark trial changed practice patterns for treatment of patients with displaced midshaft clavicle fractures.

DESIGN

Retrospective cohort study.

SETTING

Two level 1 trauma centres.

PARTICIPANTS

Displaced midshaft clavicle fractures.

RESULTS

686 patients met inclusion criteria. The pretrial cohort (n=108) was 68.5% male, with a mean age of 37.7 (±13.9) years. The post-trial cohort (n=578) was 76.1% male, with a mean age of 41.9 (±12.7) years. There was nearly a 10-fold increase in the patients treated with openreduction and internal fixation (ORIF) in the post-trial cohort (34.1%) compared with the pretrial cohort (3.7%) (p<0.001). Patients in the post-trial cohort were more likely to undergo ORIF if they were <40 years (OR=2.2; 95% CI 1.53 to 3.10), if their Injury Severity Score was >9 (OR=1.6; 95% CI 0.89 to 2.99) or if they were treated at a centre that participated in the Canadian Orthopaedic Trauma Society (COTS) trial (OR=5.2; 95% CI 3.31 to 8.21).

CONCLUSIONS

This study demonstrated a significant shift towards more frequent ORIF for displaced midshaft clavicle fractures following the COTS trial. Quantifying changes in practice pattern following publication of level 1 evidence is important to further our understanding of the impact large randomisedclinical trails are having on clinical practice.

Educational ICU Antimicrobial Stewardship model: the daily activities of the AMS team over a 10-month period

The emergence of antibiotic resistance as a consequence of inappropriate use results in higher mortality rates and has become a major public health challenge worldwide. Antimicrobial stewardship programs (ASPs) aim to ensure proper use of antimicrobials and reduce health care costs. We assessed the impact of using a behavioral approach during a persuasive ASP on antibiotic appropriateness, consumption and costs. We conducted a prospective interventional cohort before-and-after study in the intensive care unit (ICU) of a 554-bed, university teaching hospital in Terni, Italy, 14 of which are located in the ICU. We describe a 10-month persuasive ASP intervention model used in a referral ICU with daily rounds. The aim of the study was to improve medication appropriateness through educational action and reduce the consumption of carbapenems and echinocandins by conducting post-prescription reviews, prescribing reviews and holding daily discussions with the ICU team. We analyzed the prescribing appropriateness of the ICU team in accordance with the decisions made by the Antimicrobial Stewardship (AMS) team to improve the quality of antibiotic prescribing during the first five months and the last five months of the surveillance period. The results were expressed as the defined daily dose (DDD) per 100 occupied bed-days and costs. The data were compared with those previously obtained during the pre-educational period (the year before ASP implementation). Comparisons were made between the decisions taken to improve antimicrobial treatments administered during the first half of the surveillance period (March-July) and those administered during the second half (August-December). In all, 116 decisions were made from March to July while only 65 were made from August to December (p-value 0.00001). A significant reduction was observed in the consumption of carbapenems and echinocandins (11.15% and 25.62%, respectively). Total antibiotic cost savings amounted to 57,541.16 euros. The persuasive ASP strategy positively influenced the prescribing behavior of physicians, thus improving the appropriateness of antibiotic therapy and reducing antimicrobial consumption.

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study

BACKGROUND

Iron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.

METHODS AND FINDINGS

In order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael's Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%-14.11%]; post-intervention 10.6% [95% CI 9.6%-11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.

CONCLUSIONS

The introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

Association of Medicaid Expansion With Health Insurance Coverage Among Persons With a Disability

IMPORTANCE

Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability.

OBJECTIVE

To determine the association of Medicaid expansion with health insurance coverage among persons with a disability.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019.

MAIN OUTCOMES AND MEASURES

Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties).

RESULTS

Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability.

CONCLUSIONS AND RELEVANCE

Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.

Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study

OBJECTIVES

We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.

DESIGN

Adjusted before-after analysis.

SETTING

A large hospital in the Champagne-Ardenne region, France.

PARTICIPANTS

Patients admitted to the ED between 13 January 2015 and 13 January 2017.

INTERVENTION

Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.

RESULTS

The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.

CONCLUSIONS

The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

Nutritional interventions for preventing stunting in children (birth to 59 months) living in urban slums in low- and middle-income countries (LMIC)

BACKGROUND

Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low- and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure.

OBJECTIVES

To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting.

SEARCH METHODS

The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018.

SELECTION CRITERIA

Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre- and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW).

DATA COLLECTION AND ANALYSIS

We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'.

MAIN RESULTS

The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length.The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues.Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs)There was no evidence of an effect on LBW (MD -36.13 g, 95% CI -83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low- to moderate-certainty evidence.Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs)There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD -0.02, 95% CI -0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low- to moderate-certainty evidence.Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs)There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32).Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study)There were inconclusive results on HFA, with very low- to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence.

AUTHORS' CONCLUSIONS

All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low- to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.

The impact of the Luton social prescribing programme on energy expenditure: a quantitative before-and-after study

OBJECTIVES

The objective of this study was to assess the change in energy expenditure levels of service users after participation in the Luton social prescribing programme.

DESIGN

Uncontrolled before-and-after study.

SETTING

This study was set in the East of England (Luton).

PARTICIPANTS

Service users with complete covariate information and baseline measurements (n=146) were included in the analysis.

INTERVENTION

Social prescribing, which is an initiative that aims to link patients in primary care with sources of support within the community sector to improve their health, well-being and care experience. Service users were referred to 12 sessions (free of charge), usually provided by third sector organisations.

PRIMARY OUTCOME MEASURE

Energy expenditure measured as metabolic equivalent (MET) minutes per week.

RESULTS

Using a Bayesian zero-inflated negative binomial model to account for a large number of observed zeros in the data, 95% posterior intervals show that energy expenditure from all levels of physical activities increased post intervention (walking 41.7% (40.31%, 43.11%); moderate 5.0% (2.94%, 7.09%); vigorous 107.3% (98.19%, 116.20%) and total 56.3% (54.77%, 57.69%)). The probability of engaging in physical activity post intervention increased, in three of four MET physical activity levels, for those individuals who were inactive at the start of the programme. Age has a negative effect on energy expenditure from any physical activity level. Similarly, working status has a negative effect on energy expenditure in all but one MET physical activity level. No consistent pattern was observed across physical activity levels in the association between gender and energy expenditure.

CONCLUSION

This study shows that social prescribing may have the potential to increase the physical activity levels of service users and promote the uptake of physical activity in inactive patient groups. Results of this study can inform future research in the field, which could be of use for commissioners and policy makers.

Does the Patient-Reported Apnea Questionnaire (PRAQ) increase patient-centredness in the daily practice of sleep centres? a mixed-methods study

OBJECTIVES

The objective of this exploratory study was to see how the Patient-Reported Apnea Questionnaire (PRAQ) may impact the daily clinical practice of sleep centres, and why it may or may not work as expected. The hypotheses were tested that this patient-reported outcome measure makes patients more aware of which of their health complaints may be related to obstructive sleep apnoea (OSA), and that it improves patient-centredness of care by shifting the focus of care away from (only) medical problems towards the individual burden of disease and quality of life.

DESIGN

Mixed methods. The quantitative study (surveys, patient records) was a before-and-after study.

SETTING

Three sleep centres in The Netherlands (secondary care).

PARTICIPANTS

27 patients and 14 healthcare professionals were interviewed. 487 patients completed surveys pre-implementation, and 377 patients completed surveys post-implementation of the PRAQ. For the health records, 125 patients were included in the pre-implementation group, and 124 other patients in the post-implementation group.

INTERVENTIONS

The PRAQ was used in clinical practice for six successive months.

OUTCOME MEASURES

Scores on individual survey items, number of patients receiving non-medical treatment, adjustment of treatment at first follow-up, compliance with treatment.

RESULTS

Patients were generally positive about the usefulness of the PRAQ before and during the consultation, as they felt more informed. Healthcare providers did not consider the PRAQ very useful, and they reported minor impact on their consultations. The surveys and health record study did not show an impact of the PRAQ on clinical practice.

CONCLUSIONS

Implementing the PRAQ may be beneficial to patients, but this study does not show much impact with regard to patient-centredness of care. New Dutch guidelines for OSA care may lead to a greater emphasis on quality of life and value of care for patients, making its integration in clinical care potentially more useful.

Programmatic human papillomavirus testing in cervical cancer prevention in the Jujuy Demonstration Project in Argentina: a population-based, before-and-after retrospective cohort study

BACKGROUND

Human papillomavirus (HPV) testing for cervical cancer prevention was introduced in Argentina through the Jujuy Demonstration Project (2011-14). The programme tested women aged 30 years and older attending the public health system with clinician-collected HPV tests. HPV self-collection was introduced as a programmatic strategy in 2014. We aimed to evaluate the effectiveness of programmatic HPV testing to detect cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) in comparison with cytology-based screening.

METHODS

We did a population-based, before-and-after retrospective cohort study using data from the National Cervical Cancer Prevention Program for the Jujuy province in northwest Argentina. We obtained data for the cytology-based screening period from Jan 1, 2010, until Dec 31, 2011, and for the HPV-based screening period from Jan 1, 2012, until Dec 31, 2014. The primary outcome was detection of histologically diagnosed CIN2+ among women aged 30 years and older. To assess the outcomes in all individuals included in the study, we used multivariable logistic regression and propensity score matching. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was used for the before-and-after analysis of programmatic dimensions.

FINDINGS

Of the 29 631 women who underwent cytology-based screening in 2010-11, CIN2+ was detected in 236 (0·8%) individuals. Of the 49 565 women HPV tested in 2012-14 (clinician-collected tests, n=44 700; self-collection tests, n=4865), 693 (1·4%; 658 clinician-collected tests; 35 self-collection tests) were found to have CIN2+ after the first round of screening. Compared with cytology-based screening, the odds ratio of being diagnosed with a CIN2+ lesion was 2·34 (95% CI 2·01-2·73; p<0·0010) with clinician-collected tests, and 1·08 (0·74-1·52; p=0·68) when screened with self-collection tests, after controlling for age and health insurance status. Screening coverage was similar in both periods (52·7% vs 53·2%); improvements of programmatic indicators were observed in the HPV testing period in relation to laboratory centralisation, lower overscreening (6·6% vs 0·0%), higher adherance to age recommendations (79·3% vs 98·8%), and a decrease of inadequate samples (3·6% vs 0·2%).

INTERPRETATION

HPV testing in middle-income settings increases detection of CIN2+ lesions and allows for improvement of programmatic indicators. Evidence suggests that the introduction of HPV testing will accelerate the reduction of cervical cancer burden.

FUNDING

Argentinian National Cancer Institute and National Council of Scientific and Technologic Research.

Safety effects of automated section speed control on the Italian motorway network

INTRODUCTION

Automated Section Speed Control (ASSC) has been identified as an effective countermeasure to reduce speeds and improve speed limit compliance.

METHOD

An Empirical Bayes (EB) before-and-after study was performed in this research in order to evaluate the impact of the ASSC system on the expected crash frequency. The study was carried out on a sample of 125 ASSC sites of the Italian motorway network covering 1252 km, where a total of 21,721 crashes were recorded during a 10-year analysis period from 2004 to 2013.

RESULTS

Overall, the EB analysis estimated a significant 22% reduction in the expected crash frequency due to the implementation of the ASSC system. The analysis indicated that the effect is slightly larger on property damage only (PDO) crashes (-23%) than on fatal injury (FI) crashes (-18%) and that the highest reductions in crash frequency are expected for multi-vehicle FI crashes (-25%) and multi-vehicle PDO crashes (-31%). Furthermore, the results indicated that the ASSC system is more effective in reducing crash rates when traffic volume increases and it is therefore strongly recommended as a countermeasure to improve safety on high-traffic-volume motorway sections.

Fast-track protocol for perioperative care in gynecological surgery: Cross-sectional study

OBJECTIVE

To compare clinical and surgical outcomes in patients admitted to a gynecological surgery ward before and after the implementation of an evidence-based multimodal and multiprofessional care protocol by the hospital staff.

MATERIAL AND METHODS

In this historically-controlled cross-sectional study, we compared clinical and surgical outcomes among all women admitted to the gynecological ward of a university public hospital for elective surgery for various reasons before and after the implementation of a multimodal care protocol. The protocol had been implemented to adjust the following procedures to evidence-based recommendations: fluid management/hydration, antimicrobial prophylaxis, management of nausea and vomiting, antithrombotic prophylactic therapy, preoperative fasting, mechanical bowel preparation (reduction), pain management, use of urinary catheters, and stimulus to ambulation.

RESULTS

After the protocol implementation, fasting time was reduced in approximately 10 h. Patients had to undergo bowel preparation significantly less frequently, and the volume of fluids was reduced too. The use of nausea and vomit prophylaxis increased almost 20 times, but only nausea episodes were reduced. The frequency of antithrombotic prophylactic therapy more than doubled. Hospitalization time decreased significantly.

CONCLUSIONS

In this study, we observed significant improvements in clinical outcomes after the implementation of a multimodal protocol for perioperative care in the gynecological ward of a public university hospital in Brazil. The protocol implementation was associated with reductions in fasting time, bowel preparation, administration of fluids, pain, nausea and hospitalization time, allowing the treatment of more patients per year in the same ward.

The effect of community dialogues and sensitization on patient reporting of adverse events in rural Uganda: Uncontrolled before-after study

Background

Patients experiencing adverse drug events (ADE) in many developing countries are in the best position to report these events to the authorities but need to be empowered to do so. Systematic evaluation of community engagement and patient support especially in rural areas would provide evidence for a program to monitor potential harm from medicines. The aim of this study was to assess the effects of a community dialogue and sensitization (CDS) program on the knowledge, attitude and practises of community members for reporting ADE.

Methods

This an uncontrolled before-after study was conducted in two eastern Ugandan districts between September 2016 and August 2017

Results

After implementation of the community dialogue and sensitization (CDS) program, there was an overall 20% (95% CI:16% to 25%) increase in knowledge about ADE in the community compared to before the program began. Awareness levels increased by 50% (95% CI: 37% to 63%) among those with little or no education and by41% (95% CI: 31% to 52%) among young people (15–24 years). Furthermore, 5% (95% CI: 3% to 7%) more respondents recognized the need for reporting ADEs compared to before the program. Finally, there was a significant increase of 115% (95% CI:137% to 217%) in respondent recognition and reporting of ADEs compared to the beginning of the CDS program. Overall, this community found the CDS program acceptable and proposed aspects that could be improved for future use.

Conclusion

Our evaluation showed that the CDS program increased knowledge and improved attitudes by catalyzing discussions among community members and healthcare professionals on health issues and monitoring safety of medicines compared to before the program. Successful implementation of the program depends on holistic health systems strengthening and adaptation to the community’s way of life.

Reducing antibiotic prescribing for lower respiratory tract infections 6 years after a multifaceted intervention

AIMS

Few studies have evaluated the long-term impact of interventions on antibiotic prescription for lower respiratory tract infections (LRTI). This study was aimed at evaluating the use of antibiotics prescribed for LRTIs by general practitioners (GP) who underwent a multifaceted intervention carried out 6 years earlier.

METHODS

General practitioners who had completed two registrations in 2008 and 2009 were again invited to participate in a third audit-based study in 2015. A multifaceted intervention was held 1-3 months before the second registration. A new group of GPs with no previous training on the rational use of antibiotics were also invited to participate and acted as controls. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable.

RESULTS

A total of 121 GPs of the 210 who underwent the intervention (57.6%) and 117 control GPs registered 4333 episodes of LRTIs. On adjustment for covariables, compared with the antibiotic prescription for LRTIs observed just after the intervention, antibiotic prescription slightly increased 6 years later among GPs who had undergone the intervention (OR 1.17, 95% CI 0.95-1.43), while control GPs prescribed significantly more antibiotics (OR 2.31, 95% CI 1.62-3.29). However, withholding antibiotic prescribing with C-reactive protein (CRP) values <10 mg/L was more frequently observed just after the intervention compared 6 years later (12.7% vs 32.2%; P < 0.01).

CONCLUSIONS

Antibiotic prescribing for LRTIs remains low 6 years after an intervention, although GPs are less confident to withhold antibiotic therapy in patients with low CRP levels.