Identifying and Investigating Ambulatory Care Sequences Before Invasive Coronary Angiography

Exploring heterogeneity in coxarthrosis medication use patterns before total hip replacement: a State Sequence Analysis

OBJECTIVE

Evidence of geographical variation in total hip replacement (THR) and deviations from treatment guidelines persists. In this exploratory study, we aim to gain an in-depth understanding of patients' healthcare trajectories by identifying and visualising medication use patterns in coxarthrosis patients before surgery. We examine their association with patient characteristics and THR, and compare them with recommendations on mild analgesics, opioid prescription and exhaustion of conservative therapy.

METHODS

In this exploratory study, we apply State Sequence Analysis (SSA) on German health insurance data (2012-2015). We analyse a cohort of coxarthrosis patients, half of whom underwent THR after a 1 year observation period and half of whom did not undergo surgery until at least 1 year after the observation period. Hierarchical states are defined based on prescriptions. We construct sequences, calculate sequence similarity using optimal matching and identify medication use patterns via clustering. Patterns are visualised, descriptive statistics are presented and logistic regression is employed to investigate the association of medication patterns with subsequent THR.

RESULTS

Seven distinct medication use patterns are identified, correlating strongly with patient characteristics and subsequent THR. Two patterns leading to THR demonstrate exhaustion of pharmacological therapy. Opioid use is concentrated in two small patterns with low odds for THR. The most frequent pattern lacks significant pharmacological therapy.

CONCLUSIONS

This SSA uncovers heterogeneity in medication use patterns before surgery in coxarthrosis patients. Cautious opioid handling and adherence to a stepped prescription approach are observed, but many patients display low medication therapy usage and lack evidence of exhausting conservative options before surgery.

Clustering care pathways of people with alcohol dependence using a data linkage of routine data in Bremen, Germany

BACKGROUND

Although many individuals with alcohol dependence (AD) are recognized in the German healthcare system, only a few utilize addiction-specific treatment services. Those who enter treatment are not well characterized regarding their prospective pathways through the highly fragmented German healthcare system. This paper aims to (1) identify typical care pathways of patients with AD and their adherence to treatment guidelines and (2) explore the characteristics of these patients using routine data from different healthcare sectors.

METHODS

We linked routinely collected register data of individuals with a documented alcohol-related diagnosis in the federal state of Bremen, Germany, in 2016/2017 and their addiction-specific health care: two statutory health insurance funds (outpatient pharmacotherapy for relapse prevention and inpatient episodes due to AD with and without qualified withdrawal treatment (QWT)), the German Pension Insurance (rehabilitation treatment) and a group of communal hospitals (outpatient addiction care). Individual care pathways of five different daily states of utilized addiction-specific treatment following an index inpatient admission due to AD were analyzed using state sequence analysis and cluster analysis. The follow-up time was 307 days (10 months). Individuals of the clustered pathways were compared concerning current treatment recommendations (1: QWT followed by postacute treatment; 2: time between QWT and rehabilitation). Patients' characteristics not considered during the cluster analysis (sex, age, nationality, comorbidity, and outpatient addiction care) were then compared using a multinomial logistic regression.

RESULTS

The analysis of 518 individual sequences resulted in the identification of four pathway clusters differing in their utilization of acute and postacute treatment. Most did not utilize subsequent addiction-specific treatment after their index inpatient episode (n = 276) or had several inpatient episodes or QWT without postacute treatment (n = 205). Two small clusters contained pathways either starting rehabilitation (n = 26) or pharmacotherapy after the index episode (n = 11). Overall, only 9.3% utilized postacute treatment as recommended.

CONCLUSIONS

A concern besides the generally low utilization of addiction-specific treatment is the implementation of postacute treatments for individuals after QWT.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Applying sequence analysis to uncover 'real-world' clinical pathways from routinely collected data: a systematic review

OBJECTIVES

This systematic review aims to elucidate the methodological practices and reporting standards associated with sequence analysis (SA) for the identification of clinical pathways in real-world scenarios, using routinely collected data.

STUDY DESIGN AND SETTING

We conducted a methodological systematic review, searching five medical and health databases: MEDLINE, PsycINFO, CINAHL, EMBASE and Web of Science. The search encompassed articles from the inception of these databases up to February 28, 2023. The search strategy comprised two distinctive sets of search terms, specifically focused on sequence analysis and clinical pathways.

RESULTS

19 studies met the eligibility criteria for this systematic review. Nearly 60% of the included studies were published in or after 2021, with a significant proportion originating from Canada (n = 7) and France (n = 5). 90% of the studies adhered to the fundamental SA steps. The optimal matching (OM) method emerged as the most frequently employed dissimilarity measure (63%), while agglomerative hierarchical clustering using Ward's linkage was the preferred clustering algorithm (53%). However, it is imperative to underline that a majority of the studies inadequately reported key methodological decisions pertaining to SA.

CONCLUSION

This review underscores the necessity for enhanced transparency in reporting both data management procedures and key methodological choices within SA processes. The development of reporting guidelines and a robust appraisal tool tailored to assess the quality of SA would be invaluable for researchers in this field.

Analytical methods for identifying sequences of utilization in health data: a scoping review

BACKGROUND

Healthcare, as with other sectors, has undergone progressive digitalization, generating an ever-increasing wealth of data that enables research and the analysis of patient movement. This can help to evaluate treatment processes and outcomes, and in turn improve the quality of care. This scoping review provides an overview of the algorithms and methods that have been used to identify care pathways from healthcare utilization data.

METHOD

This review was conducted according to the methodology of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews Extension for Scoping Reviews (PRISMA-ScR) Checklist. The PubMed, Web of Science, Scopus, and EconLit databases were searched and studies published in English between 2000 and 2021 considered. The search strategy used keywords divided into three categories: the method of data analysis, the requirement profile for the data, and the intended presentation of results. Criteria for inclusion were that health data were analyzed, the methodology used was described and that the chronology of care events was considered. In a two-stage review process, records were reviewed by two researchers independently for inclusion. Results were synthesized narratively.

RESULTS

The literature search yielded 2,865 entries; 51 studies met the inclusion criteria. Health data from different countries ([Formula: see text]) and of different types of disease ([Formula: see text]) were analyzed with respect to different care events. Applied methods can be divided into those identifying subsequences of care and those describing full care trajectories. Variants of pattern mining or Markov models were mostly used to extract subsequences, with clustering often applied to find care trajectories. Statistical algorithms such as rule mining, probability-based machine learning algorithms or a combination of methods were also applied. Clustering methods were sometimes used for data preparation or result compression. Further characteristics of the included studies are presented.

CONCLUSION

Various data mining methods are already being applied to gain insight from health data. The great heterogeneity of the methods used shows the need for a scoping review. We performed a narrative review and found that clustering methods currently dominate the literature for identifying complete care trajectories, while variants of pattern mining dominate for identifying subsequences of limited length.

Analysis of the Effect of the Communication Ability of Nurses in Outpatient Infusion Room on the Treatment Experience of Patients and Their Families

Objective

To observe the effect of nursing communication ability in outpatient infusion room on the treatment experience of outpatients and their families and analyze whether improving nurses' communication skills can reduce the incidence of doctor-patient disputes.

Methods

According to the results of the communication ability survey, the outpatient nurses in our hospital are divided into groups A (score < 65), B (65 ≤ score < 80), C (80 ≤ score < 95), and D (score ≥ 95). Taking outpatients and their families in our hospital from September 2019 to December 2020 as the research objects, they were divided into corresponding groups according to the nurses who served them. Finally, there were 73 cases in group A, 85 in group B, 92 in group C, and 65 in group D. The mental toughness scale (Connor-Davidson Resilience Scale Chinese (CD-RISC)) scores and Herth Hope Index (HHI) scores of the four groups of patients were compared, and the correlation between nurse communication scores and CD-RISC scores and HHI scores was analyzed. The incidence of negative events (patient-nurse disputes, complaints, etc.) and the results of nursing satisfaction surveys during the visits of the four study groups were also counted.

Results

The four groups of CD-RISC and HHI total scores were ranked from highest to lowest as groups D, C, B, and A, respectively (P < 0.05). There was a positive correlation between the resilience dimension scores of the family members' CD-RISC and the toughness, strength, optimism dimension scores of the HHI and the nurses' communication dimension scores (r = 0.191-0.472, P < 0.05). Besides, the incidence of negative events was higher in group A than in the other three groups, while the satisfaction with care was lower than in the other three groups (P < 0.05).

Conclusion

Improving nurses' communication skills in infusion room nursing quality management can improve the mental toughness and hope level of patients' accompanying family members, which is conducive to controlling their emotions and avoiding the occurrence of dispute incidents.