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Abstract
Length of stay of hospitalized patients is generally considered to be a significant and critical factor for healthcare policy planning which consequently affects the hospital management plan and resources. Its reliable prediction in the preadmission stage could further assist in identifying abnormality or potential medical risks to trigger additional attention for individual cases. Recently, data mining and machine learning constitute significant tools in the healthcare domain. In this work, we introduce a new decision support software for the accurate prediction of hospitalized patients’ length of stay which incorporates a novel two-level classification algorithm. Our numerical experiments indicate that the proposed algorithm exhibits better classification performance than any examined single learning algorithm. The proposed software was developed to provide assistance to the hospital management and strengthen the service system by offering customized assistance according to patients’ predicted hospitalization time.
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GENOVESE C, DE BELVIS A, RINALDI M, MANNO V, SQUERI R, LA FAUCI V, TABBI P. Quality and management care improvement of patients with chronic kidney disease: from data analysis to the definition of a targeted clinical pathway in an Italian Region. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2018; 59:E305-E310. [PMID: 30656233 PMCID: PMC6319119 DOI: 10.15167/2421-4248/jpmh2018.59.4.999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 11/06/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Clinical Diagnostic Care Pathways (CDCP) are management tools widespread throughout the world to improve the quality of patient care through a well-organized care continuum and to enhance the patient's "risk-adjusted" outcomes; indeed they could optimize the management of resources. They are particularly effective in the management of patients with chronic degenerative diseases, such as chronic kidney disease, with increasingly incidence and prevalence, with an estimated 11-13% of the population being affected. The aim of this study is to apply the Health Services Research methods to estimate the relationship between need, demand and supply in patients with stage 5 Chronic Kidney Disease (CKD) for, then to describe the definition of a CDCP dedicated to patients in Lazio Region, so to allow an appropriate patient management, to reduce the likely complications and the patients' migration to facilities outside the region. METHODS The study was conducted in 2017 in collaboration between the National Institute of Health, the University of Messina and the S. Giovanni Addolorata Hospital. RESULTS We analyzed the data for the CKD in Roma and in the San Giovanni Addolorata Hospital Trust and we found a drop out in the patients' attendance towards other regions and/or hospitals. So we defined a CDCP to be adopted at the San Giovanni Addolorata hospital. CONCLUSIONS To define management and care tools to provide adequate, efficient and patient centered care is a nowadays "must", to ensure the sustainability of the Italian NHS, which today is comparable to a "ship that is heading towards a perfect storm".
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Affiliation(s)
- C. GENOVESE
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - A.G. DE BELVIS
- Section of Hygiene-Institute of Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico “Agostino Gemelli” IRCCS, Rome, Italy
| | - M. RINALDI
- Complex Operative Unit of Anesthesia and Resuscitation, Hospital San Giovanni Addolorata, Rome, Italy
| | - V. MANNO
- Technical Statistics Service, Higher Institute of Health (Istituto Superiore di Sanità), Rome, Italy
| | - R. SQUERI
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - V. LA FAUCI
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy
| | - P. TABBI
- Complex Operative Unit of Vascular Surgery, Hospital San Giovanni Addolorata, Rome, Italy
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153
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Jabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci 2018; 13:139. [PMID: 30419942 PMCID: PMC6233585 DOI: 10.1186/s13012-018-0832-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. METHODS This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel. RESULTS Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. CONCLUSIONS Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. TRIAL REGISTRATION ClinicalTrials.gov, NCT01815710 .
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Affiliation(s)
- Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room W1415, Ottawa, ON, K1H 8L1, Canada.
- University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Amanda S Newton
- Department of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Johnson
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
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154
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Melchior I, Moser A, Veenstra MY, Jie KS. Involving "authentic" cancer patients, their caregivers, and multidisciplinary professionals in a quality improvement trajectory in a hospital cancer pathway: a study protocol. J Multidiscip Healthc 2018; 11:661-671. [PMID: 30519034 PMCID: PMC6233706 DOI: 10.2147/jmdh.s177957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The implementation of oncology care pathways that standardize organizational procedures has improved cancer care in recent years. However, the involvement of "authentic" patients and caregivers in quality improvement of these predetermined pathways is in its infancy, especially the scholarly reflection on this process. We, therefore, aim to explore the multidisciplinary challenges both in practice, when cancer patients, their caregivers, and a multidisciplinary team of professionals work together on quality improvement, as well as in our research team, in which a social scientist, health care professionals, health care researchers, and experience experts design a research project together. Methods and design Experience-based co-design will be used to involve cancer patients and their caregivers in a qualitative research design. In-depth open discovery interviews with 12 colorectal cancer patients, 12 breast cancer patients, and seven patients with cancer-associated thrombosis and their caregivers, and focus group discussions with professionals from various disciplines will be conducted. During the subsequent prioritization events and various co-design quality improvement meetings, observational field notes will be made on the multidisciplinary challenges these participants face in the process of co-design, and evaluation interviews will be done afterwards. Similar data will be collected during the monthly meetings of our multidisciplinary research team. The data will be analyzed according to the constant comparative method. Discussion This study may facilitate quality improvement programs in oncologic care pathways, by increasing our real-world knowledge about the challenges of involving "experience experts" together with a team of multidisciplinary professionals in the implementation process of quality improvement. Such co-creation might be challenging due to the traditional paternalistic relationship, actual disease-/treatment-related constraints, and a lack of shared language and culture between patients, caregivers, and professionals and between professionals from various disciplines. These challenges have to be met in order to establish equality, respect, team spirit, and eventual meaningful participation.
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Affiliation(s)
- Inge Melchior
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard, The Netherlands, .,Research Centre Autonomy and Participation of Chronically Ill people, Zuyd University of Applied Sciences, Heerlen, The Netherlands,
| | - Albine Moser
- Research Centre Autonomy and Participation of Chronically Ill people, Zuyd University of Applied Sciences, Heerlen, The Netherlands, .,Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Marja Y Veenstra
- Burgerkracht Limburg [Citizen Power in Limburg], Sittard, The Netherlands
| | - Kon-Siong Jie
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard, The Netherlands, .,Research Centre Autonomy and Participation of Chronically Ill people, Zuyd University of Applied Sciences, Heerlen, The Netherlands,
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155
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Butow P, Shaw J, Shepherd HL, Price M, Masya L, Kelly B, Rankin NM, Girgis A, Hack TF, Beale P, Viney R, Dhillon HM, Coll J, Kelly P, Lovell M, Grimison P, Shaw T, Luckett T, Cuddy J, White F. Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): study protocol of a cluster randomised controlled trial. BMC Cancer 2018. [PMID: 30404619 DOI: 10.1186/s12885‐018‐4962‐9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Health service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period. METHODS This cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will "Go-live", implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live). DISCUSSION This will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care. TRIAL REGISTRATION The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.
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Affiliation(s)
- Phyllis Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.
| | - Joanne Shaw
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Heather L Shepherd
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Melanie Price
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Lindy Masya
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Brian Kelly
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Nicole M Rankin
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Afaf Girgis
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, Australia
| | - Thomas F Hack
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,CancerCare Manitoba Research Institute, Winnipeg, Canada
| | - Philip Beale
- Cancer Services for the Sydney Local Health District (Incorporating Royal Prince Alfred, Concord and Canterbury Hospitals, Campsie, NSW, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW, Australia
| | - Haryana M Dhillon
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Joseph Coll
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Patrick Kelly
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Lovell
- HammondCare Northern Sydney, Sydney, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Peter Grimison
- Chris O'Brien Lifehouse, Camperdown, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Charles Perkins Centre Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Jessica Cuddy
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Fiona White
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
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156
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Butow P, Shaw J, Shepherd HL, Price M, Masya L, Kelly B, Rankin NM, Girgis A, Hack TF, Beale P, Viney R, Dhillon HM, Coll J, Kelly P, Lovell M, Grimison P, Shaw T, Luckett T, Cuddy J, White F. Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): study protocol of a cluster randomised controlled trial. BMC Cancer 2018; 18:1077. [PMID: 30404619 PMCID: PMC6223096 DOI: 10.1186/s12885-018-4962-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/16/2018] [Indexed: 12/02/2022] Open
Abstract
Background Health service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period. Methods This cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will “Go-live”, implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live). Discussion This will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care. Trial registration The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347
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Affiliation(s)
- Phyllis Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.
| | - Joanne Shaw
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Heather L Shepherd
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Melanie Price
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Lindy Masya
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Brian Kelly
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Nicole M Rankin
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Afaf Girgis
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, Australia
| | - Thomas F Hack
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,CancerCare Manitoba Research Institute, Winnipeg, Canada
| | - Philip Beale
- Cancer Services for the Sydney Local Health District (Incorporating Royal Prince Alfred, Concord and Canterbury Hospitals, Campsie, NSW, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW, Australia
| | - Haryana M Dhillon
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Joseph Coll
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Patrick Kelly
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Lovell
- HammondCare Northern Sydney, Sydney, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Peter Grimison
- Chris O'Brien Lifehouse, Camperdown, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Charles Perkins Centre Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Jessica Cuddy
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Fiona White
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
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Bjurling-Sjöberg P, Wadensten B, Pöder U, Jansson I, Nordgren L. Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study. BMC Health Serv Res 2018; 18:831. [PMID: 30400985 PMCID: PMC6219016 DOI: 10.1186/s12913-018-3629-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 10/16/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context. METHODS The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data. RESULTS A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational. CONCLUSIONS The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.
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Affiliation(s)
- Petronella Bjurling-Sjöberg
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Kungsgatan 41, 631 88, Eskilstuna, Sweden. .,Department of Patient safety, Mälar Hospital, 631 88, Eskilstuna, Sweden.
| | - Barbro Wadensten
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Ulrika Pöder
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Inger Jansson
- Institute of Health and Caring Sciences, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden
| | - Lena Nordgren
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden.,Centre for Clinical Research Sörmland, Uppsala University, Kungsgatan 41, 631 88, Eskilstuna, Sweden
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158
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Zhu L, Bai J, Chen Y, Xue D. Effects of a clinical pathway on antibiotic use in patients with community-acquired pneumonia: a multi-site study in China. BMC Infect Dis 2018; 18:471. [PMID: 30231869 PMCID: PMC6146630 DOI: 10.1186/s12879-018-3369-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 08/30/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common condition with high mortality, morbidity and healthcare costs. This study aimed to determine whether clinical pathway (CP) implementation in different hospitals in China increased antibiotic compliance with the national CP in inpatients with CAP. METHODS Chart reviews of CAP cases were conducted in 18 public hospitals from 3 different regions of China in 2015. Chi-square tests and the t-test were used to compare differences between hospitals that implemented CP (CP group) and those that did not (non-CP group). Multivariate logistic analysis was adopted to test whether CP implementation for CAP in hospitals affected their overall antibiotic use compliance rates with the national CP for CAP. RESULTS The overall compliance rate with the national CP for inpatients with CAP was 43.69%. The compliance rates for timely initial antibiotic use, recommended antibiotic use and use of the recommended combination of antibiotics and the overall compliance rate were substantially higher in the CP group than in the non-CP group. A multivariate logistic model for overall compliance in inpatients with CAP showed that the hospitals in the CP group had greater overall compliance than those in the non-CP group (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.16-2.71) after controlling for hospital and inpatient characteristics. CONCLUSION In China, the overall compliance rate with the national CP for inpatients with CAP was low, but inpatients with CAP in the hospitals in the CP group received antibiotics more concordantly with the national CP. Since adherence to evidence-based care has been shown to improve clinical outcomes, internal and external support from hospitals is required to facilitate CP implementation for inpatients with CAP. Additionally, governmental commitment, hospital input and population involvement are required to improve antibiotic utilization.
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Affiliation(s)
- Liping Zhu
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Jie Bai
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Yongcong Chen
- School of Public Health, Lanzhou University, Lanzhou, People’s Republic of China
| | - Di Xue
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
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Kingsland M, Doherty E, Anderson AE, Crooks K, Tully B, Tremain D, Tsang TW, Attia J, Wolfenden L, Dunlop AJ, Bennett N, Hunter M, Ward S, Reeves P, Symonds I, Rissel C, Azzopardi C, Searles A, Gillham K, Elliott EJ, Wiggers J. A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial. Implement Sci 2018; 13:112. [PMID: 30126437 PMCID: PMC6102816 DOI: 10.1186/s13012-018-0806-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/07/2018] [Indexed: 12/20/2022] Open
Abstract
Background Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women. Methods The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at ‘booking in’, 27–28 weeks gestation and 35–36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome. Discussion This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child. Trial registrations Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).
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Affiliation(s)
- Melanie Kingsland
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia. .,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia. .,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.
| | - Emma Doherty
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Amy E Anderson
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kristy Crooks
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Belinda Tully
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Danika Tremain
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Tracey W Tsang
- School of Medicine, The University of Sydney, Camperdown, New South Wales, Australia.,Sydney Children's Hospital Network, Kids' Research Institute, Westmead, New South Wales, Australia
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Nicole Bennett
- Maternity and Gynaecology John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mandy Hunter
- Maternity and Gynaecology John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Sarah Ward
- Foundation for Alcohol Research and Education, Deakin, Australian Capital Territory, Australia
| | - Penny Reeves
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Ian Symonds
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Chris Rissel
- School of Medicine, The University of Sydney, Camperdown, New South Wales, Australia.,New South Wales Office of Preventive Health, Liverpool, New South Wales, Australia
| | - Carol Azzopardi
- Maternity and Gynaecology John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Andrew Searles
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Karen Gillham
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Elizabeth J Elliott
- School of Medicine, The University of Sydney, Camperdown, New South Wales, Australia.,Sydney Children's Hospital Network, Kids' Research Institute, Westmead, New South Wales, Australia
| | - John Wiggers
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Li HM, Chen YC, Gao HX, Zhang Y, Chen L, Chang JJ, Su D, Lei SH, Jiang D, Hu XM. Effectiveness evaluation of quota payment for specific diseases under global budget: a typical provider payment system reform in rural China. BMC Health Serv Res 2018; 18:635. [PMID: 30103736 PMCID: PMC6090661 DOI: 10.1186/s12913-018-3415-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/24/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Quota payment for specific diseases under global budget is one of the most typical modes of provider payment system reform in rural China. This study aimed to assess this reform mode from aspects of the total fee, structure of the fee and enrollees' benefits. METHODS A total of 127,491 inpatient records from 2014 to 2016 were extracted from the New Rural Cooperative Medical Scheme (NRCMS) database in Weiyuan County, Gansu Province. Total fee, actual compensation ratio, out-of-pocket ratio, constituent ratio of the treatment fee, constituent ratio of the inspection and laboratory fee, and length of stay were selected as dependent variables. Both generalized additive models (GAMs) and multiple linear regression models were used to measure the change in dependent variables along with year. RESULTS Prior to the adjustment of the compensation type, out-of-pocket ratio and length of stay decreased, while total fee, actual compensation ratio, constituent ratio of the treatment fee, and constituent ratio of the inspection and laboratory fee increased. After the compensation type was adjusted, the mean of the total fee increased rapidly in 2015 and remained stable in 2016. The mean length of stay increased in 2015 but decreased in 2016. A comparison of inpatients suffering from diseases covered by quota payments and those suffering from general diseases revealed that total fee, out-of-pocket ratio, and length of stay decreased and actual compensation ratio increased for the former, whereas the opposite was true for the latter. Constituent ratio of the treatment fee and constituent ratio of the inspection and laboratory fee increased for both samples, except for the constituent ratio of the inspection and laboratory fee of quota payment diseases in 2016, which did not change. CONCLUSIONS Quota payment for specific diseases under global budget had obviously positive effects on cost control in Weiyuan, Gansu. Considering the limited coverage of quota payment for diseases, the long-term effect of this reform mode and its replicability awaits further evaluation.
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Affiliation(s)
- Hao-miao Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Ying-chun Chen
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Hong-xia Gao
- Research center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, 430030 Hubei China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Liangkai Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Jing-jing Chang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Dai Su
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Shi-han Lei
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Di Jiang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
| | - Xiao-mei Hu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 Hubei China
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Ebm C, Aggarwal G, Huddart S, Cecconi M, Quiney N. Cost-effectiveness of a quality improvement bundle for emergency laparotomy. BJS Open 2018; 2:262-269. [PMID: 30079396 PMCID: PMC6069361 DOI: 10.1002/bjs5.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 02/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The recent Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) study showed that the use of a specific care bundle reduced mortality in patients undergoing emergency laparotomy. However, the costs of implementation of the ELPQuiC bundle remain unknown. The aim of this study was to assess the in-hospital and societal costs of implementing the ELPQuiC bundle. METHODS The ELPQuiC study employed a before-after approach using quality improvement methodology. To assess the costs and cost-effectiveness of the bundle, two models were constructed: a short-term model to assess in-hospital costs and a long-term model (societal decision tree) to evaluate the patient's lifetime costs (in euros). RESULTS Using health economic modelling and data collected from the ELPQuiC study, estimated costs for initial implementation of the ELPQuiC bundle were €30 026·11 (range 1794·64-40 784·06) per hospital. In-hospital costs per patient were estimated at €14 817·24 for standard (non-care bundle) treatment versus €15 971·24 for the ELPQuiC bundle treatment. Taking a societal perspective, lifetime costs of the patient in the standard group were €23 058·87, compared with €19 102·37 for patients receiving the ELPQuiC bundle. The increased life expectancy of 4 months for patients treated with the ELPQuiC bundle was associated with cost savings of €11 410·38 per quality-adjusted life-year saved. CONCLUSION Implementation of the ELPQuiC bundle is associated with lower mortality and higher in-hospital costs but reduced societal costs.
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Affiliation(s)
- C. Ebm
- Department of Anaesthesia and General ManagementWiener Privatklinik (WPK) ViennaViennaAustria
| | - G. Aggarwal
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
| | - S. Huddart
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
| | - M. Cecconi
- Department of Intensive Care MedicineSt George's Healthcare Trust and St George's University of LondonLondonUK
| | - N. Quiney
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
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Approaches to Medical Decision-Making Based on Big Clinical Data. JOURNAL OF HEALTHCARE ENGINEERING 2018; 2018:3917659. [PMID: 29973977 PMCID: PMC6008823 DOI: 10.1155/2018/3917659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/14/2018] [Accepted: 04/30/2018] [Indexed: 12/02/2022]
Abstract
The paper discusses different approaches to building a medical decision support system based on big data. The authors sought to abstain from any data reduction and apply universal teaching and big data processing methods independent of disease classification standards. The paper assesses and compares the accuracy of recommendations among three options: case-based reasoning, simple single-layer neural network, and probabilistic neural network. Further, the paper substantiates the assumption regarding the most efficient approach to solving the specified problem.
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Samokhvalov AV, Probst C, Awan S, George TP, Le Foll B, Voore P, Rehm J. Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study. BMC Psychiatry 2018; 18:189. [PMID: 29898697 PMCID: PMC6001012 DOI: 10.1186/s12888-018-1770-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/29/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015-2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project. METHODS Data on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. STATISTICAL METHODS descriptive statistics, t-test, chi-square, ANOVA, generalized linear models. RESULTS Two hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 - at community hospitals (CH) and 27 - in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy. CONCLUSIONS The study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.
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Affiliation(s)
- Andriy V. Samokhvalov
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Charlotte Probst
- 0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2111 7257grid.4488.0Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen Germany ,WHO Collaborating Centre on Mental Health and Addiction, Toronto, ON Canada
| | - Saima Awan
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada
| | - Tony P. George
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Bernard Le Foll
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Toronto, ON Canada
| | - Peter Voore
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Jürgen Rehm
- 0000 0000 8793 5925grid.155956.bAddictions Division, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office T519, Toronto, ON M5S 2S1 Canada ,0000 0001 2157 2938grid.17063.33Institute for Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bInstitute for Mental Health Policy Research, CAMH, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Division of Adult Psychiatry and Health Systems, Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada ,0000 0001 2111 7257grid.4488.0Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Sachsen Germany ,WHO Collaborating Centre on Mental Health and Addiction, Toronto, ON Canada
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Grimsmo A, Løhre A, Røsstad T, Gjerde I, Heiberg I, Steinsbekk A. Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study. Scand J Prim Health Care 2018; 36:152-160. [PMID: 29644927 PMCID: PMC6066276 DOI: 10.1080/02813432.2018.1459167] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVE To explore the feasibility of disease-specific clinical pathways when used in primary care. DESIGN A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. SETTING Primary care and specialist care collaborating to manage care coordination. RESULTS Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. CONCLUSIONS The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.
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Affiliation(s)
- Anders Grimsmo
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
- CONTACT Anders GrimsmoDepartment of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, 7491Trondheim, Norway
| | - Audhild Løhre
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
| | - Tove Røsstad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
| | - Ingunn Gjerde
- Faculty of Business Administration and Social Sciences, Molde University College, Specialized University in Logistics, Molde, Norway;
| | - Ina Heiberg
- Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway
| | - Aslak Steinsbekk
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
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Huang Q, Jiang P, Feng L, Xie L, Wang S, Xia D, Shen B, Jin B, Zheng L, Wang W. Pre- and intra-operative predictors of postoperative hospital length of stay in patients undergoing radical prostatectomy for prostate cancer in China: a retrospective observational study. BMC Urol 2018; 18:43. [PMID: 29776408 PMCID: PMC5960128 DOI: 10.1186/s12894-018-0351-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 05/02/2018] [Indexed: 01/24/2023] Open
Abstract
Background Hospital length of stay (LOS) has recently been receiving increasing attention as a marker of medical resource consumption. Identifying predictors of longer LOS can better equip doctors to counsel patients and facilitate more efficient patient flow and utilization of medical resources. The objective of this study was to identify pre- and intra-operative risk factors for postoperative hospital LOS in patients who had undergone radical prostatectomy in China. Methods We retrospectively analyzed data of 793 eligible patients with prostate cancer who had undergone radical prostatectomy in our institution between January 2011 and March 2016. Relevant preoperative variables, including patient characteristics, medical comorbidities, prostate cancer disease-specific variables, urinary tract symptoms, preoperative laboratory values, and intraoperative variables including operation type, operation duration, and blood loss, were analyzed. The outcome was postoperative length of stay which was calculated as the time from the date of operation to the date of discharge. Multiple linear regression analysis was used to identify predictors of this outcome. Results The mean postoperative LOS was 11.7 days (±4.6 days) and the median 10 days (range, 5–46 days). According to univariate and multivariate analysis, operation type (open or laparoscopic), blood loss, Gleason score (≥8) and preoperative laboratory values of white blood count (WBC) were found to be the main explanatory predictors of postoperative LOS of patients with prostate cancer in our institution. Additionally, open surgery was the strongest significant predictor of longer LOS according to the standardized coefficients in this model. Conclusions Our findings indicate that significant predictors of longer postoperative LOS in patients who have undergone radical prostatectomy in China include both preoperative variables of Gleason score, WBC and intraoperative variables of operation type (open or laparoscopic), blood loss. To shorten hospital LOS in patients with prostate cancer and optimize utilization of Chinese medical resources, efforts should be made to improve the intraoperative process and reduce the prevalence of preoperative risk factors.
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Affiliation(s)
- Qingmei Huang
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Ping Jiang
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Lina Feng
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Liping Xie
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Shuo Wang
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Dan Xia
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Baihua Shen
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Baiye Jin
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Li Zheng
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China
| | - Wei Wang
- Department of Urology, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, China.
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Bai J, Bai F, Zhu H, Xue D. The perceived and objectively measured effects of clinical pathways' implementation on medical care in China. PLoS One 2018; 13:e0196776. [PMID: 29734350 PMCID: PMC5937784 DOI: 10.1371/journal.pone.0196776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 04/19/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes. Methods Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study. Results The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs. Conclusions CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.
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Affiliation(s)
- Jie Bai
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
| | - Fei Bai
- Center for Medical Service Administration, National Health Commission of China, Beijing, P.R. China
| | - Hongbo Zhu
- Medical Administration and Management, Health and Family Planning Commission of Hubei Province, Wuhan, P.R. China
| | - Di Xue
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
- * E-mail:
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 02/02/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the 'boundary object' concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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168
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Baek H, Cho M, Kim S, Hwang H, Song M, Yoo S. Analysis of length of hospital stay using electronic health records: A statistical and data mining approach. PLoS One 2018; 13:e0195901. [PMID: 29652932 PMCID: PMC5898738 DOI: 10.1371/journal.pone.0195901] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 04/02/2018] [Indexed: 12/14/2022] Open
Abstract
Background The length of stay (LOS) is an important indicator of the efficiency of hospital management. Reduction in the number of inpatient days results in decreased risk of infection and medication side effects, improvement in the quality of treatment, and increased hospital profit with more efficient bed management. The purpose of this study was to determine which factors are associated with length of hospital stay, based on electronic health records, in order to manage hospital stay more efficiently. Materials and methods Research subjects were retrieved from a database of patients admitted to a tertiary general university hospital in South Korea between January and December 2013. Patients were analyzed according to the following three categories: descriptive and exploratory analysis, process pattern analysis using process mining techniques, and statistical analysis and prediction of LOS. Results Overall, 55% (25,228) of inpatients were discharged within 4 days. The department of rehabilitation medicine (RH) had the highest average LOS at 15.9 days. Of all the conditions diagnosed over 250 times, diagnoses of I63.8 (cerebral infarction, middle cerebral artery), I63.9 (infarction of middle cerebral artery territory) and I21.9 (myocardial infarction) were associated with the longest average hospital stay and high standard deviation. Patients with these conditions were also more likely to be transferred to the RH department for rehabilitation. A range of variables, such as transfer, discharge delay time, operation frequency, frequency of diagnosis, severity, bed grade, and insurance type was significantly correlated with the LOS. Conclusions Accurate understanding of the factors associating with the LOS and progressive improvements in processing and monitoring may allow more efficient management of the LOS of inpatients.
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Affiliation(s)
- Hyunyoung Baek
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Minsu Cho
- Department of Industrial and Management Engineering, Pohang University of Science and Technology, Pohang, South Korea
- School of Management Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Seok Kim
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hee Hwang
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Minseok Song
- Department of Industrial and Management Engineering, Pohang University of Science and Technology, Pohang, South Korea
- * E-mail: (MS); (SY)
| | - Sooyoung Yoo
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, South Korea
- * E-mail: (MS); (SY)
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Outcomes of a Clinical Pathway for Pleural Disease Management: "Pleural Pathway". Pulm Med 2018; 2018:2035248. [PMID: 29805807 PMCID: PMC5899858 DOI: 10.1155/2018/2035248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Clinical pathways are evidence based multidisciplinary team approaches to optimize patient care. Pleural diseases are common and accounted for 3.4 billion US $ in 2014 US inpatient aggregate charges (HCUPnet data). An institutional clinical pathway ("pleural pathway") was implemented in conjunction with a dedicated pleural service. Design, implementation, and outcomes of the pleural pathway (from August 1, 2014, to July 31, 2015) in comparison to a previous era (from August 1, 2013, to July 31, 2014) are described. Methods Tuality Healthcare is a 215-bed community healthcare system in Hillsboro, OR, USA. With the objective of standardizing pleural disease care, locally adapted British Thoracic Society guidelines and a centralized pleural service were implemented in the "pathway" era. System-wide consensus regarding institutional guidelines for care of pleural disease was achieved. Preimplementation activities included training, acquisition of ultrasound equipment, and system-wide education. An audit database was set up with the intent of prospective audits. An administrative database was used for harvesting outcomes data and comparing them with the "prior to pathway" era. Results 54 unique consults were performed. A total of 55 ultrasound examinations and 60 pleural procedures were performed. All-cause inpatient pleural admissions were lower in the "pathway" era (n = 9) compared to the "prior to pathway" era (n = 17). Gains in average case charges (21,737$ versus 18,818.2$/case) and average length of stay (3.65 versus 2.78 days/case) were seen in the "pathway" era. Conclusion A "pleural pathway" and a centralized pleural service are associated with reduction in case charges, inpatient admissions, and length of stay for pleural conditions.
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170
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van Hoeve JC, Vernooij RWM, Lawal AK, Fiander M, Nieboer P, Siesling S, Rotter T. Effects of oncological care pathways in primary and secondary care on patient, professional, and health systems outcomes: protocol for a systematic review and meta-analysis. Syst Rev 2018; 7:49. [PMID: 29580293 PMCID: PMC5870525 DOI: 10.1186/s13643-018-0693-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/25/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The high impact of a cancer diagnosis on patients and their families and the increasing costs of cancer treatment call for optimal and efficient oncological care. To improve the quality of care and to minimize healthcare costs and its economic burden, many healthcare organizations introduce care pathways to improve efficiency across the continuum of cancer care. However, there is limited research on the effects of cancer care pathways in different settings. METHODS The aim of this systematic review and meta-analysis described in this protocol is to synthesize existing literature on the effects of oncological care pathways. We will conduct a systematic search strategy to identify all relevant literature in several biomedical databases, including Cochrane library, MEDLINE, Embase, and CINAHL. We will follow the methodology of Cochrane Effective Practice and Organisation of Care (EPOC), and we will include randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies. In addition, we will include full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses), cost analyses, and comparative resource utilization studies, if available. Two reviewers will independently screen all studies and evaluate those included for risk of bias. From these studies, we will extract data regarding patient, professional, and health systems outcomes. Our systematic review will follow the PRISMA set of items for reporting in systematic reviews and meta-analyses. DISCUSSION Following the protocol outlined in this article, we aim to identify, assess, and synthesize all available evidence in order to provide an evidence base on the effects of oncological care pathways as reported in the literature. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017057592 .
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Affiliation(s)
- Jolanda C. van Hoeve
- Department Health Technology and Services Research (HTSR), University of Twente, P.O. Box 217, 7500 AE Enschede, the Netherlands
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Robin W. M. Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Adegboyega K. Lawal
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Michelle Fiander
- College of Pharmacy, Department of Pharmacology, University of Utah, Salt Lake City, USA
| | | | - Sabine Siesling
- Department Health Technology and Services Research (HTSR), University of Twente, P.O. Box 217, 7500 AE Enschede, the Netherlands
- Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB Utrecht, the Netherlands
| | - Thomas Rotter
- Healthcare Quality Programs, School of Nursing, Queen’s University, Kingston, Ontario Canada
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Abstract
Purpose
Each year approximately 3,200 women have a stillbirth in the UK. Although national evidence-based guidance has existed since 2010, case reviews continue to identify suboptimal clinical care and communication with parents. Inconsistencies in management include induction and management of labour and the frequency of investigation after stillbirth. The paper aims to discuss these issues.
Design/methodology/approach
An audit of stillbirths was performed in 2014 in 13 maternity units in the North West of England, this confirmed variation in practice described nationally. An integrated care pathway (ICP) was developed from national guidelines to enable optimal care for the management of stillbirth, reduce variation, standardise investigations and coordinate patient-focussed care. This was launched in 2015 and updated in 2016 to resolve the issues that were apparent after implementation.
Findings
Each participating unit had commenced using the ICP by May 2015. Following implementation there were changes in care, most notably from diverse methods for the induction of labour to guideline-directed induction of labour. There were trends towards better care in terms of information given, choices offered, more appropriate analgesia in labour and improved post-delivery investigation for cause. Staff feedback about the ICP was positive.
Practical implications
The use of this ICP improved care for women who had a stillbirth and their families. Issues with implementing a changed care pathway meant that further iterations were required, ongoing improvement is expected following the refinement of the ICP.
Originality/value
ICPs have been used for various clinical conditions. However, this is the first example of their use in women who had a stillbirth.
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172
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Jennings AA, Foley T, McHugh S, Browne JP, Bradley CP. 'Working away in that Grey Area…' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia. Age Ageing 2018; 47:295-303. [PMID: 29220480 PMCID: PMC6016685 DOI: 10.1093/ageing/afx175] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 10/26/2017] [Indexed: 12/16/2022] Open
Abstract
Background general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs' management decisions; and to identify strategies for overcoming these challenges. Design qualitative study of GPs experiences of managing BPSD. Methods semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs' confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.
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Affiliation(s)
| | - Tony Foley
- Dept. of General Practice, University College Cork, Cork, Ireland
| | - Sheena McHugh
- Dept. of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - John P Browne
- Dept. of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Colin P Bradley
- Dept. of General Practice, University College Cork, Cork, Ireland
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 01/29/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('the LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review. The ensuing debate among clinicians polarised between 'blaming' of the LCP and regret at its removal. Employing the concept of 'boundary objects', we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP 'scandal' demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Krishnan MN, Natesan S, Gopinath R, Viswanathan S, Stigi J, Joseph J, Chozhakkat S, Lloyd-Jones DM, Prabhakaran D. Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial. JAMA 2018; 319:567-578. [PMID: 29450524 PMCID: PMC5838631 DOI: 10.1001/jama.2017.21906] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India. OBJECTIVE To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation. INTERVENTIONS Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome's individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. RESULTS Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevation myocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3% of the intervention participants and 6.4% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09% [95% CI, -1.32% to 1.14%]; adjusted odds ratio, 0.98 [95% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02256657.
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Affiliation(s)
- Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Lihui Zhao
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Mumtaj Ali
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | | | | | | | | | | | | | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, England
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175
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Improving cancer patient emergency room utilization: A New Jersey state assessment. Cancer Epidemiol 2017; 51:15-22. [DOI: 10.1016/j.canep.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 01/07/2023]
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176
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Mertens S, Gailly F, Poels G. Discovering health-care processes using DeciClareMiner. Health Syst (Basingstoke) 2017; 7:195-211. [PMID: 31214348 DOI: 10.1080/20476965.2017.1405876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/09/2017] [Accepted: 11/08/2017] [Indexed: 10/27/2022] Open
Abstract
Flexible, human-centric and knowledge-intensive processes occur in many service industries and are prominent in the health-care sector. Knowledge workers (e.g., doctors or other health-care personnel) are given the flexibility to address each process instance (i.e., episode of care) in the way that they deem most suitable. As a result, the knowledge of these processes is generally of a tacit nature, with many stakeholders lacking a clear view of a process. In this paper, we propose an algorithm called DeciClareMiner that combines process and decision mining to extract a process model and the corresponding knowledge from past executions of these processes. The algorithm was evaluated by applying it to a realistic health-care case and comparing the results to a complete search benchmark. In a relatively short time (10 min), DeciClareMiner was able to produce a DeciClare model that represents 93% of episodes of care with atomic constraints. Compared to the 50 h required to calculate the 100%-episode model via an exhaustive search approach, our result is considered a major improvement.
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Affiliation(s)
- Steven Mertens
- Faculty of Economics and Business Administration, Department of Business Informatics and Operations Management, Ghent University, Ghent, Belgium
| | - Frederik Gailly
- Faculty of Economics and Business Administration, Department of Business Informatics and Operations Management, Ghent University, Ghent, Belgium
| | - Geert Poels
- Faculty of Economics and Business Administration, Department of Business Informatics and Operations Management, Ghent University, Ghent, Belgium
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Rotter T, Plishka C, Hansia MR, Goodridge D, Penz E, Kinsman L, Lawal A, O’Quinn S, Buchan N, Comfort P, Patel P, Anderson S, Winkel T, Lang RL, Marciniuk DD. The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation. BMC Health Serv Res 2017; 17:782. [PMID: 29183318 PMCID: PMC5704544 DOI: 10.1186/s12913-017-2750-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/21/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) has substantial economic and human costs; it is expected to be the third leading cause of death worldwide by 2030. To minimize these costs high quality guidelines have been developed. However, guidelines alone rarely result in meaningful change. One method of integrating guidelines into practice is the use of clinical pathways (CPWs). CPWs bring available evidence to a range of healthcare professionals by detailing the essential steps in care and adapting guidelines to the local context. METHODS/DESIGN We are working with local stakeholders to develop CPWs for COPD with the aims of improving care while reducing utilization. The CPWs will employ several steps including: standardizing diagnostic training, unifying components of chronic disease care, coordinating education and reconditioning programs, and ensuring care uses best practices. Further, we have worked to identify evidence-informed implementation strategies which will be tailored to the local context. We will conduct a three-year research project using an interrupted time series (ITS) design in the form of a multiple baseline approach with control groups. The CPW will be implemented in two health regions (experimental groups) and two health regions will act as controls (control groups). The experimental and control groups will each contain an urban and rural health region. Primary outcomes for the study will be quality of care operationalized using hospital readmission rates and emergency department (ED) presentation rates. Secondary outcomes will be healthcare utilization and guideline adherence, operationalized using hospital admission rates, hospital length of stay and general practitioner (GP) visits. Results will be analyzed using segmented regression analysis. DISCUSSION Funding has been procured from multiple stakeholders. The project has been deemed exempt from ethics review as it is a quality improvement project. Intervention implementation is expected to begin in summer of 2017. This project is expected to improve quality of care and reduce healthcare utilization. In addition it will provide evidence on the effects of CPWs in both urban and rural settings. If the CPWs are found effective we will work with all stakeholders to implement similar CPWs in surrounding health regions. TRIAL REGISTRATION Clinicaltrials.gov ( NCT03075709 ). Registered 8 March 2017.
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Affiliation(s)
- Thomas Rotter
- College of Pharmacy and Nutrition, University of Saskatchewan E3315 Health Sciences Building, 104 Clinic Place, Saskatoon, SK S7N 5E5 Canada
- Healthcare Quality Programs, Queen’s University School of Nursing, Kingston, Canada
| | - Christopher Plishka
- College of Pharmacy and Nutrition, University of Saskatchewan E3315 Health Sciences Building, 104 Clinic Place, Saskatoon, SK S7N 5E5 Canada
| | | | - Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
- University of Saskatchewan Respiratory Research Centre, Saskatoon, Canada
| | - Erika Penz
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Leigh Kinsman
- University of Tasmania and Tasmanian Health Organisation (North), Launceston, TAS Australia
| | - Adegboyega Lawal
- College of Pharmacy and Nutrition, University of Saskatchewan E3315 Health Sciences Building, 104 Clinic Place, Saskatoon, SK S7N 5E5 Canada
| | | | | | | | | | | | | | | | - Darcy D. Marciniuk
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
- University of Saskatchewan Respiratory Research Centre, Saskatoon, Canada
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Siouta N, Van Beek K, Payne S, Radbruch L, Preston N, Hasselaar J, Centeno C, Menten J. Is the content of guidelines/pathways a barrier for the integration of palliative Care in Chronic Heart Failure (CHF) and chronic pulmonary obstructive disease (COPD)? A comparison with the case of cancer in Europe. BMC Palliat Care 2017; 16:62. [PMID: 29179703 PMCID: PMC5704525 DOI: 10.1186/s12904-017-0243-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a notable inequity in access to palliative care (PC) services between cancer and Chronic Heart Failure (CHF)/Chronic Obstructive Pulmonary Disease (COPD) patients which also translates into discrepancies in the level of integration of PC. By cross-examining the levels of PC integration in published guidelines/pathways for CHF/COPD and cancer in Europe, this study examines whether these discrepancies may be attributed to the content of the guidelines. DESIGN A quantitative evaluation was made between integrated PC in published guidelines for cancer and CHF/COPD in Europe. The content of integrated PC in guidelines/pathways was measured using an 11 point integrated PC criteria tool (IPC criteria). A statistical analysis was carried out to detect similarities and differences in the level of integrated PC between the two groups. RESULTS The levels of integration between CHF/COPD and cancer guidelines/pathways have been shown to be statistically similar. Moreover, the quality of evidence utilized and the date of development of the guidelines/pathways appear not to impact upon the PC integration in the guidelines. CONCLUSION In Europe, the empirically observed imbalance in integration of PC for patients with cancer and CHF/COPD may only partially be attributed to the content of the guidelines/pathways that are utilized for the PC implementation. Given the similarities detected between cancer and CHF/COPD, other barriers appear to play a more prominent role.
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Affiliation(s)
- Naouma Siouta
- Dept. of Radiation-Oncology and Palliative Medicine, KU Leuven, Leuven, Belgium
| | - Karen Van Beek
- Dept. of Radiation-Oncology and Palliative Medicine, University Hospital Gasthuisberg, Leuven, Belgium
| | - Sheila Payne
- International Observatory on End of Life Care Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital of Bonn, Bonn, Germany
| | - Nancy Preston
- International Observatory on End of Life Care Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Jeroen Hasselaar
- Anesthesiology, Pain and Palliative Care, UMC St Radboud, Nijmegen, The Netherlands
| | - Carlos Centeno
- Institute for Culture and Society, University of Navarra, Pamplona, Spain
| | - Johan Menten
- Dept. of Radiation-Oncology and Palliative Medicine, University Hospital Gasthuisberg, Leuven, Belgium
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Minué-Lorenzo S, Fernández-Aguilar C. [Critical view and argumentation on chronic care programs in Primary and Community Care]. Aten Primaria 2017; 50:114-129. [PMID: 29174714 PMCID: PMC6836966 DOI: 10.1016/j.aprim.2017.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/27/2017] [Indexed: 11/17/2022] Open
Abstract
El análisis detallado de los planes de atención a la cronicidad desarrollados por los servicios regionales de salud pone de manifiesto un sorprendente nivel de uniformidad en su diseño y despliegue, a pesar de las diferencias existentes entre dichos servicios. La revisión de la literatura sobre los modelos teóricos que lo sustentan y los instrumentos que lo desarrollan no aporta evidencias concluyentes que permitan afirmar que los modelos de atención a pacientes crónicos alcanzan mejores resultados que modelos de atención alternativos. A pesar de que todos los planes de atención a la cronicidad incluyen sistemas de evaluación de los mismos, no se han publicado hasta la fecha estudios rigurosos sobre su efecto. Dado que, por el contrario, sí existen pruebas sólidas y reiteradas de que modelos con una Atención Primaria fuerte obtienen mejores resultados, cabe preguntarse sobre la necesidad de buscar modelos alternativos, cuando las metas propuestas probablemente podrían alcanzarse de fortalecer realmente la Atención Primaria.
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Affiliation(s)
- Sergio Minué-Lorenzo
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre, Escuela Andaluza de Salud Pública, Granada, España.
| | - Carmen Fernández-Aguilar
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre, Escuela Andaluza de Salud Pública, Granada, España
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Sanei-Moghaddam A, Goughnour S, Edwards R, Comerci J, Kelley J, Donnellan N, Linkov F, Mansuria S. Hysterectomy Pathway as the Global Engine of Practice Change: Implications for Value in Care. Cent Asian J Glob Health 2017; 6:299. [PMID: 29138742 DOI: 10.5195/cajgh.2017.299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Introduction In 2012, University of Pittsburgh Medical Center (UPMC) introduced a hysterectomy clinical pathway to reduce the number of total abdominal hysterectomies performed for benign gynecological indications. This study focused on exploring physician and patient factors impacting the utilization of hysterectomy clinical pathways. Methods An online survey with 24 questions was implemented to explore physicians' attitudes and perceived barriers toward implementing the pathway. A survey consisting of 27 questions was developed for patients to determine the utility of a pathway-based educational tool for making surgery decisions and to measure satisfaction with the information provided. Descriptive statistics were used to describe survey results, while thematic analysis was performed on verbal feedback submitted by respondents. Results Physician respondents found the clinical pathway to be practical, beneficial to patients, and up-to-date with the latest evidence-based literature. Key barriers to the use of the pathway that were identified by physicians included perceived waste of time, inappropriateness for some of the patient groups, improper incentive structure, and excessive bureaucracy surrounding the process. Overall, patient respondents were satisfied with the tool and found it to be helpful with the decision-making process of choosing a hysterectomy route. Conclusions Physicians and patients found the developed tools to be practical and beneficial. Findings of this study will help to use pathways as a unifying framework to shape future care of patients needing hysterectomy and add value to their care.
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Affiliation(s)
- Amin Sanei-Moghaddam
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Sharon Goughnour
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Robert Edwards
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Hospital
| | - John Comerci
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Hospital
| | - Joseph Kelley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Hospital
| | - Nicole Donnellan
- Divisions of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Hospital
| | - Faina Linkov
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Suketu Mansuria
- Divisions of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Hospital
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Abstract
Introduction There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact. Methods Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake. Results Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators. Conclusions Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.
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Holderried M, Hummel R, Falch C, Kirschniak A, Koenigsrainer A, Ernst C, Muller S. Compliance of Clinical Pathways in Elective Laparoscopic Cholecystectomy: Evaluation of Different Implementation Methods. World J Surg 2017; 40:2888-2891. [PMID: 27431317 DOI: 10.1007/s00268-016-3645-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Clinical pathways aim to standardize perioperative and postoperative care of surgical procedures and are shown to result in a significant optimization associated with cost reduction. The aim of this study was to establish the impact of two different implementations forms of clinical pathways on the pathway compliance and resulting costs. METHODS Data of patients undergoing elective cholecystectomy for symptomatic cholecystolithiasis were collected over two different periods: using a clinical pathway in the form of a paper-based checklist, or a clinical pathway integrated into the paper-based medical treatment and nursing documentation. Outcome measures were compliance of the clinical pathway and total costs per case. RESULTS The compliance was significantly higher using integrated pathways compared to paper-based checklists (n = 117 of 123, 95 % vs 54 of 118, 46 %; p < 0.001). Mean total costs (€2206 vs €2458, p = 0.027) and length of hospital stay (2.13 vs 2.77 days, p < 0.001) were significantly reduced by the integrated clinical pathway compared to checklists. Further, the variation of costs per case and variation of length of hospital stay were significantly smaller with integrated clinical pathway (±€440 vs ±€538, p = 0.039 and ±0.53 vs ±0.68 days, p < 0.001, respectively). No difference regarding postoperative complication was observed (n = 3 vs. 4 events; p = 0.67). CONCLUSION Integrated clinical pathways display a significant higher compliance compared to checklists resulting in reduced total costs, shorter hospital stay and a smaller variation of cost, making it a useful tool in process controlling and planning.
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Affiliation(s)
- Martin Holderried
- Department of Quality Management, Medical and Business Development, Tuebingen University Hospital, Tübingen, Germany.,Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Rebecca Hummel
- Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Claudius Falch
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Andreas Kirschniak
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Alfred Koenigsrainer
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany
| | - Christian Ernst
- Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany
| | - Sven Muller
- Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Waldhörnlestrasse 22, 72076, Tübingen, Germany. .,Division of Economics and Management of Social Services, within the Institute of Health Care and Public Management, Hohenheim University, Stuttgart, Germany.
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Ronellenfitsch U, Böckler D, Schwarzbach M. Klinische Pfade zum Prozessmanagement in der Gefäßchirurgie. GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00772-017-0317-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011083. [PMID: 28901005 PMCID: PMC5621087 DOI: 10.1002/14651858.cd011083.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions. AUTHORS' CONCLUSIONS A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | | | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Lilian Dudley
- Stellenbosch UniversityDivision of Community Health, Faculty of Medicine and Health SciencesFransie Van Zyl DriveTygerbergCape TownSouth Africa7505
| | - Signe Flottorp
- Norwegian Institute of Public HealthDepartment for Evidence SynthesisPO Box 4404 NydalenOsloNorway0403
| | - Marie‐Pierre Gagnon
- CHU de Québec ‐ Université Laval Research CentrePopulation Health and Optimal Health Practices Research Unit10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Claire Glenton
- Norwegian Institute of Public HealthGlobal Health UnitPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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Seys D, Bruyneel L, Deneckere S, Kul S, Van der Veken L, van Zelm R, Sermeus W, Panella M, Vanhaecht K. Better organized care via care pathways: A multicenter study. PLoS One 2017; 12:e0180398. [PMID: 28672030 PMCID: PMC5495424 DOI: 10.1371/journal.pone.0180398] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 06/15/2017] [Indexed: 11/18/2022] Open
Abstract
An increased need for efficiency and effectiveness in today’s healthcare system urges professionals to improve the organization of care. Care pathways are an important tool to achieve this. The overall aim of this study was to analyze if care pathways lead to better organization of care processes. For this, the Care Process Self-Evaluation tool (CPSET) was used to evaluate how healthcare professionals perceive the organization of care processes. Based on information from 2692 health care professionals gathered between November 2007 and October 2011 we audited 261 care processes in 108 organizations. Multilevel analysis was used to compare care processes without and with care pathways and analyze if care pathways led to better organization of care processes. A significant difference between care processes with and without care pathways was found. A care pathway in use led to significant better scores on the overall CPSET scale (p<0.001) and its subscales, “coordination of care” (p<0.001) and “follow-up of care” (p<0.001). Physicians had the highest score on the overall CPSET scale and the five subscales. Care processes organized by care pathways had a 2.6 times higher probability that the care process was well-organized. In around 75% of the cases a care pathway led to better organized care processes. Care processes supported by care pathways were better organized, but not all care pathways were well-organized. Managers can use care pathways to make healthcare professionals more aware of their role in the organization of the care process.
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Affiliation(s)
- Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, UZ Leuven, Leuven, Belgium
| | - Svin Deneckere
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Medical Department, Delta Hospitals Roeselare, Roeselare, Belgium
| | - Seval Kul
- Department of Biostatistics, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Liz Van der Veken
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ruben van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Q Consult, Utrecht, The Netherlands
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont 'A. Avogadro', Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, UZ Leuven, Leuven, Belgium
- * E-mail:
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Röthlisberger F, Boes S, Rubinelli S, Schmitt K, Scheel-Sailer A. Challenges and potential improvements in the admission process of patients with spinal cord injury in a specialized rehabilitation clinic - an interview based qualitative study of an interdisciplinary team. BMC Health Serv Res 2017. [PMID: 28651583 PMCID: PMC5485498 DOI: 10.1186/s12913-017-2399-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The admission process of patients to a hospital is the starting point for inpatient services. In order to optimize the quality of the health services provision, one needs a good understanding of the patient admission workflow in a clinic. The aim of this study was to identify challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic from the perspective of an interdisciplinary team of health professionals. Methods Semi-structured interviews with eight health professionals (medical doctors, physical therapists, occupational therapists, nurses) at the Swiss Paraplegic Centre (acute and rehabilitation clinic) were conducted based on a maximum variety purposive sampling strategy. The interviews were analyzed using a thematic analysis approach. Results The interviewees described the challenges and potential improvements in this admission process, focusing on five themes. First, the characteristics of the patient with his/her health condition and personality and his/her family influence different areas in the admission process. Improvements in the exchange of information between the hospital and the patient could speed up and simplify the admission process. In addition, challenges and potential improvements were found concerning the rehabilitation planning, the organization of the admission process and the interdisciplinary work. Conclusion This study identified five themes of challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic. When planning adaptations of process steps in one of the areas, awareness of effects in other fields is necessary. Improved pre-admission information would be a first important step to optimize the admission process. A common IT-system providing an interdisciplinary overview and possibilities for interdisciplinary exchange would support the management of the admission process. Managers of other hospitals can supplement the results of this study with their own process analyses, to improve their own patient admission processes. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2399-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fabian Röthlisberger
- Swiss Paraplegic Centre (SPC), Guido Zäch Strasse 1, 6207, Nottwil, Switzerland.,Department of Health Sciences and Health Policy, University of Lucerne, Frohburgstrasse 3, 6002, Lucerne, Switzerland.,Inselspital Bern, 3010, Berne, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Health Policy, University of Lucerne, Frohburgstrasse 3, 6002, Lucerne, Switzerland
| | - Sara Rubinelli
- Department of Health Sciences and Health Policy, University of Lucerne, Frohburgstrasse 3, 6002, Lucerne, Switzerland.,Swiss Paraplegic Research (SPF), Guido Zäch Strasse 4, 6207, Nottwil, Switzerland
| | - Klaus Schmitt
- Swiss Paraplegic Centre (SPC), Guido Zäch Strasse 1, 6207, Nottwil, Switzerland.,Swiss Paraplegic Centre, Corporate Development, Guido Zäch Strasse 1, 6207, Nottwil, Switzerland
| | - Anke Scheel-Sailer
- Swiss Paraplegic Centre (SPC), Guido Zäch Strasse 1, 6207, Nottwil, Switzerland. .,Department of Health Sciences and Health Policy, University of Lucerne, Frohburgstrasse 3, 6002, Lucerne, Switzerland.
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Vrijhoef HJ, de Belvis AG, de la Calle M, de Sabata MS, Hauck B, Montante S, Moritz A, Pelizzola D, Saraheimo M, Guldemond NA. IT-supported integrated care pathways for diabetes: A compilation and review of good practices. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017; 20:26-40. [PMID: 28690856 PMCID: PMC5476194 DOI: 10.1177/2053434517714427] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction Integrated Care Pathways (ICPs) are a method for the mutual decision-making and organization of care for a well-defined group of patients during a well-defined period. The aim of a care pathway is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To describe this concept, different names are used, e.g. care pathways and integrated care pathways. Modern information technologies (IT) can support ICPs by enabling patient empowerment, better management, and the monitoring of care provided by multidisciplinary teams. This study analyses ICPs across Europe, identifying commonalities and success factors to establish good practices for IT-supported ICPs in diabetes care. Methods A mixed-method approach was applied, combining desk research on 24 projects from the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) with follow-up interviews of project participants, and a non-systematic literature review. We applied a Delphi technique to select process and outcome indicators, derived from different literature sources which were compiled and applied for the identification of successful good practices. Results Desk research identified sixteen projects featuring IT-supported ICPs, mostly derived from the EIP on AHA, as good practices based on our criteria. Follow-up interviews were then conducted with representatives from 9 of the 16 projects to gather information not publicly available and understand how these projects were meeting the identified criteria. In parallel, the non-systematic literature review of 434 PubMed search results revealed a total of eight relevant projects. On the basis of the selected EIP on AHA project data and non-systematic literature review, no commonalities with regard to defined process or outcome indicators could be identified through our approach. Conversely, the research produced a heterogeneous picture in all aspects of the projects’ indicators. Data from desk research and follow-up interviews partly lacked information on outcome and performance, which limited the comparison between practices. Conclusion Applying a comprehensive set of indicators in a multi-method approach to assess the projects included in this research study did not reveal any obvious commonalities which might serve as a blueprint for future IT-supported ICP projects. Instead, an unexpected high degree of heterogeneity was observed, that may reflect diverse local implementation requirements e.g. specificities of the local healthcare system, local regulations, or preexisting structures used for the project setup. Improving the definition of and reporting on project outcomes could help advance research on and implementation of effective integrated care solutions for chronic disease management across Europe.
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Affiliation(s)
- Hubertus Jm Vrijhoef
- Department of Patient & Care, Maastricht University Medical Center, The Netherlands.,Vrije Universiteit Brussels, Belgium.,Panaxea b.v., Amsterdam, The Netherlands
| | | | | | | | | | - Sabrina Montante
- Fondazione Policlinico A. Gemelli - Università Cattolica S. Cuore, Italy
| | | | | | | | - Nick A Guldemond
- Institute of Health Policy & Management, Department of Health Services Management & Organisation, Erasmus University Rotterdam, The Netherlands
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Kaiser SV, Rodean J, Bekmezian A, Hall M, Shah SS, Mahant S, Parikh K, Morse R, Puls H, Cabana MD. Rising utilization of inpatient pediatric asthma pathways. J Asthma 2017; 55:196-207. [PMID: 28521558 DOI: 10.1080/02770903.2017.1316392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally. OBJECTIVES (1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways. METHODS We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables). RESULTS Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05). CONCLUSIONS From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.
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Affiliation(s)
- Sunitha V Kaiser
- a Department of Pediatrics , University of California , San Francisco , CA , USA
| | - Jonathan Rodean
- b Department of Data Analytics and Research , Children's Hospital Association , Lenexa , KS , USA
| | - Arpi Bekmezian
- a Department of Pediatrics , University of California , San Francisco , CA , USA
| | - Matt Hall
- b Department of Data Analytics and Research , Children's Hospital Association , Lenexa , KS , USA
| | - Samir S Shah
- c Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
| | - Sanjay Mahant
- d Division of Paediatric Medicine, Department of Paediatrics , Hospital for Sick Children Research Institute, University of Toronto , Toronto , ON , Canada
| | - Kavita Parikh
- e Department of Pediatrics , George Washington University , Washington, DC , USA
| | - Rustin Morse
- f Department of Pediatrics , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Henry Puls
- g Department of Pediatrics , Children's Mercy Hospital , Kansas City , MO , USA
| | - Michael D Cabana
- a Department of Pediatrics , University of California , San Francisco , CA , USA
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Adjemian R, Zirkohi AM, Coombs R, Mickan S, Vaillancourt C. Validation of descriptive clinical pathway criteria in the systematic identification of publications in emergency medicine. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517707971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Heterogeneity in both the definition and terminology of clinical pathways presents a challenge to the systematic identification of primary studies for review purposes. Recently developed clinical pathway identification criteria may facilitate both the identification and assessment of clinical pathway studies. The goal of this publication is the validation of these five criteria in a descriptive systematic review of actively implemented clinical pathway studies in the emergency department setting. The main outcome measure is the inter-rater agreement of investigators using the clinical pathway criteria. Methods We performed a systematic literature search from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. We identified relevant publications using the above-mentioned clinical pathway criteria. Two reviewers independently collected data using a piloted data abstraction tool. Results We identified 5947 publications, with 472 potentially relevant full text publications retrieved. Of these, 357 did not meet preliminary study inclusion criteria, leaving 115 publications where the clinical pathway criteria were applied. Ultimately, 44 publications were included. The inter-rater agreement of the criteria was very good (κ = 0.81, 95% Confidence Interval = 0.70–0.92). The vast majority of studies were excluded because the intervention did not meet the criterion of being multidisciplinary in nature. Conclusion These criteria are a useful instrument to reliably identify clinical pathway publications for systematic review purposes in an emergency department setting. Future modification of these criteria may improve their usefulness. Particular attention should be placed on clarifying what is meant by multidisciplinary involvement within the context of clinical pathway interventions, with specific emphasis placed on delineating the level of involvement of each discipline and their decision-making responsibility.
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Affiliation(s)
| | | | | | - Sharon Mickan
- University of Oxford, UK
- Griffith University, Australia
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190
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Yin L, Huang Z, Dong W, He C, Duan H. Utilizing Electronic Medical Records to Discover Changing Trends of Medical Behaviors Over Time. Methods Inf Med 2017; 56:e49-e66. [PMID: 28474729 PMCID: PMC5435874 DOI: 10.3414/me16-01-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 12/12/2016] [Indexed: 12/31/2022]
Abstract
Objectives Medical behaviors are playing significant roles in the delivery of high quality and cost-effective health services. Timely discovery of changing frequencies of medical behaviors is beneficial for the improvement of health services. The main objective of this work is to discover the changing trends of medical behaviors over time. Methods This study proposes a two-steps approach to detect essential changing patterns of medical behaviors from Electronic Medical Records (EMRs). In detail, a probabilistic topic model, i.e., Latent Dirichlet allocation (LDA), is firstly applied to disclose yearly treatment patterns in regard to the risk stratification of patients from a large volume of EMRs. After that, the changing trends by comparing essential/critical medical behaviors in a specific time period are detected and analyzed, including changes of significant patient features with their values, and changes of critical treatment interventions with their occurring time stamps. Results We verify the effectiveness of the proposed approach on a clinical dataset containing 12,152 patient cases with a time range of 10 years. Totally, 135 patients features and 234 treatment interventions in three treatment patterns were selected to detect their changing trends. In particular, evolving trends of yearly occurring probabilities of the selected medical behaviors were categorized into six content changing patterns (i.e, 112 growing, 123 declining, 43 up-down, 16 down-up, 35 steady, and 40 jumping), using the proposed approach. Besides, changing trends of execution time of treatment interventions were classified into three occurring time changing patterns (i.e., 175 early-implemented, 50 steady-implemented and 9 delay-implemented). Conclusions Experimental results show that our approach has an ability to utilize EMRs to discover essential evolving trends of medical behaviors, and thus provide significant potential to be further explored for health services redesign and improvement.
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Affiliation(s)
| | - Zhengxing Huang
- Zhengxing Huang, College of Biomedical Engineering and Instrument Science, Zhejiang University, Zhou Yiqin building 510, Zheda road 38#, Hangzhou 310008, China, E-mail:
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Elliott MJ, Gil S, Hemmelgarn BR, Manns BJ, Tonelli M, Jun M, Donald M. A scoping review of adult chronic kidney disease clinical pathways for primary care. Nephrol Dial Transplant 2017; 32:838-846. [PMID: 27257274 PMCID: PMC5837585 DOI: 10.1093/ndt/gfw208] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/15/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) affects ∼10% of the adult population. The majority of patients with CKD are managed by primary care physicians, and despite the availability of effective treatment options, the use of evidence-based interventions for CKD in this setting remains suboptimal. Clinical pathways have been identified as effective tools to guide primary care physicians in providing evidence-based care. We aimed to describe the availability, characteristics and credibility of clinical pathways for adult CKD using a scoping review methodology. METHODS We searched Medline, Embase, CINAHL and targeted Internet sites from inception to 31 October 2014 to identify studies and resources that identified adult CKD clinical pathways for primary care settings. Study selection and data extraction were independently performed by two reviewers. RESULTS From 487 citations, 41 items were eligible for review: 7 published articles and 34 grey literature resources published between 2001 and 2014. Of the 41 clinical pathways, 32, 24 and 22% were from the UK, USA and Canada, respectively. The majority (66%, n = 31) of clinical pathways were static in nature (did not have an online interactive feature). The majority (76%) of articles/resources reported using one or more clinical practice guidelines as a resource to guide the clinical pathway content. Few articles described a dissemination and evaluation plan for the clinical pathway, but most reported the targeted end-users. CONCLUSIONS Our scoping review synthesized available literature on CKD clinical pathways in the primary care setting. We found that existing clinical pathways are diverse in their design, content and implementation. These results can be used by researchers developing or testing new or existing clinical pathways and by practitioners and health system stakeholders who aim to implement CKD clinical pathways in clinical practice.
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Affiliation(s)
- Meghan J. Elliott
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sarah Gil
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
- Interdisciplinary Chronic Disease Collaboration, Calgary, AB, Canada T2N 4Z6
| | - Brenda R. Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
- Interdisciplinary Chronic Disease Collaboration, Calgary, AB, Canada T2N 4Z6
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Braden J. Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
- Interdisciplinary Chronic Disease Collaboration, Calgary, AB, Canada T2N 4Z6
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
- Interdisciplinary Chronic Disease Collaboration, Calgary, AB, Canada T2N 4Z6
| | - Min Jun
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada T2N 4N1
- Interdisciplinary Chronic Disease Collaboration, Calgary, AB, Canada T2N 4Z6
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Hoffmann-Eßer W, Siering U, Neugebauer EAM, Brockhaus AC, Lampert U, Eikermann M. Guideline appraisal with AGREE II: Systematic review of the current evidence on how users handle the 2 overall assessments. PLoS One 2017; 12:e0174831. [PMID: 28358870 PMCID: PMC5373625 DOI: 10.1371/journal.pone.0174831] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/15/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument is the most commonly used guideline appraisal tool. It includes 23 appraisal criteria (items) organized within 6 domains and 2 overall assessments (1. overall guideline quality; 2. recommendation for use). The aim of this systematic review was twofold. Firstly, to investigate how often AGREE II users conduct the 2 overall assessments. Secondly, to investigate the influence of the 6 domain scores on each of the 2 overall assessments. MATERIALS AND METHODS A systematic bibliographic search was conducted for publications reporting guideline appraisals with AGREE II. The impact of the 6 domain scores on the overall assessment of guideline quality was examined using a multiple linear regression model. Their impact on the recommendation for use (possible answers: "yes", "yes, with modifications", "no") was examined using a multinomial regression model. RESULTS 118 relevant publications including 1453 guidelines were identified. 77.1% of the publications reported results for at least one overall assessment, but only 32.2% reported results for both overall assessments. The results of the regression analyses showed a statistically significant influence of all domains on overall guideline quality, with Domain 3 (rigour of development) having the strongest influence. For the recommendation for use, the results showed a significant influence of Domains 3 to 5 ("yes" vs. "no") and Domains 3 and 5 ("yes, with modifications" vs. "no"). CONCLUSIONS The 2 overall assessments of AGREE II are underreported by guideline assessors. Domains 3 and 5 have the strongest influence on the results of the 2 overall assessments, while the other domains have a varying influence. Within a normative approach, our findings could be used as guidance for weighting individual domains in AGREE II to make the overall assessments more objective. Alternatively, a stronger content analysis of the individual domains could clarify their importance in terms of guideline quality. Moreover, AGREE II should require users to transparently present how they conducted the assessments.
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Affiliation(s)
- Wiebke Hoffmann-Eßer
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne, Cologne, Germany
| | - Ulrich Siering
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Edmund A. M. Neugebauer
- Brandenburg Medical School – Theodor Fontane Neuruppin, Germany & University of Witten/Herdecke, Witten/Herdecke, Germany
| | | | - Ulrike Lampert
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Michaela Eikermann
- Medical Advisory Service of the German Social Health Insurance (MDS), Essen, Germany
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Ma J, Yan HY, Yang YH. Clinical effects of clinical nursing pathway for acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2017; 25:816-821. [DOI: 10.11569/wcjd.v25.i9.816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of clinical nursing pathway for acute pancreatitis (AP).
METHODS One hundred and sixty patients with AP treated at our hospital from January 2015 to December 2016 were enrolled in this study. The patients were randomly divided into either an observation group or a control group, with 80 cases in each group. Clinical nursing pathway was used in the observation group, while conventional nursing care was used in the control group. Clinical symptoms, length of hospital stay, and adverse effects were compared between the two groups.
RESULTS The duration of stomach ache and abdominal distention was significantly shorter in the observation group than in the control group (6.02 d ± 4.23 d vs 8.56 d ± 5.33 d, t = 3.308, P = 0.001; 6.78 d ± 4.21 d vs 9.67 d ± 5.92 d, t = 3.558, P < 0.001). The length of hospital stay was significantly shorter in the observation group than in the control group (27.50 d ± 9.32 d vs 34.45 d ± 12.72 d, t = 3.942, P < 0.001). The rate of adverse effects such as esophageal mucosal injury, lower limb vein thrombosis, and lung infection was significantly lower in the observation group than in the control group.
CONCLUSION Clinical nursing pathway can promote the rehabilitation of AP and reduce adverse effect and negative emotion.
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Cogen JD, Oron AP, Gibson RL, Hoffman LR, Kronman MP, Ong T, Rosenfeld M. Characterization of Inpatient Cystic Fibrosis Pulmonary Exacerbations. Pediatrics 2017; 139:peds.2016-2642. [PMID: 28126911 PMCID: PMC5472380 DOI: 10.1542/peds.2016-2642] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pulmonary exacerbations lead to significant morbidity and mortality in patients with cystic fibrosis (CF). National consensus guidelines exist, but few studies report current practice in the treatment and monitoring of pulmonary exacerbations. The goal of this study was to characterize consistency and variability in the inpatient management of CF-related pulmonary exacerbations. We focused on the use of guideline-recommended maintenance therapies, antibiotic selection and treatment regimens, use of systemic corticosteroids, and frequency of lung function testing. We hypothesized that significant variability in these treatment practices exists nationally. METHODS This trial was a retrospective cross-sectional study. It included patients with CF aged ≤18 years hospitalized for pulmonary exacerbations between July 1, 2010, and June 30, 2015, at hospitals within the US Pediatric Health Information System database that are also Cystic Fibrosis Foundation-accredited care centers. One exacerbation per patient was randomly selected over the 5-year study period. RESULTS From 38 hospitals, 4827 individual pulmonary exacerbations were examined. Median length of stay was 10.0 days (interquartile range, 6-14.0 days). Significant variation was seen among centers in the use of hypertonic saline (11%-100%), azithromycin (5%-83%), and systemic corticosteroids (3%-61%) and in the frequency of lung function testing. Four different admission antibiotic regimens were used >10% of the time, and the most commonly used admission antibiotic regimen comprised 2 intravenous antibiotics with no additional oral or inhaled antibiotics (29%). CONCLUSIONS Significant variation exists in the treatment and monitoring of pulmonary exacerbations across Pediatric Health Information System-participating, Cystic Fibrosis Foundation-accredited care centers. Results from this study can inform future research working toward standardized inpatient pulmonary exacerbation management to improve CF care for children and adolescents.
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Affiliation(s)
- Jonathan D. Cogen
- Divisions of Pulmonary Medicine and Sleep Medicine and,Address correspondence to Jonathan D. Cogen, MD, MPH, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105. E-mail:
| | - Assaf P. Oron
- Core for Biomedical Statistics, Center for Clinical & Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Matthew P. Kronman
- Infectious Diseases, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and
| | - Thida Ong
- Divisions of Pulmonary Medicine and Sleep Medicine and
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Wiese A, Kilty C, Bergin C, Flood P, Fu N, Horgan M, Higgins A, Maher B, O'Kane G, Prihodova L, Slattery D, Bennett D. Protocol for a realist review of workplace learning in postgraduate medical education and training. Syst Rev 2017; 6:10. [PMID: 28103925 PMCID: PMC5244579 DOI: 10.1186/s13643-017-0415-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postgraduate medical education and training (PGMET) is a complex social process which happens predominantly during the delivery of patient care. The clinical learning environment (CLE), the context for PGMET, shapes the development of the doctors who learn and work within it, ultimately impacting the quality and safety of patient care. Clinical workplaces are complex, dynamic systems in which learning emerges from non-linear interactions within a network of related factors and activities. Those tasked with the design and delivery of postgraduate medical education and training need to understand the relationship between the processes of medical workplace learning and these contextual elements in order to optimise conditions for learning. We propose to conduct a realist synthesis of the literature to address the overarching questions; how, why and in what circumstances do doctors learn in clinical environments? This review is part of a funded projected with the overall aim of producing guidelines and recommendations for the design of high quality clinical learning environments for postgraduate medical education and training. METHODS We have chosen realist synthesis as a methodology because of its suitability for researching complexity and producing answers useful to policymakers and practitioners. This realist synthesis will follow the steps and procedures outlined by Wong et al. in the RAMESES Publication Standards for Realist Synthesis and the Realist Synthesis RAMESES Training Materials. The core research team is a multi-disciplinary group of researchers, clinicians and health professions educators. The wider research group includes experts in organisational behaviour and human resources management as well as the key stakeholders; doctors in training, patient representatives and providers of PGMET. DISCUSSION This study will draw from the published literature and programme, and substantive, theories of workplace learning, to describe context, mechanism and outcome configurations for PGMET. This information will be useful to policymakers and practitioners in PGMET, who will be able to apply our findings within their own contexts. Improving the quality of clinical learning environments can improve the performance, humanism and wellbeing of learners and improve the quality and safety of patient care. SYSTEMATIC REVIEW REGISTRATION The review is not registered with the PROSPERO International Prospective Register of Systematic Reviews as the review objectives relate solely to education outcomes.
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Affiliation(s)
- Anel Wiese
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Caroline Kilty
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | | | - Patrick Flood
- Dublin City University Business School, Dublin, Ireland
| | - Na Fu
- Trinity College Dublin Business School, Dublin, Ireland
| | - Mary Horgan
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Agnes Higgins
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Bridget Maher
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | | | | | | | - Deirdre Bennett
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland.
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Peebles R, Lesser A, Park CC, Heckert K, Timko CA, Lantzouni E, Liebman R, Weaver L. Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders. J Eat Disord 2017; 5:7. [PMID: 28265411 PMCID: PMC5331684 DOI: 10.1186/s40337-017-0134-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/26/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Medical stabilization through inpatient nutritional rehabilitation is often necessary for patients with eating disorders (EDs) but includes the inherent risk of refeeding syndrome. Here we describe our experience of implementing and sustaining an inpatient nutritional rehabilitation protocol designed to strategically prepare patients with EDs and their families for discharge to a home setting in an efficient and effective manner from a general adolescent medicine unit. We report outcomes at admission, discharge, and 4-weeks follow-up. METHODS Protocol development, implementation, and unique features of the protocol, are described. Data were collected retrospectively as part of a continuous quality improvement (QI) initiative. Safety outcomes were the clinical need for phosphorus, potassium, and magnesium supplementation, other evidence of refeeding syndrome, and unexpected readmissions within one month of discharge. The value outcome was length of stay (LOS). Treatment outcomes were the percentage median BMI (MBMI) change from admission to discharge, and from discharge to 4-weeks follow-up visit. RESULTS A total of 215 patients (88% F, 12% M) were included. Patients averaged 15.3 years old (5.8-23.2y); 64% had AN, 18% had atypical anorexia (AtAN), 6% bulimia nervosa (BN), 5% purging disorder (PD), 4% avoidant-restrictive food intake disorder (ARFID), and 3% had an unspecified food and eating disorder (UFED). Average LOS was 11 days. Initial mean calorie level for patients at admission was 1466 and at discharge 3800 kcals/day. Phosphorus supplementation for refeeding hypophosphatemia (RH) was needed in 14% of inpatients; full-threshold refeeding syndrome did not occur. Only 3.8% were rehospitalized in the thirty days after discharge. Patients averaged 86.1% of a median MBMI for age and gender, 91.4% MBMI at discharge, and 100.9% MBMI at 4-weeks follow-up. Mean percentage MBMI differences between time points were significantly different (admission-discharge: 5.3%, p <0.001; discharge-follow-up: 9.2%, p <0.001). CONCLUSIONS Implementation of the CHOP inpatient nutritional rehabilitation protocol aimed at rapid, efficient, and safe weight gain and integration of caregivers in treatment of patients with diverse ED diagnoses led to excellent QI outcomes in percentage MBMI at discharge and 4-weeks follow-up, while maintaining a short LOS and low rates of RH phosphorus supplementation.
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Affiliation(s)
- Rebecka Peebles
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.,The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA
| | - Andrew Lesser
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA
| | - Courtney Cheek Park
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA
| | - Kerri Heckert
- The Children's Hospital of Philadelphia, Department of Clinical Nutrition, Philadelphia, Pennsylvania USA
| | - C Alix Timko
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
| | - Eleni Lantzouni
- The Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, Philadelphia, Pennsylvania USA.,The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA
| | - Ronald Liebman
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
| | - Laurel Weaver
- The University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania USA.,The Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Philadelphia, Pennsylvania USA
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Vanhaecht K, Lodewijckx C, Sermeus W, Decramer M, Deneckere S, Leigheb F, Boto P, Kul S, Seys D, Panella M. Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial. Int J Chron Obstruct Pulmon Dis 2016; 11:2897-2908. [PMID: 27920516 PMCID: PMC5126002 DOI: 10.2147/copd.s119849] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate. Secondary outcomes were the 30 days readmission rate, mortality, length of stay and adherence to guidelines. PATIENTS AND METHODS An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation. RESULTS Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6 months readmission rate. However, the 30 days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222-0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%). CONCLUSION The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6 months readmission rate, but it significantly reduces the 30 days readmission rate.
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Affiliation(s)
- Kris Vanhaecht
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Department of Quality Management, University Hospitals Leuven
| | - Cathy Lodewijckx
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Walter Sermeus
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Marc Decramer
- Department of Clinical and Experimental Medicine, KU Leuven - University of Leuven; University Hospitals Leuven, Leuven
| | - Svin Deneckere
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Medical Department, Delta Hospitals Roeselare, Roeselare, Belgium
| | - Fabrizio Leigheb
- Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
| | - Paulo Boto
- Department of Health Services Policy and Management, Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Seval Kul
- Department of Biostatistics, School of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Deborah Seys
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Massimiliano Panella
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
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Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open 2016; 6:e012555. [PMID: 27687901 PMCID: PMC5051502 DOI: 10.1136/bmjopen-2016-012555] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. DESIGN Systematic review of systematic reviews. DATA SOURCES PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. STUDY SELECTION English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. RESULTS Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. CONCLUSIONS The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.
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Affiliation(s)
- Marieke Zegers
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gijs Hesselink
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Wytske Geense
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Hub Wollersheim
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Strandjord SE, Sieke EH, Richmond M, Khadilkar A, Rome ES. Medical stabilization of adolescents with nutritional insufficiency: a clinical care path. Eat Weight Disord 2016; 21:403-410. [PMID: 26597679 DOI: 10.1007/s40519-015-0245-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/07/2015] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.
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Affiliation(s)
- Sarah E Strandjord
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Erin H Sieke
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Miranda Richmond
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Arjun Khadilkar
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Ellen S Rome
- Department of General Pediatrics, Cleveland Clinic Children's Hospital, 9500 Euclid Ave/A120, Cleveland, OH, 44195, USA
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Salamonsen A, Kiil MA, Kristoffersen AE, Stub T, Berntsen GR. "My cancer is not my deepest concern": life course disruption influencing patient pathways and health care needs among persons living with colorectal cancer. Patient Prefer Adherence 2016; 10:1591-600. [PMID: 27574408 PMCID: PMC4994880 DOI: 10.2147/ppa.s108422] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The concept of "patient pathways" in cancer care is most commonly understood as clinical pathways, operationalized as standardized packages of health care based on guidelines for the condition in question. In this understanding, patient pathways do not address multimorbidity or patient experiences and preferences. This study explored patient pathways understood as the individual and cultural life course, which includes both life and health events. The overall aim was to contribute to supportive and targeted cancer care. MATERIALS AND METHODS Nine Norwegian patients recently diagnosed with rectal cancer Tumor-Node-Metastasis stage I-III participated in qualitative interviews, five times over 1 year. Five patients later participated in a workshop where they made illustrations of and discussed patient pathways. RESULTS Patient pathways including both health and life events were illustrated and described as complex and circular. Stress, anxiety, and depression caused by life events had significant disruptive effects and influenced patient-defined health care needs. The participants experienced the Norwegian public health service as focused on hospital-based standardized cancer care. They expressed unmet health care needs in terms of emotional and practical support in their everyday life with cancer, and some turned to complementary and alternative medicine. CONCLUSION This study suggests that acknowledging life course disruption before cancer diagnosis may have significant relevance for understanding complex patient pathways and individual health care needs. Approaching patient pathways as individual and socially constructed may contribute important knowledge to support targeted cancer care.
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Affiliation(s)
- Anita Salamonsen
- National Research Center in Complementary and Alternative Medicine, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Mona A Kiil
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Agnete Egilsdatter Kristoffersen
- National Research Center in Complementary and Alternative Medicine, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Trine Stub
- National Research Center in Complementary and Alternative Medicine, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Gro R Berntsen
- National Research Center in Complementary and Alternative Medicine, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
- Norwegian Center for eHealth Research, University Hospital of Northern Norway, Tromsø, Norway
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