1
|
Arce-Cabrera D, Escamilla-Asiain G, Nájera-Castillo MF, Navarro-Martín del Campo RM, Ortiz-Azpilcueta M, Pantoja-Guillén FJ, Arreguín González FE, Zapata-Sosa I, Lugo-Juárez JZ, Santillán Cortéz D, Morales-La Madrid A, Moreira DC, Benito-Reséndiz AE. Resources for the practice of pediatric neuro-oncology in Mexico: a cross-sectional evaluation. Front Oncol 2024; 14:1330705. [PMID: 38974245 PMCID: PMC11224457 DOI: 10.3389/fonc.2024.1330705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/20/2024] [Indexed: 07/09/2024] Open
Abstract
Background The evaluation of existing resources and services is key to identify gaps and prioritize interventions to expand care capacity for children with central nervous system (CNS) tumors. We sought to evaluate the resources for pediatric neuro-oncology (PNO) in Mexico. Methods A cross-sectional online survey with 35 questions was designed to assess PNO resources and services, covering aspects including number of patients, infrastructure, human resources, and diagnostic and treatment time intervals. The survey was distributed to the members of the Mexican Association of Pediatric Oncology and Hematology (AMOHP) who belong to the nation's many different health systems. Results Responses were obtained from 33 institutions, distributed throughout the country and part of the many health systems that exist in Mexico. Twenty-one (64%) institutions had less than 10 new cases of pediatric CNS tumors per year. Although 30 (91%) institutions saw pediatric patients up to the age of 18 years, 2 (6%) had a cutoff of 15 years. Twenty-four (73%) institutions had between 1 and 3 pediatric oncologists providing care for children with CNS tumors. Six (18%) institutions did not have a neurosurgeon, while 19 (57%) institutions had a pediatric neurosurgeon. All centers had a pathology department, but 13 (39%) institutions only had access to basic histopathology. Eleven (33%) institutions reported histopathological diagnoses within one week, but 3 (9%) took more than 4 weeks. Radiotherapy for pediatric CNS tumors was referred to outside centers at 18 (55%) institutions. All centers had access to conventional cytotoxic chemotherapy, but only 6 (18%) had access to targeted therapy. Eighteen (55%) respondents estimated a survival rate of less than 60%. Fifteen (45%) centers attributed the main cause of mortality to non-tumor related factors, including infection and post-surgical complications. Conclusions This is the first national assessment of the resources available in Mexico for the treatment of CNS tumors. It shows disparities in resource capacity and a lack of the specific and efficient diagnoses that allow timely initiation of treatment. These data will enable the prioritization of collaborative interventions in the future.
Collapse
Affiliation(s)
- Daniela Arce-Cabrera
- Pediatric Oncology Department, Sinaloa Pediatric Hospital, Culiacan, Sinaloa, Mexico
| | - Gabriela Escamilla-Asiain
- Pediatric Oncology Department, Teletón Children’s Hospital of Oncology, Querétaro, Querétaro, Mexico
| | - Melisa F. Nájera-Castillo
- Pediatric Oncology Department Hospital for Children of Toluca. Maternal and Child Institute of the State of Mexico, Toluca, Estado de Mexico, Mexico
| | | | - Mariana Ortiz-Azpilcueta
- Pediatric Oncology Department, Pediatric Hospital of the National Medical Center 21st century Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | | | | | - Imelda Zapata-Sosa
- Pediatric Oncology Department, Zacatecas General Hospital, Zacatecas, Zacatecas, Mexico
| | - Jocelyn Z. Lugo-Juárez
- Pediatric Oncology Department, Teletón Children’s Hospital of Oncology, Querétaro, Querétaro, Mexico
| | - Daniel Santillán Cortéz
- Pediatric Oncology Department, National Medical Center November 20 ISSSTE, Mexico City, Mexico
| | | | - Daniel C. Moreira
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alma E. Benito-Reséndiz
- Pediatric Oncology Department, National Medical Center November 20 ISSSTE, Mexico City, Mexico
| |
Collapse
|
2
|
Acramel A, Blondeel-Gomes S, Dupré M, Kayembe OT, Rochereau A, Escalup L, Desmaris R, Jourdan N, Cordary A, Vaflard P, Cottu P, Bellesoeur A. Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach. Br J Clin Pharmacol 2024; 90:1333-1343. [PMID: 38403473 DOI: 10.1111/bcp.16020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
AIMS The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day. METHODS An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix. RESULTS During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks. CONCLUSIONS Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.
Collapse
Affiliation(s)
- Alexandre Acramel
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
- Université Paris Cité, CiTCoM, CNRS UMR 8038, Inserm U1268, Paris, France
| | - Sandy Blondeel-Gomes
- Département de Radiopharmacologie, Institut Curie, PSL Research University, Paris, France
| | - Mathilde Dupré
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | | | - Aude Rochereau
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | - Laurence Escalup
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | - Romain Desmaris
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | | | - Adeline Cordary
- Département de Qualité et Gestion des risques, Institut Curie, PSL Research University, Paris, France
| | - Pauline Vaflard
- Département d'Oncologie médicale, Institut Curie, PSL Research University, Paris, France
| | - Paul Cottu
- Département d'Oncologie médicale, Institut Curie, PSL Research University, Paris, France
- Université Paris Cité, Paris, France
| | - Audrey Bellesoeur
- Département de Radiopharmacologie, Institut Curie, PSL Research University, Paris, France
- Département d'Oncologie médicale, Institut Curie, PSL Research University, Paris, France
| |
Collapse
|
3
|
Bolous NS, Chokwenda-Makore N, Bonilla M, Chingo G, Kambugu J, Mulindwa JM, Noleb M, Chitsike I, Bhakta N. Addressing the gap in health economics data to support national cancer control plans in low- and middle-income countries: The Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity (CC-BRIDGE) tool. Cancer 2024; 130:1112-1124. [PMID: 38100617 DOI: 10.1002/cncr.35146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND National cancer control plans (NCCPs) are complex public health programs that incorporate evidence-based cancer control strategies to improve health outcomes for all individuals in a country. Given the scope of NCCPs, small and vulnerable populations, such as patients with childhood cancer, are often missed. To support planning efforts, a rapid, modifiable tool was developed that estimates a context-specific national budget to fund pediatric cancer programs, provides 5-year scale-up scenarios, and calculates annual cost-effectiveness. METHODS The tool was codeveloped by teams of policymakers, clinicians, and public health advocates in Zimbabwe, Zambia, and Uganda. The 11 costing categories included real-world data, modeled data, and data from the literature. A base-case and three 5-year scale-up scenarios were created using modifiable inputs. The cost-effectiveness of the disability-adjusted life years averted was calculated. Results were compared with each country's projected gross domestic product per capita for 2022 through 2026. RESULTS The number of patients/total budget for year 1 was 250/$1,109,366 for Zimbabwe, 280/$1,207,555 for Zambia, and 1000/$2,277,397 for Uganda. In year 5, these values were assumed to increase to 398/$5,545,445, 446/$4,926,150, and 1594/$9,059,331, respectively. Base-case cost per disability-adjusted life year averted/ratio to gross domestic product per capita for year 1, assuming 20% survival, was: $807/0.5 for Zimbabwe, $785/0.7 for Zambia, and $420/0.5 for Uganda. CONCLUSIONS This costing tool provided a framework to forecast a budget for childhood-specific cancer services. By leveraging minimal primary data collection with existing secondary data, local teams obtained rapid results, ensuring that childhood cancer budgeting is not neglected once in every 5 to 6 years of planning processes.
Collapse
Affiliation(s)
- Nancy S Bolous
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Nester Chokwenda-Makore
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Miguel Bonilla
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Grace Chingo
- Department of Pediatric Oncology, Cancer Disease Hospital, Lusaka, Zambia
| | - Joyce Kambugu
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Justin M Mulindwa
- Department of Pediatric Oncology, Cancer Disease Hospital, Lusaka, Zambia
| | - Mugisha Noleb
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Inam Chitsike
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
4
|
McKay V, Chen Y, Prewitt K, Malone S, Puerto-Torres M, Acuña-Aguirre C, Alfonso-Carreras Y, Alvarez-Arellano SY, Andrade-Sarmiento LA, Arce-Cabrera D, Argüello-Vargas D, Barragán-García MDC, Batista-Del-Cid R, Blasco-Arriaga EE, Cach-Castaneda MDC, Ceballo-Batista GI, Chávez-Rios M, Costa ME, Cuencio-Rodriguez ME, Diaz-Coronado R, Fing-Soto EA, García-Sarmiento TDJ, Gómez-García WC, Hernández-González CJ, Jimenez-Antolinez YV, Juarez-Tobias MS, León-López EM, Lopez-Facundo NA, Martínez Soria RA, Miralda-Méndez ST, Montalvo E, Pérez-Alvarado CM, Perez-Fermin CK, Quijano-Lievano ML, Salas-Mendoza B, Sanchez-Fuentes EE, Serrano-Landivar MX, Soto-Chavez V, Tejocote-Romero I, Valle S, Vasquez-Roman EA, Costa JT, Cardenas-Aguirre A, Devidas M, Luke DA, Agulnik A. Connecting Clinical Capacity and Intervention Sustainability in Resource-Variable Pediatric Oncology Centers in Latin America. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2024; 4:102-115. [PMID: 38566954 PMCID: PMC10987010 DOI: 10.1007/s43477-023-00106-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/10/2023] [Indexed: 04/04/2024]
Abstract
Clinical capacity for sustainability, or the clinical resources needed to sustain an evidence-based practice, represent proximal determinants that contribute to intervention sustainment. We examine the relationship between clinical capacity for sustainability and sustainment of PEWS, an evidence-based intervention to improve outcomes for pediatric oncology patients in resource-variable hospitals. We conducted a cross-sectional survey among Latin American pediatric oncology centers participating in Proyecto Escala de Valoración de Alerta Temprana (EVAT), an improvement collaborative to implement Pediatric Early Warning Systems (PEWS). Hospitals were eligible if they had completed PEWS implementation. Clinicians were eligible to participate if they were involved in PEWS implementation or used PEWS in clinical work. The Spanish language survey consisted of 56 close and open-ended questions about the respondent, hospital, participants' assessment of clinical capacity to sustain PEWS using the clinical sustainability assessment tool (CSAT), and perceptions about PEWS and its use as an intervention. Results were analyzed using a multi-level modeling approach to examine the relationship between individual, hospital, intervention, and clinical capacity determinants to PEWS sustainment. A total of 797 responses from 37 centers in 13 countries were included in the analysis. Eighty-seven percent of participants reported PEWS sustainment. After controlling for individual, hospital, and intervention factors, clinical capacity was significantly associated with PEWS sustainment (OR 3.27, p < .01). Marginal effects from the final model indicate that an increasing capacity score has a positive influence (11% for every additional CSAT point) of predicting PEWS sustainment. PEWS is a sustainable intervention and clinical capacity to sustain PEWS contributes meaningfully to PEWS sustainment.
Collapse
Affiliation(s)
- Virginia McKay
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Sara Malone
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
- Division of Population Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maria E. Costa
- Hospital del Nino de la Santísima Trinidad, Cordoba, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Clara K. Perez-Fermin
- Hospital Infantil Regional Universitario Dr. Arturo Grullon, Santiago, Dominican Republic
| | | | | | | | | | | | | | - Sergio Valle
- Unidad Nacional de Oncologia Pediatrica (UNOP), Guatemala, Guatemala
| | | | - Juliana Texeira Costa
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Adolfo Cardenas-Aguirre
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Douglas A. Luke
- Brown School, Washington University, MSC 1196-251-46, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| |
Collapse
|
5
|
Bolous NS, Mercredi P, Bonilla M, Friedrich P, Bhakta N, Metzger ML, Gassant PY. Determining the cost and cost-effectiveness of childhood cancer treatment in Haiti. Ecancermedicalscience 2024; 18:1675. [PMID: 38439808 PMCID: PMC10911665 DOI: 10.3332/ecancer.2024.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Indexed: 03/06/2024] Open
Abstract
Haiti is a low-income country with one of the lowest human development index rankings in the world. Its childhood cancer services are provided by a single hospital with the only dedicated paediatric oncology department in the country. Our objective was to assess the cost and cost-effectiveness of all types of childhood cancer in Haiti to help prioritise investments and to support national cancer control planning. All costing data were collected from the year 2017 or 2018 hospital records. Costs were classified into 11 cost categories, and the proportion of the overall budget represented by each was calculated and converted from Haitian Gourde to United States dollars. The 5-year survival rate was retrieved from hospital records and used to calculate the cost-effectiveness of disability-adjusted life year (DALY) averted, using a healthcare costing perspective. Additional sensitivity analyses were conducted accounting for late-effect morbidity and early mortality and discounting rates of 0%, 3% and 6%. The annual cost of operating a paediatric oncology unit in Haiti treating 74 patients with newly diagnosed cancer was $803,184 overall or $10,854 per patient. The largest cost category was pharmacy, constituting 25% of the overall budget, followed by medical personnel (20%) and administration (12%). The cost per DALY averted in the base-case scenario was $1,128, which is 76% of the gross domestic product per capita, demonstrating that treating children with cancer in Haiti is very cost-effective according to the World Health Organisation Choosing Interventions that are Cost-Effective (WHO-CHOICE) threshold. In the most conservative scenario, the cost per DALY averted was cost-effective by WHO-CHOICE criteria. Our data will add to the growing body of literature illustrating a positive return on investment associated with diagnosing and treating children with cancer in even the most resource-limited environments. We anticipate that these data will aid local stakeholders and policymakers when identifying cancer control priorities and making budgetary decisions.
Collapse
Affiliation(s)
- Nancy S Bolous
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | | | - Miguel Bonilla
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | | | - Pascale Y Gassant
- Nos Petit Frères et Sœurs-St Damien Hospital, Port-au-Prince 6124, Haiti
| |
Collapse
|
6
|
McKay V, Carothers B, Graetz D, Malone S, Puerto-Torres M, Prewitt K, Cardenas A, Chen Y, Devidas M, Luke DA, Agulnik A. Sustainability determinants of an intervention to identify clinical deterioration and improve childhood cancer survival in Latin American hospitals: the INSPIRE study protocol. Implement Sci Commun 2023; 4:141. [PMID: 37978404 PMCID: PMC10657009 DOI: 10.1186/s43058-023-00519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND More than 90% of children with cancer live in low-resourced settings, where survival is only 20%. Sustainable evidence-based (EB) interventions yielding ongoing beneficial patient outcomes are critical to improve childhood cancer survival. A better understanding of factors promoting intervention sustainability in these settings is urgently needed. The aim of this study is to provide an empirical understanding of how clinical capacity for sustainability, or the resources needed to sustain an intervention, impacts the sustainment of Pediatric Early Warning System (PEWS), an EB intervention that improves pediatric oncology outcomes in low-resource hospitals by detecting clinical deterioration and preventing the need for more intense treatment. METHODS We will conduct a prospective, longitudinal study of approximately 100 resource-variable hospitals implementing and sustaining PEWS participating in Proyecto EVAT, a quality improvement collaborative of Latin American pediatric oncology centers. Aim 1: We will evaluate how clinical capacity for sustainability changes over time through 5 to 9 prospective measurements of capacity via survey of clinical staff using PEWS (approximately n = 13 per center) during the phases of PEWS adoption, implementation, and sustainability using the Clinical Sustainability Assessment Tool (CSAT). Aim 2: We will determine the relationship between capacity and a) PEWS sustainment and b) clinical deterioration mortality among pediatric oncology patients at centers sustaining PEWS for 2 to 10 years using chart review and an existing patient outcomes registry. Aim 3: We will develop novel strategies to promote sustainability by gaining a deeper understanding of perceived challenges to building capacity and PEWS sustainment. In combination with quantitative outcomes, we will conduct 24 focus groups with staff (doctors, nurses, and administrators) from hospitals with both high (n = 4) and low capacity (n = 4). We will then use implementation mapping to generate theoretically driven, empirically-supported sustainability strategies. DISCUSSION This study will advance implementation science by providing a theoretically driven, foundational understanding of factors that predict sustainability among a large, diverse cohort of hospitals. We will then use this knowledge to develop sustainability evidence-informed strategies that optimize capacity and promote long-term sustainment of PEWS and improvements in patient outcomes, thus promoting equity in childhood cancer care globally.
Collapse
Affiliation(s)
- Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - Bobbi Carothers
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Dylan Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sara Malone
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Division of Population Health Science, Washington University in St. Louis School of Medicine, St Louis, MO, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Adolfo Cardenas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Douglas A Luke
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
7
|
Ehrlich BS, McNeil MJ, Pham LTD, Chen Y, Rivera J, Acuna C, Sniderman L, Sakaan FM, Aceituno AM, Villegas CA, Force LM, Bolous NS, Wiphatphumiprates PP, Slone JS, Carrillo AK, Gillipelli SR, Duffy C, Arias AV, Devidas M, Rodriguez-Galindo C, Mukkada S, Agulnik A. Treatment-related mortality in children with cancer in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Oncol 2023; 24:967-977. [PMID: 37517410 PMCID: PMC10812862 DOI: 10.1016/s1470-2045(23)00318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Approximately 90% of children with cancer live in low-income and middle-income countries (LMICs), where 5-year survival is lower than 20%. Treatment-related mortality in high-income countries is approximately 3-5%; however, in LMICs, treatment-related mortality has been reported in up to 45% of children with cancer. This study aimed to systematically explore the burden of treatment-related mortality in children with cancer in LMICs and to explore the association between country income level and treatment-related mortality. METHODS For this systematic review and meta-analysis we identified articles published between Jan 1, 2010, and June 22, 2021, describing treatment-related mortality in paediatric patients (aged 0-21 years) with cancer in LMICs. We searched PubMed, Trip, Web of Science, Embase, and the WHO Global Metric Index databases. The search was limited to full-text articles and excluded case reports (<10 patients) and haematopoietic stem-cell transplantation recipients. Two reviewers independently screened studies for eligibility, extracted data from included publications, and evaluated data quality. Random and mixed-effects models were used to estimate treatment-related mortality burden and trends. The Cochran-Q statistic was used to assess heterogeneity between studies. This study is registered on PROSPERO (CRD42021264849). FINDINGS Of 13 269 identified abstracts, 501 studies representing 68 351 paediatric patients with cancer were included. The treatment-related mortality estimate was 6·82% (95% CI 5·99-7·64), accounting for 30·9% of overall mortality (4437 of 14 358 deaths). Treatment-related mortality was inversely related to country income. Treatment-related mortality was 14·19% (95% CI 9·65-18·73) in low-income countries, 9·21% (7·93-10·49) in lower-middle-income countries, and 4·47% (3·42-5·53) in upper-middle-income countries (Cochran-Q 42·39, p<0·0001). In upper-middle-income countries, the incidence of treatment-related mortality decreased over time (slope -0·002, p=0·0028); however, outcomes remained unchanged in low-income (p=0·21) and lower-middle-income countries (p=0·16). INTERPRETATION Approximately one in 15 children receiving cancer treatment in LMICs die from treatment-related complications. Although treatment-related mortality has decreased in upper-middle-income countries over time, it remains unchanged in LMICs. There is an urgent need for targeted supportive care interventions to reduce global disparities in childhood cancer survival. FUNDING American Lebanese Syrian Associated Charities and National Cancer Institute.
Collapse
Affiliation(s)
- Bella S Ehrlich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Michael J McNeil
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Linh T D Pham
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jocelyn Rivera
- Department of Pediatric Emergency Medicine, Hospital Infantil Teletón de Oncología, Querétaro, México
| | - Carlos Acuna
- Department of Pediatric Intensive Care, Dr Luis Calvo Mackenna Children's Hospital, Santiago, Chile
| | - Liz Sniderman
- Northern Alberta Children's Cancer Program, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Firas M Sakaan
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Alejandra Mendez Aceituno
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Pediatric Intensive Care Unit, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Cesar A Villegas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lisa M Force
- Department of Health Metrics Sciences and Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Washington, Seattle, WA, USA
| | - Nancy S Bolous
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Jeremy S Slone
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Caitlyn Duffy
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Anita V Arias
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Sheena Mukkada
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA.
| |
Collapse
|
8
|
Agulnik A, Muniz-Talavera H, Pham LTD, Chen Y, Carrillo AK, Cárdenas-Aguirre A, Gonzalez Ruiz A, Garza M, Conde Morelos Zaragoza TM, Soberanis Vasquez DJ, Méndez-Aceituno A, Acuña-Aguirre C, Alfonso-Carreras Y, Alvarez Arellano SY, Andrade Sarmiento LA, Batista R, Blasco Arriaga EE, Calderon P, Chavez Rios M, Costa ME, Díaz-Coronado R, Fing Soto EA, Gómez García WC, Herrera Almanza M, Juarez Tobías MS, León López EM, López Facundo NA, Martinez Soria RA, Miller K, Miralda Méndez ST, Mora Robles LN, Negroe Ocampo NDC, Noriega Acuña B, Osuna Garcia A, Pérez Alvarado CM, Pérez Fermin CK, Pineda Urquilla EE, Portilla Figueroa CA, Ríos Lopez LE, Rivera Mijares J, Soto Chávez V, Suarez Soto JI, Teixeira Costa J, Tejocote Romero I, Villanueva Hoyos EE, Villegas Pacheco M, Devidas M, Rodriguez-Galindo C. Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study. Lancet Oncol 2023; 24:978-988. [PMID: 37433316 PMCID: PMC10727097 DOI: 10.1016/s1470-2045(23)00285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America. METHODS Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics. FINDINGS Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9-13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10-13) before PEWS implementation and 18 months (16-18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 [95% CI 0·69-0·97]; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 [95% CI 1·22-1·43]; p<0·0001), being a teaching hospital (1·18 [1·09-1·27]; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 [1·21-1·57]; p<0·0001), and having fewer PEWS omissions (0·95 [0·92-0·99]; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 [95% CI 0·68-1·09]; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 [0·97-1·12]; p=0·29). INTERPRETATION PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer. FUNDING American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation. TRANSLATIONS For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Asya Agulnik
- St Jude Children's Research Hospital, Memphis, TN, USA.
| | | | - Linh T D Pham
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Marcela Garza
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kenia Miller
- Hospital del Niño "Jose Renan Esquivel", Panama, Panama
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jorge Iván Suarez Soto
- Hospital del Niño. Sistema integral para el Desarrollo de la Familia (DIF), Pachuca, Mexico
| | | | | | | | | | | | | |
Collapse
|
9
|
Woo MC, Ferrara G, Puerto‐Torres M, Gillipelli SR, Elish P, Muniz‐Talavera H, Gonzalez‐Ruiz A, Armenta M, Barra C, Diaz‐Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Peñafiel E, Pineda E, Graetz DE, Kortz T, Agulnik A. Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource-limited pediatric oncology centers. Cancer Med 2023; 12:15358-15370. [PMID: 37403745 PMCID: PMC10417083 DOI: 10.1002/cam4.6087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Pediatric Early Warning Systems (PEWS) assist early detection of clinical deterioration in hospitalized children with cancer. Relevant to successful PEWS implementation, the "stages of change" model characterizes stakeholder support for PEWS based on willingness and effort to adopt the new practice. METHODS At five resource-limited pediatric oncology centers in Latin America, semi-structured interviews were conducted with 71 hospital staff involved in PEWS implementation. Purposive sampling was used to select centers requiring variable time to complete PEWS implementation, with low-barrier centers (3-4 months) and high-barrier centers (10-11 months). Interviews were conducted in Spanish, professionally transcribed, and translated into English. Thematic content analysis explored "stage of change" with constant comparative analysis across stakeholder types and study sites. RESULTS Participants identified six interventions (training, incentives, participation, evidence, persuasion, and modeling) and two policies (environmental planning and mandates) as effective strategies used by implementation leaders to promote stakeholder progression through stages of change. Key approaches involved presentation of evidence demonstrating PEWS effectiveness, persuasion and incentives addressing specific stakeholder interests, enthusiastic individuals serving as models for others, and policies enforced by hospital directors facilitating habitual PEWS use. Effective engagement targeted hospital directors during early implementation phases to provide programmatic legitimacy for clinical staff. CONCLUSION This study identifies strategies to promote adoption and maintained use of PEWS, highlighting the importance of tailoring implementation strategies to the motivations of each stakeholder type. These findings can guide efforts to implement PEWS and other evidence-based practices that improve childhood cancer outcomes in resource-limited hospitals.
Collapse
Affiliation(s)
| | - Gia Ferrara
- St. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | | | - Paul Elish
- Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
| | | | | | | | | | | | | | - Susana Juarez
- Hospital Central Dr. Ignacio Morones PrietoSan Luis PotosíMexico
| | | | | | | | | | - Estuardo Pineda
- Hospital Nacional de Niños Benjamín BloomSan SalvadorEl Salvador
| | | | - Teresa Kortz
- University of CaliforniaSan FranciscoCaliforniaUSA
| | - Asya Agulnik
- St. Jude Children's Research HospitalMemphisTennesseeUSA
| |
Collapse
|
10
|
Rojas-Roque C, Palacios A. A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:419-440. [PMID: 36720754 DOI: 10.1007/s40258-023-00791-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Little is known about the quality, quantity and disease areas analysed by health economic research that inform healthcare decision-making in Central America. This study aimed to review the existing health economic evaluations (HEEs) and budget impact analyses (BIAs) evidence in Central America based on scope and reporting quality. METHODS HEEs and BIAs published from 2000 to April 2021 were searched in five electronic databases: PubMed, Embase, LILACS (Latin American and Caribbean Health Science Literature), EconLIT and OVID Global Health. Two reviewers assessed titles, abstracts and full texts of studies for eligibility. The quality appraisal for the reporting was based on La Torre and colleagues' version of the Drummond checklist and the ISPOR good practices for BIA. For each country, we correlated the number of studies by disease area with their respective burden of disease to identify under-researched health areas. RESULTS 102 publications were eligible for this review. Ninety-four publications reported a HEE, six publications reported a BIA, and two studies reported both a HEE and a BIA. Costa Rica had the highest number of publications (n = 28, 27.5%), followed by Guatemala (n = 25, 24.5%). Cancer and respiratory infections were the most common types of disease studied. Diabetes mellitus, chronic kidney diseases, and mental disorders were under-researched relative to their disease burden in most of the countries. The overall mean quality reporting score for HEE and BIA studies were 71/119 points (60%) and 7/10 points (70%), respectively; however, these assessments were made on different scales. CONCLUSION In Central America, health economic research is sparse and is considered as suboptimal quality for reporting. The findings reported information useful to other low- and middle-income countries with similar advances in the application of economics to promote health policy decision-making.
Collapse
Affiliation(s)
- Carlos Rojas-Roque
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina.
| | - Alfredo Palacios
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina
- Facultad de Ciencias Económicas, Universidad de Buenos Aires, Buenos Aires, Argentina
- Centre for Health Economics (CHE), University of York, York, UK
| |
Collapse
|
11
|
Wiphatphumiprates PP, Graetz DE, Ferrara G, Puerto‐Torres M, Gillipelli SR, Elish P, Muniz‐Talavera H, Gonzalez‐Ruiz A, Armenta M, Barra C, Carpio Z, Hernandez C, Juarez S, de Jesus Loeza J, Mendez A, Montalvo E, Penafiel E, Pineda E, McKay V, Agulnik A. The COVID-19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource-limited hospitals. Cancer Med 2023; 12:11878-11888. [PMID: 37022012 PMCID: PMC10242859 DOI: 10.1002/cam4.5876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic impacted healthcare delivery worldwide, including pediatric cancer care, with a disproportionate effect in resource-limited settings. This study evaluates its impact on existing quality improvement (QI) programs. METHODS We conducted 71 semi-structured interviews of key stakeholders at five resource-limited pediatric oncology centers participating in a collaborative to implement Pediatric Early Warning System (PEWS). Interviews were conducted virtually using a structured interview guide, recorded, transcribed, and translated into English. Two coders developed a codebook of a priori and inductive codes and independently coded all transcripts, achieving a kappa of 0.8-0.9. Thematic analysis explored the impact of the pandemic on PEWS. RESULTS All hospitals reported limitations in material resources, reduction in staffing, and impacts on patient care due to the pandemic. However, the impact on PEWS varied across centers. Identified factors that promoted or limited ongoing PEWS use included the availability of material resources needed for PEWS, staff turnover, PEWS training for staff, and the willingness of staff and hospital leaders to prioritize PEWS. Consequently, some hospitals were able to sustain PEWS; others halted or reduced PEWS use to prioritize other work. Similarly, the pandemic delayed plans at all hospitals to expand PEWS to other units. Several participants were hopeful for future expansion of PEWS post-pandemic. CONCLUSION The COVID-19 pandemic created challenges for sustainability and scale of PEWS, an ongoing QI program, in these resource-limited pediatric oncology centers. Several factors mitigated these challenges and promoted ongoing PEWS use. These results can guide strategies to sustain effective QI interventions during future health crises.
Collapse
Affiliation(s)
| | - Dylan E. Graetz
- Global Pediatric Medicine at St. Jude Children's Research HospitalTennesseeMemphisUSA
| | - Gia Ferrara
- Global Pediatric Medicine at St. Jude Children's Research HospitalTennesseeMemphisUSA
| | - Maria Puerto‐Torres
- Global Pediatric Medicine at St. Jude Children's Research HospitalTennesseeMemphisUSA
| | | | - Paul Elish
- Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
| | | | | | - Miriam Armenta
- Pediatric OncologyHospital General de TijuanaTijuanaMexico
| | - Camila Barra
- Pediatric OncologyHospital Dr. Luis Calvo MackennaSantiagoChile
| | - Zulma Carpio
- Pediatric OncologyInstituto Nacional de Enfermedades NeoplásicasLimaPeru
| | - Cinthia Hernandez
- Pediatric OncologyHospital Infantil Teletón de OncologíaQuerétaroMexico
| | - Susana Juarez
- PediatricsHospital Central Dr. Ignacio Morones PrietoSan Luis PotosíMexico
| | | | - Alejandra Mendez
- Pediatric Critical CareUnidad Nacional de Oncología PediátricaGuatemala CityGuatemala
| | - Erika Montalvo
- Pediatric Critical CareHospital Oncológico Solca Núcleo de QuitoQuitoEcuador
| | - Eulalia Penafiel
- Pediatric OncologyInstituto del Cáncer SOLCA CuencaCuencaEcuador
| | - Estuardo Pineda
- Pediatric OncologyHospital Nacional de Niños Benjamín BloomSan SalvadorEl Salvador
| | - Virginia McKay
- Bloom School of MedicineWashington UniversitySt. LouisMissouriUSA
| | - Asya Agulnik
- Global Pediatric Medicine at St. Jude Children's Research HospitalTennesseeMemphisUSA
| |
Collapse
|
12
|
Agulnik A. Management of septic shock in children with cancer-Common challenges and research priorities. J Pediatr (Rio J) 2023; 99:101-104. [PMID: 36706794 PMCID: PMC10031354 DOI: 10.1016/j.jped.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN.
| |
Collapse
|
13
|
Arias AV, Sakaan FM, Puerto-Torres M, Al Zebin Z, Bhattacharyya P, Cardenas A, Gunasekera S, Kambugu J, Kirgizov K, Libes J, Martinez A, Matinyan NV, Mendez A, Middlekauff J, Nielsen KR, Pappas A, Ren H, Sharara-Chami R, Torres SF, McArthur J, Agulnik A. Development and pilot testing of PROACTIVE: A pediatric onco-critical care capacity and quality assessment tool for resource-limited settings. Cancer Med 2023; 12:6270-6282. [PMID: 36324249 PMCID: PMC10028058 DOI: 10.1002/cam4.5395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Nearly 90% children with cancer reside in low- and middle-income countries, which face multiple challenges delivering high-quality pediatric onco-critical care (POCC). We recently identified POCC quality and capacity indicators for PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), a tool that evaluates strengths and limitations in POCC services. This study describes pilot testing of PROACTIVE, development of center-specific reports, and identification of common POCC challenges. METHODS The original 119 consensus-derived PROACTIVE indicators were converted into 182 questions divided between 2 electronic surveys for intensivists and oncologists managing critically ill pediatric cancer patients. Alpha-testing was conducted to confirm face-validity with four pediatric intensivists. Eleven centers representing diverse geographic regions, income levels, and POCC services conducted beta-testing to evaluate usability, feasibility, and applicability of PROACTIVE. Centers' responses were scored and indicators with mean scores ≤75% in availability/performance were classified as common POCC challenges. RESULTS Alpha-testing ensured face-validity and beta-testing demonstrated feasibility and usability of PROACTIVE (October 2020-June 2021). Twenty-two surveys (response rate 99.4%) were used to develop center-specific reports. Adjustments to PROACTIVE were made based on focus group feedback and surveys, resulting in 200 questions. Aggregated data across centers identified common POCC challenges: (1) lack of pediatric intensivists, (2) absence of abstinence and withdrawal symptoms monitoring, (3) shortage of supportive care resources, and (4) limited POCC training for physicians and nurses. CONCLUSIONS PROACTIVE is a feasible and contextually appropriate tool to help clinicians and organizations identify challenges in POCC services across a wide range of resource-levels. Widespread use of PROACTIVE can help prioritize and develop tailored interventions to strengthen POCC services and outcomes globally.
Collapse
Affiliation(s)
- Anita V Arias
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Firas M Sakaan
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zebin Al Zebin
- Pediatric Hematology and Oncology, King Hussein Cancer Center, Amman, Jordan
| | | | - Adolfo Cardenas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Sanjeeva Gunasekera
- Department of Pediatric Oncology, National Cancer Institute Sri Lanka, Maharagama, Sri Lanka
| | - Joyce Kambugu
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | | | - Jaime Libes
- Department of Pediatric Hematology and Oncology, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Angelica Martinez
- Pediatric Hemato-Oncology Unit, Hospital General de Tijuana, Tijuana, Baja California, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica (UNOP), Guatemala City, Guatemala
| | - Janet Middlekauff
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Andrew Pappas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Hong Ren
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai, China
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Silvio F Torres
- Pediatric Intensive Care Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
14
|
Donovan T, Abell B, Fernando M, McPhail SM, Carter HE. Implementation costs of hospital-based computerised decision support systems: a systematic review. Implement Sci 2023; 18:7. [PMID: 36829247 PMCID: PMC9960445 DOI: 10.1186/s13012-023-01261-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/17/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The importance of accurately costing implementation strategies is increasingly recognised within the field of implementation science. However, there is a lack of methodological guidance for costing implementation, particularly within digital health settings. This study reports on a systematic review of costing analyses conducted alongside implementation of hospital-based computerised decision support systems. METHODS PubMed, Embase, Scopus and CINAHL databases were searched between January 2010 and August 2021. Two reviewers independently screened and selected original research studies that were conducted in a hospital setting, examined the implementation of a computerised decision support systems and reported implementation costs. The Expert Recommendations for Implementing Change Framework was used to identify and categorise implementation strategies into clusters. A previously published costing framework was applied to describe the methods used to measure and value implementation costs. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS Titles and abstracts of 1836 articles were screened, with nine articles eligible for inclusion in the review. Implementation costs were most frequently reported under the 'evaluative and iterative strategies' cluster, followed by 'provide interactive assistance'. Labour was the largest implementation-related cost in the included papers, irrespective of implementation strategy. Other reported costs included consumables, durable assets and physical space, which was mostly associated with stakeholder training. The methods used to cost implementation were often unclear. There was variation across studies in the overall quality of reporting. CONCLUSIONS A relatively small number of papers have described computerised decision support systems implementation costs, and the methods used to measure and value these costs were not well reported. Priorities for future research should include establishing consistent terminology and appropriate methods for estimating and reporting on implementation costs. TRIAL REGISTRATION The review protocol is registered with PROSPERO (ID: CRD42021272948).
Collapse
Affiliation(s)
- Thomasina Donovan
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Bridget Abell
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia
| | - Manasha Fernando
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia
| | - Steven M. McPhail
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia ,grid.474142.0Digital Health and Informatics, Metro South Health, Brisbane, QLD Australia
| | - Hannah E. Carter
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia
| |
Collapse
|
15
|
Abutineh F, Graetz DE, Muniz-Talavera H, Ferrara G, Puerto-Torres M, Chen Y, Gillipelli SR, Elish P, Gonzalez-Ruiz A, Alfonso Carreras Y, Alvarez S, Arce Cabrera D, Arguello Vargas D, Armenta Cruz M, Barra C, Calderon Sotelo P, Carpio Z, Chavez Rios M, Covarrubias D, de Leon Vasquez L, Diaz Coronado R, Fing Soto EA, Gomez-Garcia W, Hernandez C, Juarez Tobias MS, Leon E, Loeza Oliva JDJ, Mendez A, Miller K, Montalvo Cozar E, Negroe Ocampo NDC, Penafiel E, Pineda E, Rios L, Rodriguez Ordonez E, Soto Chavez V, Devidas M, Agulnik A. Impact of hospital characteristics on implementation of a Pediatric Early Warning System in resource-limited cancer hospitals. Front Oncol 2023; 13:1122355. [PMID: 37207162 PMCID: PMC10189109 DOI: 10.3389/fonc.2023.1122355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation. Methods This convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using a priori and novel codes. Thematic content analysis explored the impact of hospital characteristics and QI experience on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time. Results In both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges. Conclusions Hospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings.
Collapse
Affiliation(s)
- Farris Abutineh
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | | | - Shillel Alvarez
- Pediatric Oncology, Benemérito Hospital General con Especialidades “Juan María de Salvatierr”, La Paz, Mexico
| | - Daniela Arce Cabrera
- Pediatric Hemato-Oncology Unit, Hospital Pediatrico de Sinaloa, Culiacan, Mexico
| | | | | | - Camila Barra
- Pediatric Oncology, Centro de Investigacion Bradford Hill, Santiago, Chile
| | | | - Zulma Carpio
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru
| | | | - Daniela Covarrubias
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | - Lucy de Leon Vasquez
- Pediatric Oncology, Hospital Infantil Regional Universitario Dr. Arturo Grullon, Santiago, Dominican Republic
| | | | | | - Wendy Gomez-Garcia
- Oncology Unit, Hospital Infantil Dr. Robert Reid Cabral, Santo, Domingo, Dominican Republic
| | | | | | - Esmeralda Leon
- Medical Oncology, Hospital Guillermo Almenara Irigoyen, Lima, Peru
| | | | - Alejandra Mendez
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kenia Miller
- Pediatric Hemato-Oncology, Hospital del Niño “Jose Renan Esquivel”, Panama City, Panama
| | - Erika Montalvo Cozar
- Pediatric Intensive Care Unit, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | | | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Hemato-Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Ligia Rios
- Pediatric Hemato-Oncology, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | | | | | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
| |
Collapse
|
16
|
Agulnik A, Gonzalez Ruiz A, Muniz‐Talavera H, Carrillo AK, Cárdenas A, Puerto‐Torres MF, Garza M, Conde T, Soberanis Vasquez DJ, Méndez Aceituno A, Acuña Aguirre C, Alfonso Y, Álvarez Arellano SY, Argüello Vargas D, Batista R, Blasco Arriaga EE, Chávez Rios M, Cuencio Rodríguez ME, Fing Soto EA, Gómez‐García W, Guillén Villatoro RH, Gutiérrez Rivera MDL, Herrera Almanza M, Jimenez Antolinez YV, Juárez Tobias MS, López Facundo NA, Martínez Soria RA, Miller K, Miralda S, Morales R, Negroe Ocampo N, Osuna A, Pascual Morales C, Pérez Fermin CK, Pérez Alvarado CM, Pineda E, Andrés Portilla C, Rios López LE, Rivera J, Sagaón Olivares AS, Saguay Tacuri MC, Salas Mendoza BT, Solano Picado I, Soto Chávez V, Tejocote Romero I, Tatay D, Teixeira Costa J, Villanueva E, Villegas Pacheco M, McKay VR, Metzger ML, Friedrich P, Rodriguez‐Galindo C. Model for regional collaboration: Successful strategy to implement a pediatric early warning system in 36 pediatric oncology centers in Latin America. Cancer 2022; 128:4004-4016. [PMID: 36161436 PMCID: PMC9828186 DOI: 10.1002/cncr.34427] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer; however, they are under-used in resource-limited settings. The authors use the knowledge-to-action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality-improvement collaborative, to scale-up PEWS in pediatric oncology centers in Latin America. METHODS Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact. RESULTS From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3-13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high-quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care. CONCLUSIONS Evidence-based interventions like PEWS can be successfully scaled-up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes. LAY SUMMARY Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer; however, implementation challenges limit their use in resource-limited settings. Proyecto EVAT is a multicenter quality-improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America. This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale-up PEWS. The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.
Collapse
Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Alejandra Gonzalez Ruiz
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Hilmarie Muniz‐Talavera
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Angela K. Carrillo
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Adolfo Cárdenas
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Maria F. Puerto‐Torres
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Marcela Garza
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | | | | | | | | | - Yvania Alfonso
- Pediatric Hemato‐oncologyHospital St DamienPort‐Au‐PrinceHaiti
| | | | | | - Rosario Batista
- Pediatric Hemato‐OncologyHospital Jose Domingo De ObaldíaChiriquiPanama
| | | | | | | | | | - Wendy Gómez‐García
- Pediatric Hemato‐OncologyHospital Infantil Dr Robert Reid CabralSanto DomingoDominican Republic
| | | | | | - Martha Herrera Almanza
- Pediatric Hemato‐OncologyHospital Infantil de Especialidades de ChihuahuaChihuahuaMexico
| | - Yajaira V. Jimenez Antolinez
- Pediatric Hemato‐OncologyHospital Universitario Dr José Eleuterio González, Universidad Autónoma de Nuevo LeónMonterreyMexico
| | | | - Norma Araceli López Facundo
- Pediatric Hemato‐OncologyInstituto de Seguridad Social del Estado de México y Municipos Hospital Materno InfantilTolucaMexico
| | | | - Kenia Miller
- Pediatric Hemato‐OncologyHospital del Niño “Jose Renan Esquivel”PanamaPanama
| | | | - Roxana Morales
- Pediatric Hemato‐OncologyInstituto Nacional de Enfermedades NeoplásicasLimaPeru
| | | | - Alejandra Osuna
- Pediatric Hemato‐OncologyHospital Pediátrico de SinaloaCuliacanMexico
| | | | - Clara Krystal Pérez Fermin
- Pediatric Hemato‐OncologyHospital Infantil Regional Universitario Dr Arturo GrullónSantiagoDominican Republic
| | | | - Estuardo Pineda
- Pediatric Hemato‐OncologyHospital de Niños Benjamín BloomSan SalvadorEl Salvador
| | | | | | - Jocelyn Rivera
- Department of PediatricsHospital Infantil Teletón de Oncología (HITO)QueretaroMexico
| | | | | | | | | | | | | | - Daniel Tatay
- Pediatric Hemato‐OncologyHospital del Niños de la Santísima Trinidad de CórdobaCordobaArgentina
| | | | | | | | | | - Monika L. Metzger
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | - Paola Friedrich
- Department of Global Pediatric MedicineSt Jude Children’s Research HospitalMemphisTennesseeUSA
| | | | | |
Collapse
|
17
|
Mirochnick E, Graetz DE, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Agulnik A. Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals. Front Oncol 2022; 12:1018224. [PMID: 36313665 PMCID: PMC9597682 DOI: 10.3389/fonc.2022.1018224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.
Collapse
Affiliation(s)
- Emily Mirochnick
- The Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Srinithya R. Gillipelli
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- School of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer Solca Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
| |
Collapse
|
18
|
Alturki A, Al-Eyadhy A, Alfayez A, Bendahmash A, Aljofan F, Alanzi F, Alsubaie H, Alabdulsalam M, Alayed T, Alofisan T, Alnajem A. Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience. Sci Rep 2022; 12:12436. [PMID: 35859000 PMCID: PMC9300636 DOI: 10.1038/s41598-022-16632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the "zero time", early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.
Collapse
Affiliation(s)
- Abdullah Alturki
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali Alfayez
- Maternity and Children's Hospital, Alhasa, Saudi Arabia
| | - Abdulrahman Bendahmash
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad Aljofan
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fawaz Alanzi
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hadeel Alsubaie
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Moath Alabdulsalam
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Tareq Alayed
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Tariq Alofisan
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Afnan Alnajem
- Research Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| |
Collapse
|
19
|
Haier J, Schaefers J. Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups. Cancers (Basel) 2022; 14:cancers14133158. [PMID: 35804928 PMCID: PMC9265013 DOI: 10.3390/cancers14133158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/04/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care. Abstract Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.
Collapse
|
20
|
Agulnik A, Schmidt-Grimminger G, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE, McKay V. Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America. FRONTIERS IN HEALTH SERVICES 2022; 2:1004805. [PMID: 36925775 PMCID: PMC10012640 DOI: 10.3389/frhs.2022.1004805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
Background Sustainability, or continued use of evidence-based interventions for long-term patient benefit, is the least studied aspect of implementation science. In this study, we evaluate sustainability of a Pediatric Early Warning System (PEWS), an evidence-based intervention to improve early identification of clinical deterioration in hospitalized children, in low-resource settings using the Clinical Capacity for Sustainability Framework (CCS). Methods We conducted a secondary analysis of a qualitative study to identify barriers and enablers to PEWS implementation. Semi-structured interviews with PEWS implementation leaders and hospital directors at 5 Latin American pediatric oncology centers sustaining PEWS were conducted virtually in Spanish from June to August 2020. Interviews were recorded, professionally transcribed, and translated into English. Exploratory thematic content analysis yielded staff perceptions on PEWS sustainability. Coded segments were analyzed to identify participant perception about the current state and importance of sustaining PEWS, as well as sustainability successes and challenges. Identified sustainability determinants were mapped to the CCS to evaluate its applicability. Results We interviewed 71 staff including physicians (45%), nurses (45%), and administrators (10%). Participants emphasized the importance of sustaining PEWS for continued patient benefits. Identified sustainability determinants included supportive leadership encouraging ongoing interest in PEWS, beneficial patient outcomes enhancing perceived value of PEWS, integrating PEWS into the routine of patient care, ongoing staff turnover creating training challenges, adequate material resources to promote PEWS use, and the COVID-19 pandemic. While most identified factors mapped to the CCS, COVID-19 emerged as an additional external sustainability challenge. Together, these challenges resulted in multiple impacts on PEWS sustainment, ranging from a small reduction in PEWS quality to complete disruption of PEWS use and subsequent loss of benefits to patients. Participants described several innovative strategies to address identified challenges and promote PEWS sustainability. Conclusion This study describes clinician perspectives on sustainable implementation of evidence-based interventions in low-resource settings, including sustainability determinants and potential sustainability strategies. Identified factors mapped well to the CCS, however, external factors, such as the COVID pandemic, may additionally impact sustainability. This work highlights an urgent need for theoretically-driven, empirically-informed strategies to support sustainable implementation of evidence-based interventions in settings of all resource-levels.
Collapse
Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Virginia McKay
- Brown School, Washington University, St. Louis, MO, United States
| |
Collapse
|
21
|
Agulnik A, Malone S, Puerto-Torres M, Gonzalez-Ruiz A, Vedaraju Y, Wang H, Graetz D, Prewitt K, Villegas C, Cardenas-Aguierre A, Acuna C, Arana AE, Díaz R, Espinoza S, Guerrero K, Martínez A, Mendez A, Montalvo E, Soberanis D, Torelli A, Quelal J, Villanueva E, Devidas M, Luke D, McKay V. Reliability and validity of a Spanish-language measure assessing clinical capacity to sustain Paediatric Early Warning Systems (PEWS) in resource-limited hospitals. BMJ Open 2021; 11:e053116. [PMID: 34670767 PMCID: PMC8529978 DOI: 10.1136/bmjopen-2021-053116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paediatric Early Warning Systems (PEWSs) improve identification of deterioration, however, their sustainability has not been studied. Sustainability is critical to maximise impact of interventions like PEWS, particularly in low-resource settings. This study establishes the reliability and validity of a Spanish-language Clinical Sustainability Assessment Tool (CSAT) to assess clinical capacity to sustain interventions in resource-limited hospitals. METHODS Participants included PEWS implementation leadership teams of 29 paediatric cancer centres in Latin America involved in a collaborative to implement PEWS. The CSAT, a sustainability assessment tool validated in high-resource settings, was translated into Spanish and distributed to participants as an anonymous electronic survey. Psychometric, confirmatory factor analysis (CFA), and multivariate analyses were preformed to assess reliability, structure and initial validity. Focus groups were conducted after participants reviewed CSAT reports to assess their interpretation and utility. RESULTS The CSAT survey achieved an 80% response rate (n=169) with a mean score of 4.4 (of 5; 3.8-4.8 among centres). The CSAT had good reliability with an average internal consistency of 0.77 (95% CI 0.71 to 0.81); and CFAs supported the seven-domain structure. CSAT results were associated with respondents' perceptions of the evidence for PEWS, its implementation and use in their centre, and their assessment of the hospital culture and implementation climate. The mean CSAT score was higher among respondents at centres with longer time using PEWS (p<0.001). Focus group participants noted the CSAT report helped assess their centre's clinical capacity to sustain PEWS and provided constructive feedback for improvement. CONCLUSIONS We present information supporting the reliability and validity of the CSAT tool, the first Spanish-language instrument to assess clinical capacity to sustain evidence-based interventions in hospitals of variable resource levels. This assessment demonstrates a high capacity to sustain PEWS in these resource-limited centres with improvement over time from PEWS implementation.
Collapse
Affiliation(s)
- Asya Agulnik
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sara Malone
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Maria Puerto-Torres
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Yuvanesh Vedaraju
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Huiqi Wang
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Dylan Graetz
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim Prewitt
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Cesar Villegas
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carlos Acuna
- Pediatric Critical Care, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Ana Edith Arana
- Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Silvana Espinoza
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | | | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Dora Soberanis
- Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Antonella Torelli
- Pediatric Oncology, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Janeth Quelal
- Pediatric Oncology, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Erika Villanueva
- Pediatric Oncology, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Meenakshi Devidas
- Global Pediatric Medicine, Saint Jude Children's Research Hospital, Memphis, Tennessee, USA
- Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Douglas Luke
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Virginia McKay
- Center for Public Health Systems Science, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, USA
| |
Collapse
|
22
|
Graetz D, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Mack JW, Agulnik A. Qualitative Study of Pediatric Early Warning Systems' Impact on Interdisciplinary Communication in Two Pediatric Oncology Hospitals With Varying Resources. JCO Glob Oncol 2021; 6:1079-1086. [PMID: 32673079 PMCID: PMC7392735 DOI: 10.1200/go.20.00163] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Hospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings. METHODS This qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software. RESULTS The study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action. CONCLUSION PEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.
Collapse
Affiliation(s)
- Dylan Graetz
- St. Jude Children's Research Hospital, Memphis, TN
| | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Gia Ferrara
- St. Jude Children's Research Hospital, Memphis, TN
| | - Mario Rodriguez
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | | | | | | | - Jennifer W Mack
- Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA
| | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN
| |
Collapse
|
23
|
van der Fluit KS, Boom MC, Brandão MB, Lopes GD, Barreto PG, Leite DCF, Gurgel RQ. How to implement a PEWS in a resource-limited setting: A quantitative analysis of the bedside-PEWS implementation in a hospital in northeast Brazil. Trop Med Int Health 2021; 26:1240-1247. [PMID: 34192384 PMCID: PMC8596539 DOI: 10.1111/tmi.13646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Quantitative analysis of the implementation of the bedside paediatric early warning system (B-PEWS) in a resource-limited setting. The B-PEWS serves to pre-emptively identify hospitalised children who are at risk for cardiopulmonary arrest and subsequently to provide critical care in time. METHODS We performed a retrospective review through the medical data records of patients after discharge from the paediatric ward of a philanthropic hospital in Brazil. Nurses' performance using the system was measured with various parameters. RESULTS A total of 499 patients were included, and a total of 8024 scores were checked. During the 21-week research period, the implementation rate increased significantly from 66.5% (SD 26.0) in Period 1 to 93.1% (SD 16.6) in Period 2. The number of scores that resulted in a correct total score went from 7.5% in Period 1 to 32.2% in Period 2, p < 0.001. There was an improvement in the correct choice of age group between the two periods (from 32.2% to 53.4%). There was no difference in the mean admission time of patients in the two periods: in the first period 4.8 days (SD 2.9) and in the second period 4.8 days (SD 4.1). CONCLUSIONS It is possible to implement a PEWS in resource-limited settings while achieving high implementation rates. However, this is a time- and energy-consuming process. Having an active and involved team that is responsible for implementation is key for a successful implementation. Factors that likely hindered implementation were a large change in workflow for the nursing staff, non-native speakers as main investigators.
Collapse
Affiliation(s)
- Karin S van der Fluit
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthijs C Boom
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Marlon B Brandão
- Department of Pediatrics, Hospital e Maternidade Santa Isabel, Aracaju, Brazil.,Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
| | - Gabriel D Lopes
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Paula G Barreto
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Deborah C F Leite
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Ricardo Q Gurgel
- Graduate Program in Health Sciences and Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
| |
Collapse
|
24
|
Garza M, Graetz DE, Kaye EC, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings. Front Oncol 2021; 11:660051. [PMID: 34249696 PMCID: PMC8260684 DOI: 10.3389/fonc.2021.660051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
Background Children with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting. Methods We conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively. Results Providers discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse. Conclusion Providers that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.
Collapse
Affiliation(s)
- Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States.,Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| |
Collapse
|
25
|
Mezgebu E, Anwarali S, Durañona M, Challinor J. Pediatric Oncology Nursing Research in Low- and Middle-Income Countries: Exemplars from Three Regions. Semin Oncol Nurs 2021; 37:151168. [PMID: 34148741 DOI: 10.1016/j.soncn.2021.151168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study examined the status of pediatric oncology nursing research in three low- and middle-income countries (LMICs) as examples across three World Health Organization regions: East Africa, Eastern Mediterranean region, and Latin America. DATA SOURCES Published literature was identified from Google Scholar, PubMed, Scielo, Virtual Health Library, and reference lists of some articles. CONCLUSION The experiences of the three LMIC pediatric oncology nurses illustrate the situation of nurse research in their setting and identify relevant published literature. The authors highlight the challenges for nurses to conduct research (eg, lack of training, mentors, funding, and opportunities). Local evidence to inform nursing practice in LMICs is needed. Recommendations for ameliorating the situation include increased advanced practice nurse education, physician and hospital support, funding, and protected time. IMPLICATIONS FOR NURSING PRACTICE Pediatric oncology nursing practice is culturally and context-driven and requires locally acquired evidence to support best practices. Only when sufficient, sustainable, and local nursing research training and education is available in LMICs, will this evidence be generated. Nursing research training (eg, master's and PhD programs), funding, and protected time are three key steps to guide and motivate staff nurses as well as academic nurses to participate in research that informs the care of children and adolescents with cancer across all countries and not only those with significant resources.
Collapse
Affiliation(s)
| | - Shenila Anwarali
- Pediatric Oncology Department, Indus Hospital, Karachi, Pakistan
| | | | - Julia Challinor
- School of Nursing, University of California San Francisco, San Francisco, CA.
| |
Collapse
|
26
|
Graetz DE, Giannars E, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillon-Klussmann F, Gattuso JS, Andes KL, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration. Front Oncol 2021; 11:626457. [PMID: 33718195 PMCID: PMC7947818 DOI: 10.3389/fonc.2021.626457] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background Pediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians' emotional responses to deterioration events. Methods Semi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children's Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content. Results Emotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children's Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study. Conclusion Clinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.
Collapse
Affiliation(s)
- Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Emily Giannars
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Karen L Andes
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| |
Collapse
|
27
|
Park SJ, Cho KJ, Kwon O, Park H, Lee Y, Shim WH, Park CR, Jhang WK. Development and validation of a deep-learning-based pediatric early warning system: A single-center study. Biomed J 2021; 45:155-168. [PMID: 35418352 PMCID: PMC9133255 DOI: 10.1016/j.bj.2021.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/23/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Seong Jong Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Kyung-Jae Cho
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Oyeon Kwon
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Hyunho Park
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Yeha Lee
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Woo Hyun Shim
- Department of Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae Ri Park
- Department of Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
| |
Collapse
|
28
|
Clinical audit of a Paediatric Emergency Warning Score (PEWS) in the paediatric oncology unit of a newly established tertiary cancer institute. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2020. [DOI: 10.1016/j.phoj.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
29
|
Arias AV, Garza M, Murthy S, Cardenas A, Diaz F, Montalvo E, Nielsen KR, Kortz T, Sharara-Chami R, Friedrich P, McArthur J, Agulnik A. Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus. Cancer Med 2020; 9:6984-6995. [PMID: 32777172 PMCID: PMC7541142 DOI: 10.1002/cam4.3351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.
Collapse
Affiliation(s)
- Anita V Arias
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Adolfo Cardenas
- Hospital Infantil Teletón de Oncología (HITO), Querétaro, México
| | - Franco Diaz
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Erika Montalvo
- Pediatric Critical Care Unit, SOLCA Quito, Quito, Ecuador
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Teresa Kortz
- Division of Pediatric Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer McArthur
- Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.,Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|