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Jasaui Y, Mortazhejri S, Dowling S, Duquette D, L’Heureux G, Linklater S, Mrklas KJ, Wilkinson G, Beesoon S, Patey AM, Ruzycki SM, Grimshaw JM. Beyond guideline knowledge: a theory-based qualitative study of low-value preoperative testing. Perioper Med (Lond) 2023; 12:3. [PMID: 36864470 PMCID: PMC9979452 DOI: 10.1186/s13741-023-00292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/12/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining preoperative tests before low-risk procedures. However, these recommendations alone have not reduced low-value test ordering. In this study, the theoretical domains framework (TDF) was used to understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for patients undergoing low-risk surgery ('low-value preoperative testing') among anesthesiologists, internal medicine specialists, nurses, and surgeons. METHODS Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices. RESULTS Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences). CONCLUSIONS We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.
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Affiliation(s)
- Yamile Jasaui
- grid.22072.350000 0004 1936 7697Continuing Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sameh Mortazhejri
- grid.412687.e0000 0000 9606 5108Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
| | - Shawn Dowling
- grid.22072.350000 0004 1936 7697Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - D’Arcy Duquette
- Patient Partner, De-Implementing Wisely Research Group, Edmonton, Canada
| | - Geralyn L’Heureux
- Patient Partner, De-Implementing Wisely Research Group, Edmonton, Canada
| | - Stefanie Linklater
- grid.412687.e0000 0000 9606 5108Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Kelly J. Mrklas
- grid.413574.00000 0001 0693 8815Strategic Clinical Networks, Provincial Clinical Excellence, Alberta Health Services, Edmonton, AB Canada
| | - Gloria Wilkinson
- Patient Partner, De-Implementing Wisely Research Group, Edmonton, Canada
| | - Sanjay Beesoon
- grid.413574.00000 0001 0693 8815Surgery Strategic Clinical Network, Alberta Health Services, Edmonton, AB Canada
| | - Andrea M. Patey
- grid.412687.e0000 0000 9606 5108Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Shannon M. Ruzycki
- grid.17089.370000 0001 2190 316XFaculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada ,grid.22072.350000 0004 1936 7697Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jeremy M. Grimshaw
- grid.412687.e0000 0000 9606 5108Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON Canada ,grid.28046.380000 0001 2182 2255Department of Medicine, University of Ottawa, Ottawa, ON Canada
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Abdoler EA, Parsons AS, Wijesekera TP. The future of teaching management reasoning: important questions and potential solutions. Diagnosis (Berl) 2023; 10:19-23. [PMID: 36420532 DOI: 10.1515/dx-2022-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.
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Affiliation(s)
- Emily A Abdoler
- Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew S Parsons
- Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Dent J. Risk and reward in the resource deplete setting: Lessons from rural, regional and remote emergency medicine. Emerg Med Australas 2023; 35:155-156. [PMID: 36543324 DOI: 10.1111/1742-6723.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- James Dent
- Emergency Department, The Tweed Hospital, Tweed Heads, New South Wales, Australia
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Oliveira J E Silva L, Khoujah D, Naples JG, Edlow JA, Gerberi DJ, Carpenter CR, Bellolio F. Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Acad Emerg Med 2022; 30:531-540. [PMID: 35975654 DOI: 10.1111/acem.14583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/10/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN. METHODS We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed. RESULTS From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low. CONCLUSIONS There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.
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Affiliation(s)
- Lucas Oliveira J E Silva
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, RS, Brazil.,Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - James G Naples
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | | | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
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Hattingh HL, Michaleff ZA, Fawzy P, Du L, Willcocks K, Tan KM, Keijzers G. Ordering of computed tomography scans for head and cervical spine: a qualitative study exploring influences on doctors' decision-making. BMC Health Serv Res 2022; 22:790. [PMID: 35717206 PMCID: PMC9206095 DOI: 10.1186/s12913-022-08156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors' decisions to order CT of the head or cervical spine. METHODS In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. RESULTS In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. CONCLUSIONS CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.
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Affiliation(s)
- H Laetitia Hattingh
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia. .,School of Pharmacy and Medical Sciences, Griffith University, Southport, Gold Coast, QLD, 4222, Australia.
| | | | - Peter Fawzy
- Neurosurgery Department, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia.,School of Medicine and Health Sciences, Bond University, Gold Coast, QLD, 4226, Australia
| | - Leanne Du
- Medical Imaging, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - Karlene Willcocks
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - K Meng Tan
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4226, Australia.,School of Medicine, Griffith University, Southport, Gold Coast, QLD, 4222, Australia
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6
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Evison H, Carrington M, Keijzers G, Marsh NM, Sweeny AL, Byrnes J, Rickard CM, Carr PJ, Ranse J. Peripheral intravenous cannulation decision-making in emergency settings: a qualitative descriptive study. BMJ Open 2022; 12:e054927. [PMID: 35273050 PMCID: PMC8915296 DOI: 10.1136/bmjopen-2021-054927] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Rates of unused ('idle') peripheral intravenous catheters (PIVCs) are high but can vary per setting. Understanding factors that influence the decision-making of doctors, nurses and paramedics in the emergency setting regarding PIVC insertion, and what factors may modify their decision is essential to identify opportunities to reduce unnecessary cannulations and improve patient-centred outcomes. This study aimed to understand factors associated with clinicians' decision-making on whether to insert or use a PIVC in the emergency care setting. DESIGN A qualitative descriptive study using in-depth semistructured interviews and thematic analysis. SETTING Gold Coast, Queensland, Australia, in a large tertiary level emergency department (ED) and local government ambulance service. PARTICIPANTS Participants recruited were ED clinicians (doctors, nurses) and paramedics who regularly insert PIVCs. RESULTS From the 15 clinicians interviewed 4 key themes: knowledge and experience, complicated and multifactorial, convenience, anticipated patient clinical course, and several subthemes emerged relating to clinician decision-making across all disciplines. The first two themes focused on decision-making to gather data and evidence, such as knowledge and experience, and decisions being complicated and multifactorial. The remaining two themes related to the actions clinicians took such as convenience and anticipated patient clinical course. CONCLUSION The decision to insert a PIVC is more complicated than clinicians, administrators and policy-makers may realise. When explored, clinician decisions were multifaceted with many factors influencing the decision to insert a PIVC. In actual practice, clinicians routinely insert PIVCs in most patients as a learnt reflex with little cognitive input. When considering PIVC insertion, more time needs to be devoted to the awareness of: (1) decision-making in the context of the clinician's own experience, (2) cognitive biases and (3) patient-centred factors. Such awareness will support an appropriate risk assessment which will benefit the patient, clinician and healthcare system.
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Affiliation(s)
- Hugo Evison
- Gold Coast Region, Queensland Ambulance Service, Brisbane, Queensland, Australia
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery/School of Pharmacy and Medical Science, Griffith University, Nathan, Queensland, Australia
| | - Mercedes Carrington
- Department of Emergency Medicine, Robina Hospital, Robina, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Nicole M Marsh
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery/School of Pharmacy and Medical Science, Griffith University, Nathan, Queensland, Australia
- Nursing and Midwifery Centre Research Centre, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
- Menzies Health Institute, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Amy Lynn Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Joshua Byrnes
- School of Medicine, Centre for Applied Health Economics, Griffith University, Nathan, Queensland, Australia
| | - Claire M Rickard
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery/School of Pharmacy and Medical Science, Griffith University, Nathan, Queensland, Australia
- Nursing and Midwifery Centre Research Centre, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
- Herston Infectious Disease Institute, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Peter J Carr
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery/School of Pharmacy and Medical Science, Griffith University, Nathan, Queensland, Australia
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Jamie Ranse
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Menzies Health Institute, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
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7
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Bone I. The art of doing nothing. Pract Neurol 2022; 22:264-265. [DOI: 10.1136/practneurol-2022-003393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
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Wu CJJ, Giles M, Terblanche M, Drabble A. Engaging consumers and health professionals in collaborative decision-making to optimize care. Nurs Health Sci 2021; 24:73-77. [PMID: 34741561 DOI: 10.1111/nhs.12901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 11/26/2022]
Abstract
Shared communication and collaborative decision-making between consumers and health professionals is essential in optimizing the quality of consumer care. However, the consumers' ability to ask questions and seek answers, as well as health professionals' communication skills to engage with the consumer, are necessary considerations for the collaborative decision-making process. This quality improvement initiative sought to understand the context of collaborative decision making from the perspective of consumers and health professionals adapted from the international Choosing Wisely program. Findings indicated health professionals acknowledged a problem with unnecessary and overuse of tests, treatments, and procedures. Consumers suggested they were confident asking questions about their health and care. The findings of this study highlight collaborative decision-making as a worthwhile and beneficial undertaking.
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Affiliation(s)
- Chiung-Jung Jo Wu
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast (USC), Moreton Bay campus, Australia.,Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
| | - Megan Giles
- Safety Quality & Innovation, Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Morne Terblanche
- Safety Quality & Innovation, Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Anne Drabble
- School of Education and Tertiary Access, University of the Sunshine Coast (USC), Sippy Downs, Australia
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Pellatt RAF, Kamona S, Chu K, Sweeny A, Kuan WS, Kinnear FB, Karamercan MA, Klim S, Wijeratne T, Graham CA, Body R, Roberts T, Horner D, Laribi S, Keijzers G, Kelly AM. The Headache in Emergency Departments study: Opioid prescribing in patients presenting with headache. A multicenter, cross-sectional, observational study. Headache 2021; 61:1387-1402. [PMID: 34632592 DOI: 10.1111/head.14217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/02/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. BACKGROUND International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. METHODS This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. RESULTS Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0). CONCLUSION Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.
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Affiliation(s)
- Richard A F Pellatt
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia.,LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Sinan Kamona
- Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand.,School of Medicine, University of Auckland, Auckland, New Zealand
| | - Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Queensland, Australia.,Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Amy Sweeny
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Frances B Kinnear
- Faculty of Medicine, University of Queensland, Queensland, Australia.,Emergency & Children's Services, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Mehmet A Karamercan
- Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Sunshine, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, St Albans, Victoria, Australia.,Public Health School, La Trobe University, Bundoora, Victoria, Australia
| | - Colin A Graham
- Emergency Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tom Roberts
- Emergency Department, North Bristol NHS Trust, Bristol, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Sunshine, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
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Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
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11
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Carpenter CR, Malone ML. Avoiding Therapeutic Nihilism from Complex Geriatric Intervention "Negative" Trials: STRIDE Lessons. J Am Geriatr Soc 2020; 68:2752-2756. [PMID: 33079398 DOI: 10.1111/jgs.16887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Emergency Care Research Core, St. Louis, Missouri, USA
| | - Michael L Malone
- Aurora Senior Services and Aurora at Home, Geriatric Medicine Fellowship Program, Advocate Aurora Health, Milwaukee, Wisconsin, USA
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12
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Carley S, Horner D, Body R, Mackway-Jones K. Evidence-based medicine and COVID-19: what to believe and when to change. Emerg Med J 2020; 37:572-575. [DOI: 10.1136/emermed-2020-210098] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 12/21/2022]
Abstract
The COVID-19 pandemic has led to a surge of information being presented to clinicians regarding this novel and deadly disease. There is a clear urgency to collate, review, appraise and act on this information if we are to do the best for clinicians and patients. However, the speed of the pandemic is a threat to traditional models of knowledge translation and practice change. In this concepts paper, we argue that clinicians need to be agile in their thinking and practice in order to find the right time to change. Adoption of new methods should be based on clinical judgement, the weight of evidence and the balance of probabilities that any new technique, test or treatment might work. The pandemic requires all of us to reach a new level of evidence-based medicine characterised by scepticism, thoughtfulness, responsiveness and clinically agility in practice.
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13
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Greenup RA, Prakash I, Sorenson C. “Choosing Wisely” in Breast Cancer Surgery: Drivers of Low Value Care. Ann Surg Oncol 2020; 27:2577-2579. [DOI: 10.1245/s10434-020-08584-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 12/23/2022]
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14
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Gérvas J, Oliver LL, Pérez-Fernandez M. Family and Community Medicine and its role in preventing health overuse (preventive, diagnostic, therapeutic and rehabilitative). CIENCIA & SAUDE COLETIVA 2019; 25:1233-1240. [PMID: 32267426 DOI: 10.1590/1413-81232020254.30082019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022] Open
Abstract
In Medicine, it is critical "to offer 100% of what is needed and avoid 100% of what is not needed." Unfortunately, this primary issue is challenging, and generally, more than required is offered, and everything that is unnecessary is not avoided. This is a nonsystematic review with a teaching objective that reviews the general issue in primary care and suggests ways to avoid overuse and shortcomings concerning preventive, diagnostic, therapeutic, and rehabilitative interventions. Knowing not to do is science and art that is hardly taught and practiced less. The overuse that harm are an almost daily part of clinical practice in prevention, diagnosis, treatment, and rehabilitation. It is essential to promote "the art and science of not doing".
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Affiliation(s)
- Juan Gérvas
- Equipo CESCA. Pradillo 68.28002 Madrid España.
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15
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Gutenstein M. Daring to be wise: We are black boxes, and artificial intelligence will be the solution. Emerg Med Australas 2019; 31:891-892. [DOI: 10.1111/1742-6723.13363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Marc Gutenstein
- Emergency DepartmentNelson Marlborough District Health Board Nelson New Zealand
- Rural Health Academic CentreUniversity of Otago Christchurch New Zealand
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16
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Zehtabchi S, Fatovich DM. Moving Beyond Diagnostic Accuracy With Systematic Reviews and Meta-analyses. Acad Emerg Med 2019; 26:580-583. [PMID: 30222234 DOI: 10.1111/acem.13617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Daniel Michael Fatovich
- Royal Perth Hospital University of Western Australia Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
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17
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Denny KJ, Keijzers G. Culturing conversation: How clinical audits can improve our ability to choose wisely. Emerg Med Australas 2019; 30:448-449. [PMID: 30129162 DOI: 10.1111/1742-6723.13121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Kerina J Denny
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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18
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Egerton-Warburton D, Cullen L, Keijzers G, Fatovich DM. ‘What the hell is water?’ How to use deliberate clinical inertia in common emergency department situations. Emerg Med Australas 2018; 30:426-430. [DOI: 10.1111/1742-6723.12950] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Diana Egerton-Warburton
- School of Clinical Science at Monash Health; Monash University Faculty of Medicine, Nursing and Health Sciences; Melbourne Victoria Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Queensland University of Technology; The University of Queensland; Brisbane Queensland Australia
| | - Gerben Keijzers
- Department of Emergency Medicine; Gold Coast University Hospital; Gold Coast Queensland Australia
- School of Medicine; Bond University; Gold Coast Queensland Australia
- School of Medicine, Griffith University; Gold Coast Queensland Australia
| | - Daniel M Fatovich
- Emergency Medicine; Royal Perth Hospital, The University of Western Australia; Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
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19
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Keijzers G, Cullen L, Egerton-Warburton D, Fatovich DM. Re: Medical student enquiries on the art of clinical inertia. Emerg Med Australas 2018; 30:435-436. [DOI: 10.1111/1742-6723.12980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 03/18/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Gerben Keijzers
- Department of Emergency Medicine; Gold Coast University Hospital; Gold Coast Queensland Australia
- School of Medicine; Bond University; Gold Coast Queensland Australia
- School of Medicine; Griffith University; Gold Coast Queensland Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital; Queensland University of Technology, The University of Queensland; Brisbane Queensland Australia
| | - Diana Egerton-Warburton
- School of Clinical Science at Monash Health; Monash University Faculty of Medicine, Nursing and Health Sciences; Melbourne Victoria Australia
| | - Daniel M Fatovich
- Emergency Medicine, Royal Perth Hospital; The University of Western Australia; Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
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20
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Xie Y. Medical student enquiries on the art of clinical inertia. Emerg Med Australas 2018; 30:434-435. [DOI: 10.1111/1742-6723.12973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Yi Xie
- College of Medicine and Public Health; Flinders University; Adelaide South Australia Australia
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