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John JB, Gray WK, O'Flynn K, Briggs TWR, McGrath JS. The Getting It right First Time (GIRFT) programme in urology; rationale and methodology. BJU Int 2024. [PMID: 38637952 DOI: 10.1111/bju.16375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data-driven insights and clinically-led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data-driven, and specialty specific. Each specialty workstream conducts deep-dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep-dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT-advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.
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Affiliation(s)
- Joseph B John
- University of Exeter Medical School, University of Exeter, Exeter, UK
- Department of Urology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Getting It Right First Time Programme, NHS England, London, UK
| | - William K Gray
- Getting It Right First Time Programme, NHS England, London, UK
| | - Kieran O'Flynn
- Getting It Right First Time Programme, NHS England, London, UK
- Department of Urology, Salford Royal, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Tim W R Briggs
- Getting It Right First Time Programme, NHS England, London, UK
- Department of Surgery, Royal National Orthopaedic Hospital, London, UK
| | - John S McGrath
- University of Exeter Medical School, University of Exeter, Exeter, UK
- Department of Urology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Getting It Right First Time Programme, NHS England, London, UK
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Lenet T, Berthelot P, Grudzinski AL, Banks A, Tropiano J, McIsaac DI, Tinmouth A, Patey AM, Fergusson DA, Martel G. Nonclinical factors affecting intraoperative red blood cell transfusion: a systematic review. Can J Anaesth 2024:10.1007/s12630-024-02739-9. [PMID: 38509437 DOI: 10.1007/s12630-024-02739-9] [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: 04/03/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 03/22/2024] Open
Abstract
PURPOSE There is significant variability in intraoperative red blood cell (RBC) transfusion practice. We aimed to use the theoretical domains framework (TDF) to categorize nonclinical and behavioural factors driving intraoperative RBC transfusion practice in a systematic review of the literature. SOURCE We searched electronic databases from inception until August 2021 to identify studies evaluating nonclinical factors affecting intraoperative RBC transfusion. Using the Mixed Methods Appraisal Tool, we assessed the quality of included studies and identified relevant nonclinical factors, which were coded into TDF domains by two independent reviewers using NVivo (Lumivero, QSR International, Burlington, MA, USA). We identified common themes within domains and sorted domains based on the frequency of reported factors. PRINCIPAL FINDINGS Our systematic review identified 18 studies: nine retrospective cohort studies, six cross-sectional surveys, and three before-and-after studies. Factors related to the social influences, behavioural regulation, environmental context/resources, and beliefs about consequences domains of the TDF were the most reported factors. Key factors underlying the observed variability in transfusion practice included the social effects of peers, patients, and institutional culture on decision-making (social influences), and characteristics of the practice environment including case volume, geographic location, and case start time (environmental context/resources). Studies reported variable beliefs about the consequences of both intraoperative transfusion and anemia (beliefs about consequences). Provider- and institutional-level audits, educational sessions, and increased communication between surgeons/anesthesiologists were identified as strategies to optimize intraoperative transfusion decision-making (behavioural regulation). CONCLUSION Our systematic review has synthesized the literature on nonclinical and behavioural factors impacting intraoperative transfusion decision-making, categorized using the TDF. These findings can inform evidence-based interventions to reduce intraoperative RBC transfusion variability. STUDY REGISTRATION Open Science Framework ( https://osf.io/pm8zs/?view_only=166299ed28964804b9360c429b1218c1 ; first posted, 3 August 2022).
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Alexa L Grudzinski
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexander Banks
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Joseph Tropiano
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Alan Tinmouth
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Andrea M Patey
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Rd, CCW 1667, Ottawa, ON, K1H 8L6, Canada.
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3
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Brousseau K, Monette L, McIsaac DI, Workneh A, Tinmouth A, Shaw J, Ramsay T, Mallick R, Presseau J, Wherrett C, Carrier FM, Fergusson DA, Martel G. Point-of-care haemoglobin accuracy and transfusion outcomes in non-cardiac surgery at a Canadian tertiary academic hospital: protocol for the PREMISE observational study. BMJ Open 2023; 13:e075070. [PMID: 38101848 PMCID: PMC10729286 DOI: 10.1136/bmjopen-2023-075070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/15/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Transfusions in surgery can be life-saving interventions, but inappropriate transfusions may lack clinical benefit and cause harm. Transfusion decision-making in surgery is complex and frequently informed by haemoglobin (Hgb) measurement in the operating room. Point-of-care testing for haemoglobin (POCT-Hgb) is increasingly relied on given its simplicity and rapid provision of results. POCT-Hgb devices lack adequate validation in the operative setting, particularly for Hgb values within the transfusion zone (60-100 g/L). This study aims to examine the accuracy of intraoperative POCT-Hgb instruments in non-cardiac surgery, and the association between POCT-Hgb measurements and transfusion decision-making. METHODS AND ANALYSIS PREMISE is an observational prospective method comparison study. Enrolment will occur when adult patients undergoing major non-cardiac surgery require POCT-Hgb, as determined by the treating team. Three concurrent POCT-Hgb results, considered as index tests, will be compared with a laboratory analysis of Hgb (lab-Hgb), considered the gold standard. Participants may have multiple POCT-Hgb measurements during surgery. The primary outcome is the difference in individual Hgb measurements between POCT-Hgb and lab-Hgb, primarily among measurements that are within the transfusion zone. Secondary outcomes include POCT-Hgb accuracy within the entire cohort, postoperative morbidity, mortality and transfusion rates. The sample size is 1750 POCT-Hgb measurements to obtain a minimum of 652 Hgb measurements <100 g/L, based on an estimated incidence of 38%. The sample size was calculated to fit a logistic regression model to predict instances when POCT-Hgb are inaccurate, using 4 g/L as an acceptable margin of error. ETHICS AND DISSEMINATION Institutional ethics approval has been obtained by the Ottawa Health Science Network-Research Ethics Board prior to initiating the study. Findings from this study will be published in peer-reviewed journals and presented at relevant scientific conferences. Social media will be leveraged to further disseminate the study results and engage with clinicians.
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Affiliation(s)
- Karine Brousseau
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Leah Monette
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Aklile Workneh
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Division of Hematology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Shaw
- Department of Biochemistry, Eastern Ontario Regional Laboratories Association, Ottawa, Ontario, Canada
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christopher Wherrett
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Carneiro AV. Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients. Eur J Intern Med 2023; 115:43-45. [PMID: 37482472 DOI: 10.1016/j.ejim.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Affiliation(s)
- António Vaz Carneiro
- Institute for Evidence Based Healthcare (ISBE), Faculdade de Medicina da Universidade de Lisboa, Av. Professor Egas Moniz, Ed. Reynaldo dos Santos, piso 3, Portugal.
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Pagano L, Hemmert C, Hirschhorn A, Francis-Auton E, Arnolda G, Long JC, Braithwaite J, Gumley G, Hibbert PD, Churruca K, Hutchinson K, Partington A, Hughes C, Gillatt D, Ellis LA, Testa L, Patel R, Sarkies MN. Implementation of consensus-based perioperative care pathways to reduce clinical variation for elective surgery in an Australian private hospital: a mixed-methods pre-post study protocol. BMJ Open 2023; 13:e075008. [PMID: 37495386 PMCID: PMC10373689 DOI: 10.1136/bmjopen-2023-075008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION Addressing clinical variation in elective surgery is challenging. A key issue is how to gain consensus between largely autonomous clinicians. Understanding how the consensus process works to develop and implement perioperative pathways and the impact of these pathways on reducing clinical variation can provide important insights into the effectiveness of the consensus process. The primary objective of this study is to understand the implementation of an organisationally supported, consensus approach to implement perioperative care pathways in a private healthcare facility and to determine its impact. METHODS A mixed-methods Effectiveness-Implementation Hybrid (type III) pre-post study will be conducted in one Australian private hospital. Five new consensus-based perioperative care pathways will be developed and implemented for specific patient cohorts: spinal surgery, radical prostatectomy, cardiac surgery, bariatric surgery and total hip and knee replacement. The individual components of these pathways will be confirmed as part of a consensus-building approach and will follow a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment framework. The process of implementation, as well as barriers and facilitators, will be evaluated through semistructured interviews and focus groups with key clinical and non-clinical staff, and participant observation. We anticipate completing 30 interviews and 15-20 meeting observations. Administrative and clinical end-points for at least 152 participants will be analysed to assess the effectiveness of the pathways. ETHICS AND DISSEMINATION This study received ethical approval from Macquarie University Human Research Ethics Medical Sciences Committee (Reference No: 520221219542374). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and reports for key stakeholders.
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Affiliation(s)
- Lisa Pagano
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Cameron Hemmert
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Hirschhorn
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Graham Gumley
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Partington
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Cliff Hughes
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Gillatt
- MQ Health, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Luke Testa
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Romika Patel
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mitchell N Sarkies
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Lenet T, Tropiano J, Skanes S, Ivankovic V, Verret M, McIsaac DI, Tinmouth A, Nicholls SG, Patey AM, Fergusson DA, Martel G. Understanding Intraoperative Transfusion Decision-Making Variability: A Qualitative Study. Transfus Med Rev 2023; 37:150726. [PMID: 37315996 DOI: 10.1016/j.tmrv.2023.150726] [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: 03/11/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 06/16/2023]
Abstract
There is evidence of significant intraoperative red blood cell (RBC) transfusion variability that cannot be explained by case-mix, and may reflect unwarranted transfusions. The objective was to explore the source of intraoperative RBC transfusion variability by eliciting the beliefs of anesthesiologists and surgeons that underlie transfusion decisions. Interviews based on the Theoretical Domains Framework were conducted to identify beliefs about intraoperative transfusion. Content analysis was performed to group statements into domains. Relevant domains were selected based on frequency of beliefs, perceived influence on transfusion, and the presence of conflicting beliefs within domains. Of the 28 transfusion experts recruited internationally (16 anesthesiologists, 12 surgeons), 24 (86%) were Canadian or American and 11 (39%) identified as female. Eight relevant domains were identified: (1) Knowledge (insufficient evidence to guide intraoperative transfusion), (2) Social/professional role and identity (surgeons/anesthesiologists share responsibility for transfusions), (3) Beliefs about consequences (concerns about morbidity of transfusion/anemia), (4) Environmental context/resources (transfusions influenced by type of surgery, local blood supply, cost of transfusion), (5) Social influences (institutional culture, judgment by peers, surgeon-anesthesiologist relationship, patient preference influencing transfusion decisions), (6) Behavioral regulation (need for intraoperative transfusion guidelines, usefulness of audits and educational sessions to guide transfusion), (7) Nature of the behaviors (overtransfusion remains commonplace, transfusion practice becoming more restrictive over time), and (8) Memory, attention, and decision processes (various patient and operative characteristics are incorporated into transfusion decisions). This study identified a range of factors underlying intraoperative transfusion decision-making and partly explain the variability in transfusion behavior. Targeted theory-informed behavior-change interventions derived from this work could help reduce intraoperative transfusion variability.
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Tropiano
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephanie Skanes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Anesthesia, CHU de Québec - Université Laval, Québec City, Québec, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Canadian Blood Services, Ottawa, Ontario, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrea M Patey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Canadian Blood Services, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Stulz N, Jörg R, Reim-Gautier C, Bonsack C, Conus P, Evans-Lacko S, Gabriel-Felleiter K, Heim E, Jäger M, Knapp M, Richter D, Schneeberger A, Thornicroft SG, Traber R, Wieser S, Tuch A, Hepp U. Mental health service areas in Switzerland. Int J Methods Psychiatr Res 2023; 32:e1937. [PMID: 35976617 PMCID: PMC9976601 DOI: 10.1002/mpr.1937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/22/2022] [Accepted: 08/01/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Small area analysis is a health services research technique that facilitates geographical comparison of services supply and utilization rates between health service areas (HSAs). HSAs are functionally relevant regions around medical facilities within which most residents undergo treatment. We aimed to identify HSAs for psychiatric outpatient care (HSA-PSY) in Switzerland. METHODS We used HSAr, a new and automated methodological approach, and comprehensive psychiatric service use data from insurances to identify HSA-PSY based on travel patterns between patients' residences and service sites. Resulting HSA-PSY were compared geographically, demographically and regarding the use of inpatient and outpatient psychiatric services. RESULTS We identified 68 HSA-PSY, which were reviewed and validated by local mental health services experts. The population-based rate of inpatient and outpatient service utilization varied considerably between HSA-PSY. Utilization of inpatient and outpatient services tended to be positively associated across HSA-PSY. CONCLUSIONS Wide variation of service use between HSA-PSY can hardly be fully explained by underlying differences in the prevalence or incidence of disorders. Whether other factors such as the amount of services supply did add to the high variation should be addressed in further studies, for which our functional mapping on a small-scale regional level provides a good analytical framework.
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Affiliation(s)
- Niklaus Stulz
- Integrated Psychiatric Services Winterthur-Zurcher Unterland, Winterthur, Switzerland
| | - Reto Jörg
- Swiss Health Observatory, Neuchatel, Switzerland
| | | | - Charles Bonsack
- Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Philippe Conus
- Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Sara Evans-Lacko
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | | | - Eva Heim
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
| | | | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Dirk Richter
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Andres Schneeberger
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Sir Graham Thornicroft
- Centre for Global Mental Health and Center for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rafael Traber
- Organizzazione Sociopsichiatrica Cantonale, Mendrisio, Switzerland
| | - Simon Wieser
- Winterthur Institute of Health Economics, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | | | - Urs Hepp
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Meilener Institute Zurich, Zurich, Switzerland
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White KM, Walton RJ, Kwedza RK, Rushton S, Currow DC, Seale H, Harrison R. Variation in ovarian cancer care in Australia: An analysis of patterns of care in diagnosis and initial treatment in New South Wales. Eur J Cancer Care (Engl) 2022; 31:e13649. [PMID: 35781903 PMCID: PMC9787805 DOI: 10.1111/ecc.13649] [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: 01/28/2021] [Revised: 05/17/2022] [Accepted: 06/24/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Ovarian cancer has the highest mortality of all gynaecological cancers. This study aimed to identify the extent to which women across New South Wales experienced variation in their care in diagnosis and initial treatment for ovarian cancer against the national optimal care pathway for ovarian cancer. METHOD Clinical audit methodology was utilised to explore variations for women with primary ovarian cancer; 171 eligible cases were identified through by the NSW Cancer Registry for the period of 1 March 2017 to 28 February 2018. RESULTS Limited variation was detected with 86% of women being reviewed by a specialist gynaecological oncology multidisciplinary team; 54% of women received their first treatment within 28 days of their first specialist appointment, 66% of women having their first surgery completed by a gynaecological oncologist and 45% of women received their first treatment in a specialist gynaecological oncology hospital. CONCLUSION Deviation from effective ovarian cancer care is apparent particularly in the location and timeliness of first treatment, with implications for the quality of care received and care outcomes. Understanding factors that contribute to variation is critical to ensure optimal and appropriate ovarian cancer care and to tackle systemic barriers to the provision of effective care.
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Affiliation(s)
- Kahren M. White
- Cancer Institute NSWSt LeonardsNew South WalesAustralia,School of Population HealthUniversity of New South WalesKensingtonNew South WalesAustralia
| | | | - Ru K. Kwedza
- Cancer Institute NSWSt LeonardsNew South WalesAustralia
| | | | | | - Holly Seale
- School of Population HealthUniversity of New South WalesKensingtonNew South WalesAustralia
| | - Reema Harrison
- School of Population HealthUniversity of New South WalesKensingtonNew South WalesAustralia
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Manley BJ, Buckmaster AG, Travadi J, Owen LS, Roberts CT, Wright IMR, Davis PG, Arnolda G. Trends in the use of non-invasive respiratory support for term infants in tertiary neonatal units in Australia and New Zealand. Arch Dis Child Fetal Neonatal Ed 2022; 107:572-576. [PMID: 35410897 DOI: 10.1136/archdischild-2021-323581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether the use of non-invasive respiratory support, such as continuous positive airway pressure and nasal high flow, to treat term infants in Australian and New Zealand tertiary neonatal intensive care units (NICUs) has changed over time, and if so, whether there are parallel changes in short-term respiratory morbidities. DESIGN Retrospective database review of patient-level data from the Australian and New Zealand Neonatal Network (ANZNN) from 2010 to 2018. Denominator data on the number of term inborn livebirths in each facility was only available as annual totals. PATIENTS AND SETTING Term, inborn infants cared for in NICUs within the ANZNN. MAIN OUTCOME MEASURES The primary outcome was the annual change in hospital-specific rates of non-invasive respiratory support per 1000 inborn livebirths, expressed as a percentage change. Secondary outcomes were the change in rates of mechanical ventilation, pneumothorax requiring drainage, exogenous surfactant treatment and death before hospital discharge. RESULTS A total of 14 656 term infants from 21 NICUs were included from 2010 to 2018, of whom 12 719 received non-invasive respiratory support. Non-invasive respiratory support use increased on average by 8.7% per year (95% CI: 7.9% to 9.4% per year); the number of term infants receiving non-invasive respiratory support almost doubled from 980 in 2010 (10.8/1000 livebirths) to 1913 in 2018 (20.8/1000). There was no change over time in rate of mechanical ventilation or death. The rate of pneumothorax requiring drainage increased over time, as did surfactant treatment. CONCLUSIONS Non-invasive respiratory support use to treat term infants cared for in NICUs within the ANZNN is increasing over time. Clinicians should be diligent in selecting infants most likely to benefit from treatment with non-invasive respiratory support in this relatively low-risk population of term newborn infants. Analysis of patient-level data by individual NICUs is recommended to control for potential confounding due to changes in population over time.
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Affiliation(s)
- Brett J Manley
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia .,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Adam G Buckmaster
- Women, Children and Families, Central Coast Local Health District, Gosford, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Javeed Travadi
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Louise S Owen
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Ian M R Wright
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia.,School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
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10
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Walsh ME, Sorensen J, Blake C, Johnsen SP, Kristensen PK. Geographic variation in hip fracture surgery rate, care quality and outcomes: a comparison between national registries in Ireland and Denmark. Arch Osteoporos 2022; 17:128. [PMID: 36161538 DOI: 10.1007/s11657-022-01169-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/12/2022] [Indexed: 02/03/2023]
Abstract
Ireland and Denmark have similar hip fracture surgery rates but differences in care quality indicators and patterns of intracapsular fracture repair. Very high variation in total hip arthroplasty rate within both countries and higher observed early mortality in Denmark require further investigation. PURPOSE To explore and compare geographic variation of hip fracture surgery rate, care quality and outcomes in Ireland and Denmark. METHODS Patients aged ≥ 65 years with surgically treated hip fracture were included from the Irish Hip Fracture Database (years = 2017-2020, n = 12,904) and the Danish Multidisciplinary Hip Fracture Registry (years = 2016-2017, n = 12,924). The age and sex standardised rate of hip fracture surgery and the proportion of patients with seven process quality indicators, three surgery types and four outcomes were calculated. Systematic components of variation (SCV) were calculated based on hospital area (6 Irish hospital groups, 5 Danish regions). RESULTS The age and sex standardised rate of hip fracture surgery per 1000 older population in 2017 was 4.7 (95% CI = 4.4-5.1) in Ireland and 5.3 (95% CI = 5.1-5.5) in Denmark. Ireland had lower rates of surgery within 36 h (59% versus 84%), nutritional assessment (27% versus 84%) and pre-discharge mobility recording (52% versus 92%). Patterns of intracapsular fracture repair also differed between countries (hemiarthroplasty: Ireland = 85%, Denmark = 52%). Both countries had very high variation for total hip arthroplasty (THA) provision (SCV Ireland = 10.6, Denmark = 97.9). Ireland had longer hospital stays (median 12 versus 7 days), but lower 7-day (1.0% versus 3.1%) and 14-day (2.0% versus 5.5%) mortality. CONCLUSION Ireland and Denmark have similar hip fracture surgery rates, but differences in care quality, surgery patterns and outcomes. High variation in THA provision and observed differences in mortality require further exploration. In Ireland, there is scope for improvement regarding early surgery, mobility, nutrition assessment and improved post-discharge follow-up.
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Affiliation(s)
- Mary E Walsh
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin 4, Ireland.
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin 4, Ireland
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Pia Kjær Kristensen
- The Department of Clinical Medicine, Orthopaedic, Aarhus University, Aarhus, Denmark
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11
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Fernando DT, Bhatt R, Saiganesh A, Schultz A, Gera P. Lung abscess: 14 years of experience in a tertiary paediatric hospital. ANZ J Surg 2022; 92:1850-1855. [PMID: 35678219 DOI: 10.1111/ans.17844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/01/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lung abscess is a rare condition in paediatrics with a paucity of literature. Intravenous antibiotics is the main therapy; however interventional radiological approaches have led to the use of percutaneous drainage. Surgery is reserved for the management of complications. The aim of this study was to describe lung abscess in a cohort of paediatric patients' and determine associations between factors at presentation and outcomes. METHODS A 14-year retrospective cohort study was conducted including all children who presented to a tertiary paediatric hospital in Western Australia with lung abscess. Clinical characteristics, laboratory and radiologic findings, management options and clinical outcomes were examined. RESULTS Sixty-eight patients (median age 3.6 (0.08-17.6) years; 44.1% female) were identified to have a lung abscess, with 81% being primary lung abscess. Staphylococcus aureus (including MRSA) and Streptococcus pneumoniae were the most common organisms identified, with S. aureus being most common in Aboriginal patients (80%). A total of 25 antibiotics were prescribed on initiation of treatment in over 20 combinations. 44.9% of patients had complications and hospitalization was prolonged. Patients with S. aureus had longer hospitalization (20.5 days (3-67) than those without (median 13 days (3-52), p = 0.04). There were no associations between factors at presentation and subsequent outcomes. Factors at presentation were not associated with outcomes. CONCLUSION There is unwarranted variation in management of paediatric lung abscess and high complication rates. There is a need for collaboration and clinical practice guidelines to standardize care for lung abscess in children.
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Affiliation(s)
- Dhanushke T Fernando
- Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Rudra Bhatt
- Department of Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Aarti Saiganesh
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - André Schultz
- Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Wal-yan Respiratory Research Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Respiratory Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Parshotam Gera
- Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Department of Paediatric Surgery, Perth Children's Hospital, Perth, Western Australia, Australia
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12
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Ropers F, Bossuyt P, Maconochie I, Smit FJ, Alves C, Greber-Platzer S, Moll HA, Zachariasse J. Practice variation across five European paediatric emergency departments: a prospective observational study. BMJ Open 2022; 12:e053382. [PMID: 35361639 PMCID: PMC8971764 DOI: 10.1136/bmjopen-2021-053382] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To compare paediatric healthcare practice variation among five European emergency departments (EDs) by analysing variability in decisions about diagnostic testing, treatment and admission. DESIGN AND POPULATION Consecutive paediatric visits in five European EDs in four countries (Austria, Netherlands, Portugal, UK) were prospectively collected during a study period of 9-36 months (2012-2015). PRIMARY OUTCOME MEASURES Practice variation was studied for the following management measures: lab testing, imaging, administration of intravenous medication and patient disposition after assessment at the ED. ANALYSIS Multivariable logistic regression was used to adjust for general patient characteristics and markers of disease severity. To assess whether ED was significantly associated with management, the goodness-of-fit of regression models based on all variables with and without ED as explanatory variable was compared. Management measures were analysed across different categories of presenting complaints. RESULTS Data from 111 922 children were included, with a median age of 4 years (IQR 1.7-9.4). There were large differences in frequencies of Manchester Triage System (MTS) urgency and selected MTS presentational flow charts. ED was a significant covariate for management measures. The variability in management among EDs was fairly consistent across different presenting complaints after adjustment for confounders. Adjusted OR (aOR) for laboratory testing were consistently higher in one hospital while aOR for imaging were consistently higher in another hospital. Iv administration of medication and fluids and admission was significantly more likely in two other hospitals, compared with others, for most presenting complaints. CONCLUSIONS Distinctive hospital-specific patterns in variability of management could be observed in these five paediatric EDs, which were consistent across different groups of clinical presentations. This could indicate fundamental differences in paediatric healthcare practice, influenced by differences in factors such as organisation of primary care, diagnostic facilities and available beds, professional culture and patient expectations.
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Affiliation(s)
- Fabienne Ropers
- Willem-Alexander Children's Hospital, department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amstersdam, Netherlands
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Netherlands
| | - Claudio Alves
- General Paediatrics, Emergency Unit, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, Portugal
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joany Zachariasse
- Department of General Paediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
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13
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Batumalai V, James M. Unwarranted variation in radiation therapy fractionation. J Med Imaging Radiat Oncol 2022; 66:233-241. [PMID: 35243787 DOI: 10.1111/1754-9485.13372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.
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Affiliation(s)
- Vikneswary Batumalai
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,GenesisCare, Sydney, New South Wales, Australia
| | - Melissa James
- Christchurch Oncology Service, Canterbury Regional Cancer and Haematology Centre, Christchurch, New Zealand.,Department of Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand
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14
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Lenet T, Baker L, Park L, Vered M, Zahrai A, Shorr R, Davis A, McIsaac DI, Tinmouth A, Fergusson DA, Martel G. A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Intraoperative Red Blood Cell Transfusion Strategies. Ann Surg 2022; 275:456-466. [PMID: 34319671 PMCID: PMC8820777 DOI: 10.1097/sla.0000000000004931] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this work was to carry out a meta-analysis of RCTs comparing intraoperative RBC transfusion strategies to determine their impact on postoperative morbidity, mortality, and blood product use. SUMMARY OF BACKGROUND DATA RBC transfusions are common in surgery and associated with widespread variability despite adjustment for casemix. Evidence-based recommendations guiding RBC transfusion in the operative setting are limited. METHODS The search strategy was adapted from a previous Cochrane Review. Electronic databases were searched from January 2016 to February 2021. Included studies from the previous Cochrane Review were considered for eligibility from before 2016. RCTs comparing intraoperative transfusion strategies were considered for inclusion. Co-primary outcomes were 30-day mortality and morbidity. Secondary outcomes included intraoperative and perioperative RBC transfusion. Meta-analysis was carried out using random-effects models. RESULTS Fourteen trials (8641 patients) were included. One cardiac surgery trial accounted for 56% of patients. There was no difference in 30-day mortality [relative risk (RR) 0.96, 95% confidence interval (CI) 0.71-1.29] and pooled postoperative morbidity among the studied outcomes when comparing restrictive and liberal protocols. Two trials reported worse composite outcomes with restrictive triggers. Intraoperative (RR 0.53, 95% CI 0.43-0.64) and perioperative (RR 0.70, 95% CI 0.62-0.79) blood transfusions were significantly lower in the restrictive group compared to the liberal group. CONCLUSIONS Intraoperative restrictive transfusion strategies decreased perioperative transfusions without added postoperative morbidity and mortality in 12/14 trials. Two trials reported worse outcomes. Given trial design and generalizability limitations, uncertainty remains regarding the safety of broad application of restrictive transfusion triggers in the operating room. Trials specifically designed to address intraoperative transfusions are urgently needed.
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laura Baker
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lily Park
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Michael Vered
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Amin Zahrai
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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15
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Sola-Visner M, Leeman KT, Stanworth SJ. Neonatal platelet transfusions: New evidence and the challenges of translating evidence-based recommendations into clinical practice. J Thromb Haemost 2022; 20:556-564. [PMID: 35112471 DOI: 10.1111/jth.15664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 01/19/2023]
Abstract
Platelet transfusions are a common intervention for thrombocytopenia. Although the main reason for transfusing platelets is to improve hemostasis, platelets have many additional physiological roles, including interactions with immune pathways. Much of the evidence base for safe and effective transfusions has been informed by randomized trials in adult patients with hematological malignancies. Only three randomized trials have been conducted in sick neonates. These trials have indicated evidence of harm, including a significantly higher rate of death or major bleeding within 28 days after randomization for the largest trial, which enrolled 660 infants. The overall research indicates limited effectiveness of platelet transfusions to reduce bleeding risk. It is important that the results of trials are implemented into practice, but uptake of research findings into neonatal medicine remains inconsistent, as for many areas of health care. There is a need to establish which potential implementation strategies (cost-) efficiently enact change, such as audit and feedback, automated reminder systems for ordering transfusions, and use of opinion leaders. Research is exploring potential mechanisms underlying the lack of effectiveness of platelet transfusions and the increased bleeding and mortality observed in neonatal randomized trials. One potential mechanism concerns the roles of platelets to promote excessive angiogenic signals during a vulnerable period of brain development. A further hypothesis explores the effects of transfusing "adult" platelets into "neonatal" thrombocytopenic blood on primary hemostasis and immune responses.
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Affiliation(s)
- Martha Sola-Visner
- Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristen T Leeman
- Pediatrics, Boston Children's Hospital, Harvard Neonatal-Perinatal Fellowship Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon J Stanworth
- Haematology and Transfusion Medicine, Department of Haematology, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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16
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Lecarpentier P, Gandré C, Coldefy M, Ellini A, Trichard C. Use of electroconvulsive therapy for individuals receiving inpatient psychiatric care on a nationwide scale in France: Variations linked to health care supply. Brain Stimul 2021; 15:201-210. [PMID: 34954085 DOI: 10.1016/j.brs.2021.12.007] [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: 10/19/2021] [Revised: 12/08/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A comprehensive understanding of variations in the use of electroconvulsive therapy (ECT) among health care providers in charge of ECT referrals is lacking. OBJECTIVE Our objectives were to document ECT use and its variations on a nationwide scale in France and to identify the factors that were significantly associated with these variations. METHODS Administrative health claims data on hospitalization were used to perform a descriptive analysis of ECT use for adult patients receiving inpatient psychiatric care in mainland France in 2019 and its variations across hospitals in charge of ECT referrals. Based on a conceptual framework drawn from the literature on medical practice variations, a multilevel logistic regression was then conducted to identify patients, hospitals and contextual characteristics that were significantly associated with ECT treatment using non-ECT-treated patients receiving inpatient psychiatric care as the reference population. RESULTS Patients receiving ECT (n = 3288) were older, more frequently female and had more severe diagnoses than other patients seen in inpatient care (n = 295,678). Significant variations were observed in the rate of ECT use across hospitals (n = 468), with a coefficient of variation largely above one. In the multivariable analysis, ECT treatment was associated with patient characteristics (which accounted for 6% of the variations) but also with characteristics of the hospitals and their environments (44% of the variations), including the type of hospital and its distance to the closest facility providing ECT. CONCLUSIONS Variations in ECT use were strongly linked to health care supply characteristics, which raises questions about access to quality mental health care.
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Affiliation(s)
- Pierre Lecarpentier
- EPS Barthélémy Durand, Psychiatry Department, Avenue Du 8 Mai 1945, 91150, Etampes, France; Institut de Recherche et Documentation en économie de la santé (IRDES), 117 bis Rue Manin, 75019, Paris, France
| | - Coralie Gandré
- Institut de Recherche et Documentation en économie de la santé (IRDES), 117 bis Rue Manin, 75019, Paris, France.
| | - Magali Coldefy
- Institut de Recherche et Documentation en économie de la santé (IRDES), 117 bis Rue Manin, 75019, Paris, France
| | - Anis Ellini
- Agence technique de l'information sur l'hospitalisation (ATIH), 13 Rue Moreau, 75012, Paris, France
| | - Christian Trichard
- EPS Barthélémy Durand, Psychiatry Department, Avenue Du 8 Mai 1945, 91150, Etampes, France
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17
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Hodgson T, Burton-Jones A, Donovan R, Sullivan C. The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review. JMIR Med Inform 2021; 9:e30432. [PMID: 34787585 PMCID: PMC8663492 DOI: 10.2196/30432] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/22/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care. OBJECTIVE A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes. METHODS Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care. RESULTS Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare. CONCLUSIONS The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.
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Affiliation(s)
- Tobias Hodgson
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Andrew Burton-Jones
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Raelene Donovan
- Princess Alexandra Hospital, Metro South Health, Woolloongabba, Australia
| | - Clair Sullivan
- The University of Queensland Centre for Health Services Research, The University of Queensland, Herston, Australia
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18
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Jepson M, Sarkies M, Haines T. Variation in inpatient allied health service provision in Australian and New Zealand hospitals. Australas J Ageing 2021; 41:70-80. [PMID: 34346159 DOI: 10.1111/ajag.12988] [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: 11/10/2020] [Revised: 06/24/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the variability of allied health services on weekends, relative to weekdays, throughout Australian and New Zealand hospitals. METHODS A prospective, cross-sectional observational study embedded within a cluster randomised control trial. Allied health managers provided administrative data relating to allied health service events. RESULTS In one month, there were a total of 243 549 allied health service events recorded from 91 sampled hospitals. The mean difference between weekday and weekend allied health service events (daily, per ward) for physiotherapy was 6.52 (95% CI 5.65 to 7.40), acute wards 12.03 (95% CI 10.25 to 13.82) and for metropolitan hospitals 14.47 (95% CI 12.22 to 16.73), revealing more allied health service events of longer duration on weekdays compared to weekends. CONCLUSIONS This research is the first of its kind to describe variation in allied health service provision and potential research to practice gaps across weekday and weekend days in various inpatient settings.
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Affiliation(s)
- Megan Jepson
- Department of Paramedicine, Monash University Peninsula Campus, Melbourne, Vic., Australia.,School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia
| | - Mitchell Sarkies
- School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia.,Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Melbourne, NSW, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia
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19
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Gray WK, Day J, Briggs TWR, Harrison S. Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme. J Eval Clin Pract 2021; 27:743-750. [PMID: 32997392 DOI: 10.1111/jep.13477] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/23/2020] [Accepted: 08/19/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The Getting It Right First Time programme aims to reduce variation in clinical practice that unduly impacts on outcomes for patients in the National Health Service (NHS) in England; often termed "unwarranted variation." However, there is no "gold standard" method for detecting unwarranted variation. The aim of this study was to describe a method to allow such variation in recorded practice or patient outcomes between NHS trusts to be detected using data over multiple time periods. By looking at variation over time, it was hoped that patterns that could be missed by looking at data at a single time point, or averaged over a longer time period, could be identified. METHODS This was a retrospective time-series analysis of observational administrative data. Data were extracted from the Hospital Episodes Statistics database for two exemplar aspects of clinical practice within the field of urology: (a) use of ureteric stents on first emergency admission to treat urinary tract stones and (b) waiting times for definitive surgery for urinary retention. Data were categorized into 3-month time periods and three rules were used to detect unwarranted variation in the outcome metric relative to the national average: (a) two of any three consecutive values greater than two standard deviations above the mean, (b) four of any five consecutive values greater than one standard deviation above the mean, and (c) eight consecutive values above the mean. RESULTS For the urinary tract stones dataset, 24 trusts were identified as having unwarranted variation in the outcomes using funnel plots and 23 trusts using the time-series method. For the urinary retention data, 18 trusted were identified as having unwarranted variation in the outcomes using funnel plots and 22 trusts using the time-series method. CONCLUSIONS The time-series method may complement other methods to help identify unwarranted variation.
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Affiliation(s)
- William K Gray
- Getting It Right First Time programme, NHS Improvement, London, UK
| | - Jamie Day
- Getting It Right First Time programme, NHS Improvement, London, UK
| | - Tim W R Briggs
- Getting It Right First Time programme, NHS Improvement, London, UK
| | - Simon Harrison
- Getting It Right First Time programme, NHS Improvement, London, UK.,Department of Urology, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
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20
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Baker L, Park L, Gilbert R, Ahn H, Martel A, Lenet T, Davis A, McIsaac DI, Tinmouth A, Fergusson DA, Martel G. Intraoperative Red Blood Cell Transfusion Decision-making: A Systematic Review of Guidelines. Ann Surg 2021; 274:86-96. [PMID: 33630462 DOI: 10.1097/sla.0000000000004710] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The objective of this work was to carry out a systematic review of clinical practice guidelines (CPGs) pertaining to intraoperative red blood cell (RBC) transfusions, in terms of indications, decision-making, and supporting evidence base. SUMMARY OF BACKGROUND DATA RBC transfusions are common during surgery and there is evidence of wide variability in practice. METHODS Major electronic databases (MEDLINE, EMBASE, and CINAHL), guideline clearinghouses and Google Scholar were systematically searched from inception to January 2019 for CPGs pertaining to indications for intraoperative RBC transfusion. Eligible guidelines were retrieved and their quality assessed using AGREE II. Relevant recommendations were abstracted and synthesized to allow for a comparison between guidelines. RESULTS Ten guidelines published between 1992 and 2018 provided indications for intraoperative transfusions. No guideline addressed intraoperative transfusion decision-making as its primary focus. Six guidelines provided criteria for transfusion based on hemoglobin (range 6.0-10.0 g/dL) or hematocrit (<30%) triggers. In the absence of objective transfusion rules, CPGs recommended considering other parameters such as blood loss (n = 7), signs of end organ ischemia (n = 5), and hemodynamics (n = 4). Evidence supporting intraoperative recommendations was extrapolated primarily from the nonoperative setting. There was wide variability in the quality of included guidelines based on AGREE II scores. CONCLUSION This review has identified several clinical practice guidelines providing recommendations for intraoperative transfusion. The existing guidelines were noted to be highly variable in their recommendations and to lack a sufficient evidence base from the intraoperative setting. This represents a major knowledge gap in the literature.
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Affiliation(s)
- Laura Baker
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lily Park
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Richard Gilbert
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Hilalion Ahn
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Andre Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Departments of Anesthesiology & Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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21
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Ulyte A, Wei W, Gruebner O, Bähler C, Brüngger B, Blozik E, von Wyl V, Schwenkglenks M, Dressel H. Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services. BMJ Open 2021; 11:e044090. [PMID: 33972336 PMCID: PMC8112440 DOI: 10.1136/bmjopen-2020-044090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/19/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES When research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation. DESIGN In this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation. SETTING Observational study of claims to mandatory health insurance in Switzerland in 2014. PARTICIPANTS Enrolees eligible for the 24 healthcare services. PRIMARY OUTCOME MEASURES The variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch's t-test. RESULTS The sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (-0.06 to 0.11) and 0.05 (-0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (-0.03 to 0.18) and 0.14 (-0.06 to 0.34), respectively) compared with positive recommendations. CONCLUSIONS In this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.
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Affiliation(s)
- Agne Ulyte
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Wenjia Wei
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Oliver Gruebner
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Department of Geography, University of Zurich, Zurich, Switzerland
| | - Caroline Bähler
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Beat Brüngger
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Viktor von Wyl
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
| | - M Schwenkglenks
- Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Holger Dressel
- Division of Occupational and Environmental Medicine, Department of Epidemiology, Epidemiology, Biostatistics & Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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22
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Carmichael K, Hughes J, Styche T. Impact of a wound management system on budget optimisation, formulary compliance and variations in care. Br J Community Nurs 2021; 26:246-250. [PMID: 33939469 DOI: 10.12968/bjcn.2021.26.5.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Optimising budgets in wound care is crucial if local health economy efficiencies are to be realised. How spending is managed and monitored can be difficult for community nursing services due to the variety of supply routes. Online wound management systems not on help tailor supply routes to reduce waste, thereby reducing cost, but also provide an audit platform for transparency across clinical practice. The non-prescription ordering system Formeo was implemented across City Health Care Partnership (CHCP), Hull, through a value-based industry collaboration. With its use, monthly spend on wound care reduced by approximately £5354 (11.9%), with a reduction in the total spend of £64 254. Further, Formeo enabled an audit of clinical practice to minimise products on the formulary. This provided CHCP, Hull, the opportunity to reduce variations in care, and therefore potentially improve clinical outcomes.
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23
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Belloni S, Arrigoni C, Dellafiore F, Biagioli V, Piredda A, Caruso R. Symptom-Level Description of Nursing Perceptions About Unwarranted Clinical Variation, Inequality in Access to Cancer Services, Specific-Symptom Knowledge: An Italian Web-Based Survey. Semin Oncol Nurs 2021; 37:151138. [PMID: 33814244 DOI: 10.1016/j.soncn.2021.151138] [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: 08/25/2020] [Accepted: 01/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study aimed to describe the cancer nurses' views regarding the relevance of cancer symptom-specific knowledge, unwarranted clinical variation, and inequities in access to cancer services. Describing how nurses perceive these aspects could help identify research priorities and a practical framework to prioritize clinical practice guidelines. DATA SOURCES A web-based survey was performed using a convenience sample of 810 nurses employed in cancer settings and cross-sectional data collection. The survey adopted a previously validated questionnaire investigating 14 symptoms. CONCLUSION This study revealed which cancer symptoms require priority attention to define evidence-grounded guidance for decreasing unwarranted clinical variation and inequities in access to cancer services. Future multiprofessional and multinational studies are recommended to provide an in-depth description of the investigated phenomena. IMPLICATIONS FOR NURSING PRACTICE Participants reported higher mean scores in pain-specific knowledge than other symptoms. Social functioning alterations and psychological disorders seem to be highly susceptible to unwarranted clinical variation and inequities in access to cancer services. This information could drive tailored interventions to improve nursing practice.
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Affiliation(s)
- Silvia Belloni
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Alessio Piredda
- Italian Association of Cancer Nurses, European Institute of Oncology, Milan, Italy
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy.
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24
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Gottlieb DJ, Watts BV, Peltzman T, Riblet NBV, Cornelius S, Forehand JA, Shiner B. Small Area Analysis of Veterans Affairs Mental Health Services Data. Psychiatr Serv 2021; 72:384-390. [PMID: 33530729 DOI: 10.1176/appi.ps.202000130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. METHODS MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. RESULTS A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. CONCLUSIONS MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.
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Affiliation(s)
- Daniel J Gottlieb
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Bradley V Watts
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Talya Peltzman
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Natalie B V Riblet
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Sarah Cornelius
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Jenna A Forehand
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
| | - Brian Shiner
- Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont
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25
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Beloni S, Arrigoni C, Dellafiore F, Diamanti O, Piredda A, Caruso R. Symptom clusters in cancer patients: An Italian survey to validate and describe unwarranted clinical variation, inequality in access to healthcare, knowledge, and risk of malpractice. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021015. [PMID: 33855990 PMCID: PMC8138803 DOI: 10.23750/abm.v92is2.11331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/04/2021] [Indexed: 12/09/2022]
Abstract
Background and aims: The perceptions of professionals involved in cancer care regarding the importance of their symptoms-specific knowledge, unwarranted clinical variation (UCV), and inequalities in access to healthcare are still underdescribed. This study aims to confirm the construct validity of a previously initially developed questionnaire and describe nurses’ perceptions about the relevance of their knowledge referred to cancer symptoms management, the UCV, the inequalities in access to healthcare, and malpractice risk. Method: A cross-sectional pan-national study was conducted using a convenience sample, collecting data through a previously initially validated questionnaire. Construct validity was corroborated through confirmatory factor analysis, and descriptive statistics were employed for summarizing the questionnaire’s scores. The scores between the nurses working in accredited cancer centers and nurses employed in general hospitals were inferentially compared. Results: The sample comprised 810 nurses, 480 were nurses working in accredited cancer centers, and 330 were nurses working in general hospitals. The questionnaire showed adequate construct validity and reliability. Nurses perceived the cluster of psychosocial symptoms with a greater risk of UCV and inequalities in access to cancer services than the cluster of physical symptoms. Discussion and conclusions: A paradigm shift aimed at integrating psychosocial cancer symptoms in the care paths emerged as pivotal for improving cancer care in Italy.
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Affiliation(s)
- Silvia Beloni
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy .
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
| | - Orejeta Diamanti
- Research Nursing Centre, IRCCS Istituto Oncologico Veneto, Padova, Italy .
| | - Alessio Piredda
- Italian Association of Cancer Nurses, European Institute of Oncology, Milan, Italy .
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
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26
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Mordaunt DA. On Clinical Utility and Systematic Reporting in Case Studies of Healthcare Process Mining. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228298. [PMID: 33182679 PMCID: PMC7697491 DOI: 10.3390/ijerph17228298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Dylan A. Mordaunt
- Shoalhaven Hospital Group, Illawarra-Shoalhaven Local Health District, Nowra 2541, Australia;
- Faculty of Medical and Health Sciences, University of Adelaide, Adelaide 5005, Australia
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- School of Medicine, University of Wollongong, Wollongong 2522, Australia
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27
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Lang DM, Oppenheimer JJ, Portnoy JM. Just listen to your patient. J Allergy Clin Immunol 2020; 146:1343-1345. [PMID: 33096128 DOI: 10.1016/j.jaci.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/08/2020] [Accepted: 10/16/2020] [Indexed: 11/15/2022]
Affiliation(s)
- David M Lang
- Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, Cleveland, Ohio.
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28
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Defining Rapid Reviews: a systematic scoping review and thematic analysis of definitions and defining characteristics of rapid reviews. J Clin Epidemiol 2020; 129:74-85. [PMID: 33038541 DOI: 10.1016/j.jclinepi.2020.09.041] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/11/2020] [Accepted: 09/29/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Rapid reviews were first mentioned in the literature in 1997, when Best et al. described the rapid health technology assessment program in the south and west regions of England but did not provide a formal definition. More recently, the only consensus around a rapid review definition is that a formal definition does not exist. The primary aim of this work is to create a repository of existing definitions and to identify key themes, which may help the knowledge synthesis community in defining rapid review products. METHODS A systematic scoping review was performed to identify definitions used in journal-published rapid reviews written in English between 2017 and January 2019. We searched Medline, Embase Classic + Embase, PsycINFO, ERIC, Cochrane Library, CINAHL, and Web of Science on December 21, 2018. Two reviewers performed study selection and data extraction using a priori-defined methods published in a protocol. Definitions from rapid review methods articles (published from 1997 onward) identified in another scoping review were added to the results, and all definitions were thematically analyzed using NVivo. A quantitative analysis was also performed around studies cited. RESULTS Definitions from 216 rapid reviews and 90 rapid review methods articles were included in the thematic analysis. Eight key themes were identified: accelerated/rapid process or approach, variation in methods shortcuts, focus/depth/breadth of scope, compare and contrast to a full traditional systematic review, stakeholder rationale, resource efficiency rationale, systematic approach, bias/limitations. Secondary referencing was a common occurrence. CONCLUSION Thematic analysis performed in this systematic scoping review has allowed for the creation of a suggested definition for rapid reviews that can be used to inform the systematic review community.
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29
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Mimmo L, Woolfenden S, Travaglia J, Harrison R. Creating equitable healthcare quality and safety for children with intellectual disability in hospital. Child Care Health Dev 2020; 46:644-649. [PMID: 32468634 PMCID: PMC7496444 DOI: 10.1111/cch.12787] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/25/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
Children with intellectual disability are susceptible to poor experiences of care and treatment outcomes, and this may compound existing health inequities. Evidence to date indicates three priority areas that must be addressed in order to reduce these inequities in the safety and quality of care for children with intellectual disability. Firstly, we need reliable methods to identify children with intellectual disability so that healthcare organizations understand their needs. Secondly, we need to develop quality metrics that can assess care quality and unwarranted care variation for children with intellectual disability in hospital. Finally, for a comprehensive understanding of the safety and quality of care for these children, and how to improve, it is critical that healthcare organizations partner with parents/carers and enable children with intellectual disability to voice their experiences of care. Children with intellectual disability have higher healthcare utilization than their peers; yet, their voice is rarely sought to optimize the safety and quality of their healthcare experience. Patient experience narratives enhance our understanding of the genesis of adverse events. By addressing these priorities, children with intellectual disability will be identified, and health services will measure and understand the problematic and beneficial variations in care delivery and can then effectively partner with children and their parents/carers to address the inequities in care quality and create safer healthcare.
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Affiliation(s)
- Laurel Mimmo
- Health Management, School of Public Health and Community Medicine, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia,Clinical Governance UnitSydney Children's Hospitals NetworkSydneyNew South WalesAustralia
| | - Susan Woolfenden
- School of Women’s and Children’s Health, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia,Community Child HealthSydney Children's HospitalRandwickNew South WalesAustralia
| | - Joanne Travaglia
- Health Services Management, Centre for Health Services Management, Faculty of HealthUniversity of Technology SydneySydneyNew South WalesAustralia
| | - Reema Harrison
- Health Management, School of Public Health and Community Medicine, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
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30
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Garand KLF, McCullough G, Crary M, Arvedson JC, Dodrill P. Assessment Across the Life Span: The Clinical Swallow Evaluation. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:919-933. [PMID: 32650662 DOI: 10.1044/2020_ajslp-19-00063] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.
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Affiliation(s)
| | - Gary McCullough
- Department of Communication Sciences and Disorders, Appalachian State University, Boone, NC
| | - Michael Crary
- School of Communication Sciences and Disorders, University of Central Florida, Orlando
| | - Joan C Arvedson
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin-Milwaukee
| | - Pamela Dodrill
- Department of Otolaryngology, Boston Children's Hospital Boston, MA
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31
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Stern KWD, McCracken CE, Gillespie SE, Lang SM, Statile CJ, Lopez L, Verghese GR, Choueiter NF, Sachdeva R. Physician variation in ordering of transthoracic echocardiography in outpatient pediatric cardiac clinics. Echocardiography 2020; 37:1056-1064. [DOI: 10.1111/echo.14756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kenan W. D. Stern
- Icahn School of Medicine at Mount Sinai Children’s Heart Center Kravis Children’s Hospital New York New York USA
| | | | - Scott E. Gillespie
- Department of Pediatrics Emory University School of Medicine Atlanta GeorgiaUSA
| | - Sean M. Lang
- The Heart Institute Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Christopher J. Statile
- The Heart Institute Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Leo Lopez
- Stanford School of Medicine Betty Irene Moore Children's Heart Center Lucile Packard Children’s Hospital Palo Alto California USA
| | - George R. Verghese
- Northwestern University Feinberg School of Medicine The Heart Center Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago Illinois USA
| | - Nadine F. Choueiter
- Albert Einstein College of Medicine Pediatric Heart Center The Children’s Hospital at Montefiore Bronx New York USA
| | - Ritu Sachdeva
- Sibley Heart Center Cardiology Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
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32
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Bergin RJ, Thomas RJS, Whitfield K, White V. Concordance between Optimal Care Pathways and colorectal cancer care: Identifying opportunities to improve quality and reduce disparities. J Eval Clin Pract 2020; 26:918-926. [PMID: 31287616 DOI: 10.1111/jep.13231] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Care pathway policies for cancer aim to reduce variation and improve the quality of patient care, and there is increasing evidence that adherence to such pathways is associated with improved survival and lower health care costs. Australia is implementing Optimal Care Pathways (OCPs) for several cancers, including colorectal cancer, but studies evaluating how well care conforms to OCP recommendations are rare. This study examined concordance between OCP recommendations and colorectal cancer care prior to policy rollout and disparities for vulnerable populations. METHOD Cross-sectional survey (2012-2014) of cancer registry-identified colorectal cancer patients aged ≥40 approached within 6 months of diagnosis (n = 433), their general practitioner (GP, n = 290), and specialist (n = 144) in Victoria, Australia. We measured concordance with 10 OCP recommendations and variation by geography, socio-economic, and health insurance status using age- and sex-adjusted logistic regression models. RESULTS Use of recommended GP investigations varied from 66% for colonoscopy to 13% for digital rectal exam. Recommended waiting times to receive a colonoscopy, see a specialist after referral, and begin adjuvant chemotherapy were exceeded for around a third of patients. Twenty-eight percent of specialists reported a pretreatment multidisciplinary meeting. Most patients received surgery in a hospital with an intensive care unit (92%) and chemotherapy for high risk disease (84%). In general, care was similar across sociodemographic groups. However, receipt of GP investigations tended to be higher and waiting times longer for rural, low socio-economic, and non-privately insured patients. For example, receiving a colonoscopy within 4 weeks was significantly less likely for rural (51%) than urban (78%) patients (odds ratio = 0.30; 95% confidence interval, 0.11-0.79). CONCLUSION Prior to implementation, a significant proportion of colorectal cancer patients received care that did not meet OCP recommendations. Low concordance and inequities for rural and disadvantaged populations highlight components of the pathway to target during policy implementation.
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Affiliation(s)
- Rebecca J Bergin
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia.,Department of General Practice/Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Robert J S Thomas
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kathryn Whitfield
- Department of Health and Human Services Victoria, Victorian Government, Melbourne, Australia
| | - Victoria White
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia.,School of Psychology, Deakin University, Melbourne, Australia
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33
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Sutherland K, Levesque JF. Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework. J Eval Clin Pract 2020; 26:687-696. [PMID: 31136047 PMCID: PMC7317701 DOI: 10.1111/jep.13181] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/17/2019] [Accepted: 04/19/2019] [Indexed: 12/25/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework. METHOD Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation. RESULTS A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics). CONCLUSION Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.
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Affiliation(s)
- Kim Sutherland
- Agency for Clinical Innovation, Chatswood, New South Wales, Australia
| | - Jean-Frederic Levesque
- Agency for Clinical Innovation, Chatswood, New South Wales, Australia.,Centre for Primary Health Care and Equity, UNSW Randwick Campus, Randwick, New South Wales, Australia
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34
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Harrison R, Hinchcliff RA, Manias E, Mears S, Heslop D, Walton V, Kwedza R. Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis. BMC Health Serv Res 2020; 20:40. [PMID: 31948447 PMCID: PMC6966854 DOI: 10.1186/s12913-019-4860-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/22/2019] [Indexed: 01/07/2023] Open
Abstract
Background Assessment of clinical variation has attracted increasing interest in health systems internationally due to growing awareness about better value and appropriate health care as a mechanism for enhancing efficient, effective and timely care. Feedback using administrative databases to provide benchmarking data has been utilised in several countries to explore clinical care variation and to enhance guideline adherent care. Whilst methods for detecting variation are well-established, methods for determining variation that is unwarranted and addressing this are strongly debated. This study aimed to synthesize published evidence of the use of feedback approaches to address unwarranted clinical variation (UCV). Methods A rapid review and narrative evidence synthesis was undertaken as a policy-focused review to understand how feedback approaches have been applied to address UCV specifically. Key words, synonyms and subject headings were used to search the major electronic databases Medline and PubMed between 2000 and 2018. Titles and abstracts of publications were screened by two reviewers and independently checked by a third reviewer. Full text articles were screened against the eligibility criteria. Key findings were extracted and integrated in a narrative synthesis. Results Feedback approaches that occurred over a duration of 1 month to 9 years to address clinical variation emerged from 27 publications with quantitative (20), theoretical/conceptual/descriptive work (4) and mixed or multi-method studies (3). Approaches ranged from presenting evidence to individuals, teams and organisations, to providing facilitated tailored feedback supported by a process of ongoing dialogue to enable change. Feedback approaches identified primarily focused on changing clinician decision-making and behaviour. Providing feedback to clinicians was identified, in a range of a settings, as associated with changes in variation such as reducing overuse of tests and treatments, reducing variations in optimal patient clinical outcomes and increasing guideline or protocol adherence. Conclusions The review findings suggest value in the use of feedback approaches to respond to clinical variation and understand when action is warranted. Evaluation of the effectiveness of particular feedback approaches is now required to determine if there is an optimal approach to create change where needed.
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Affiliation(s)
- Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Samuels Building (f25), Sydney, NSW, 2052, Australia.
| | - Reece Amr Hinchcliff
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, 4059, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Steven Mears
- Information Specialist, Hunter New England Medical Library, New Lambton, NSW, 2350, Australia
| | - David Heslop
- School of Public Health and Community Medicine, University of New South Wales, Samuels Building (f25), Sydney, NSW, 2052, Australia
| | - Victoria Walton
- Cancer Institute New South Wales, Level 9, 8 Central Avenue, Australian Technology Park, Eveleigh NSW 2015, PO Box 41, Alexandria, NSW, 1435, Australia
| | - Ru Kwedza
- Cancer Institute New South Wales, Level 9, 8 Central Avenue, Australian Technology Park, Eveleigh NSW 2015, PO Box 41, Alexandria, NSW, 1435, Australia.,Centre for Rural Health-North Coast, School of Rural Health, University of Sydney, Lismore, New South Wales, Australia
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35
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Richards JM, Burgon TB, Tamondong-Lachica D, Bitran JD, Liangco WL, Paculdo DR, Peabody JW. Reducing Unwarranted Oncology Care Variation Across a Clinically Integrated Network: A Collaborative Physician Engagement Strategy. J Oncol Pract 2019; 15:e1076-e1084. [DOI: 10.1200/jop.18.00754] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE: Addressing unwarranted clinical variation in oncology is a high priority for health systems that aspire to ensure consistent levels of high-quality and cost-effective care. Efforts to improve clinical practice and standardize care have proven challenging. Advocate Physician Partners undertook a patient simulation-based practice measurement and feedback project that was focused on breast and lung cancer to engage oncologists in the care standardization process. METHODS: One hundred three medical oncologists cared for online simulated patients using the Clinical Performance and Value platform, receiving feedback on how their care decisions compared with evidence-based guidelines and their peers. We repeated this process every 4 months over six rounds, measuring changes in quality-of-care scores. We then compared simulated patient results with available patient-level claims data. RESULTS: Over the course of the project, overall quality-of-care scores improved 11.9% ( P < .001). Diagnostic accuracy increased 6.7% ( P < .001) and correlated with improved treatment scores, including a nearly 10-percentage point increase in evidence-based chemotherapy regimens ( P = .009) and a 56% increase in addressing palliative needs for patients with late-stage disease ( P < .001). Unnecessary test ordering declined 25% ( P < .001). We compared these results with available patient data and observed concordance with the metastatic imaging workup order rate for early-stage breast cancer. As unnecessary workups declined in the simulations and became more closely aligned with evidence-based guidelines, we saw similar rates of decline in the patient-level data. CONCLUSION: This study demonstrates that an oncology care standardization system that combines simulated patients with serial feedback increases evidence-based and cost-effective clinical decisions in patient simulations and patient-level data.
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Affiliation(s)
| | | | | | | | | | | | - John W. Peabody
- QURE Healthcare, San Francisco, CA
- University of California, San Francisco, San Francisco, CA
- University of California, Los Angeles, Los Angeles, CA
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White KM, Seale H, Harrison R. Enhancing ovarian cancer care: a systematic review of guideline adherence and clinical variation. BMC Public Health 2019; 19:296. [PMID: 30866891 PMCID: PMC6416902 DOI: 10.1186/s12889-019-6633-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Clinical variation in ovarian cancer care has been reported internationally. Using Wennberg’s classification of clinical variation as effective care we can conceptualise variation through deviation from clinical guidelines. The aim of this review was to address knowledge gaps in the effectiveness of attempts to reduce unwarranted clinical variation through addressing the following questions: What is the evidence of guideline adherence in ovarian cancer and its deviation?; what are the key factors associated with variation in guideline adherence in ovarian cancer care?; and what quality improvement approaches have been used and what is the evidence of their effectiveness in enhancing guideline adherence in ovarian cancer care?. Methods Keywords and synonyms for the major concepts of ovarian cancer, guideline adherence and safety were developed and combined to form the search strategy. Systematic searches of four electronic databases were undertaken of publications from January 2007 to November 2018. Retrieved articles were assessed against the eligibility criteria to determine those for inclusion. Results Thirty-two papers were included in the review with three broad groupings identified: adherence to and deviation from guidelines (either local, national or international guidelines); factors impacting guidelines adherence; and quality improvement approaches. Conclusions Unwarranted clinical variation may be used as a marker for the effectiveness of a health system, based on the outcome of this systematic review. This review found that the implementation of quality indicators through a formal quality improvement program lead to improvements in guideline adherent care. Further research on outcomes of implementing quality improvement programs in ovarian cancer care will improve the ability to implement centralised care and further identify factors that to improve outcomes in ovarian cancer care. Electronic supplementary material The online version of this article (10.1186/s12889-019-6633-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kahren M White
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia. .,Cancer Institute NSW, PO Box 41, Alexandria, NSW, 1435, Australia.
| | - Holly Seale
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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