1
|
Kufel WD, Steele JM, Mahapatra R, Brodey MV, Wang D, Paolino KM, Suits P, Empey DW, Thomas SJ. A five-year quasi-experimental study to evaluate the impact of empiric antibiotic order sets on antibiotic use metrics among hospitalized adult patients. Infect Control Hosp Epidemiol 2024; 45:609-617. [PMID: 38268340 PMCID: PMC11027081 DOI: 10.1017/ice.2023.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Evaluation of adult antibiotic order sets (AOSs) on antibiotic stewardship metrics has been limited. The primary outcome was to evaluate the standardized antimicrobial administration ratio (SAAR). Secondary outcomes included antibiotic days of therapy (DOT) per 1,000 patient days (PD); selected antibiotic use; AOS utilization; Clostridioides difficile infection (CDI) cases; and clinicians' perceptions of the AOS via a survey following the final study phase. DESIGN This 5-year, single-center, quasi-experimental study comprised 5 phases from 2017 to 2022 over 10-month periods between August 1 and May 31. SETTING The study was conducted in a 752-bed tertiary care, academic medical center. INTERVENTION Our institution implemented AOSs in the electronic medical record (EMR) for common infections among hospitalized adults. RESULTS For the primary outcome, a statistically significant decreases in SAAR were detected from phase 1 to phase 5 (1.0 vs 0.90; P < .001). A statistically significant decreases were detected in DOT per 1,000 PD (4,884 vs 3,939; P = .001), fluoroquinolone orders (407 vs 175; P < .001), carbapenem orders (147 vs 106; P = .024), and clindamycin orders (113 vs 73; P = .01). No statistically significant change in mean vancomycin orders was detected (991 vs 902; P = .221). A statistically significant decrease in CDI cases was also detected (7.8, vs 2.4; P = .002) but may have been attributable to changes in CDI case diagnosis. Clinicians indicated that the AOSs were easy to use overall and that they helped them select the appropriate antibiotics. CONCLUSIONS Implementing AOS into the EMR was associated with a statistically significant reduction in SAAR, antibiotic DOT per 1,000 PD, selected antibiotic orders, and CDI cases.
Collapse
Affiliation(s)
- Wesley D. Kufel
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Jeffrey M. Steele
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Rahul Mahapatra
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Mitchell V. Brodey
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Dongliang Wang
- State University of New York Upstate Medical University, Syracuse, New York
| | - Kristopher M. Paolino
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Paul Suits
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Derek W. Empey
- State University of New York Upstate University Hospital, Syracuse, New York
| | - Stephen J. Thomas
- State University of New York Upstate Medical University, Syracuse, New York
- State University of New York Upstate University Hospital, Syracuse, New York
| |
Collapse
|
2
|
Ashkenazy S, Ganz FD, Kuniavsky M, Jakobson L, Levy H, Avital IL, Kolpak O, Golan D, Rebecca ML, Itzhakov S, Suliman M, Lavy A, Biton C, Broyer C, Benbenishty J. Patient mobilization in the intensive care unit: Assessing practice behavior - A multi-center point prevalence study. Intensive Crit Care Nurs 2024; 80:103510. [PMID: 37599127 DOI: 10.1016/j.iccn.2023.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVES To describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory-practice gap. METHODOLOGY A multi-center, descriptive, retrospective, one-day point prevalence study. SETTING intensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers. MAIN OUTCOME MEASURES Maximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors. RESULTS The study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility. A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001). CONCLUSION There is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior. IMPLICATIONS FOR CLINICAL PRACTICE Behaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.
Collapse
Affiliation(s)
- Shelly Ashkenazy
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel.
| | - Freda DeKeyser Ganz
- Jerusalem College of Technology, Hadassah Hebrew University School of Nursing, Jerusalem College of Technology, 11 Beit Hadfus, Jerusalem 9548311, Israel.
| | - Michael Kuniavsky
- Quality and Safety Division, Israel Ministry of Health - 39 Yirmeyahu Street, Jerusalem 9101002, Israel; Shamir (Assaf HaRofeh) Medical Center, Beer-Jaacov 7030000, Israel; Tel Aviv-Jaffa Academic College, Rabenu Yeruham St., P.O.B 840, Yaffo 6818211, Israel.
| | - Levana Jakobson
- Nahariya Galilee Medical Center, Nahariya cabri-89, Nahariya 22100001 Israel.
| | - Hadassa Levy
- Rambam Health Care Campus, P.O.B. 9602, Haifa 3109601, Haifa, Israel.
| | - Iris Levdov Avital
- Israel Poison Information Center, Rambam Health Care Campus, Ministry of Health, Haaliya Hashniya 8 Bat Galim, POB 9602, Haifa 3109601, Israel.
| | - Orly Kolpak
- Nahariya Galilee Medical Center, Nahariya cabri-89, Nahariya 22100001 Israel.
| | - Dorit Golan
- Rambam Health Care Campus, Bat Galim POB 9602, Haifa 3109601, Israel.
| | - Mor Levy Rebecca
- Sheba Medical Center, Derech Sheba 2, Tel Hashomer, Ramat Gan, Israel.
| | - Shiran Itzhakov
- Sheba Medical Center, Derech Sheba 2, Tel Hashomer, Ramat Gan, Israel.
| | - Moriya Suliman
- Sheba Medical Center, Derech Sheba 2, Tel Hashomer, Ramat Gan, Israel.
| | - Alinoy Lavy
- Shamir (Assaf HaRofeh) Medical Center, Tel Aviv University, Zerifin 70300, Israel.
| | - Chen Biton
- Shamir (Assaf HaRofeh) Medical Center, Tel Aviv University, Zerifin 70300, Israel.
| | - Chaya Broyer
- Shaare Zedek Medical Center, 12 Bait St., Jerusalem, Israel.
| | - Julie Benbenishty
- Hadassah Hebrew University Faculty of Medicine School of Nursing, Jerusalem, Israel; Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel.
| |
Collapse
|
3
|
Laily A, Duncan R, Gabhart KM, Nephew LD, Christy SM, Vadaparampil ST, Giuliano AR, Kasting ML. Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status. Prev Med Rep 2024; 38:102602. [PMID: 38375175 PMCID: PMC10874862 DOI: 10.1016/j.pmedr.2024.102602] [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: 02/22/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 02/21/2024] Open
Abstract
Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.
Collapse
Affiliation(s)
- Alfu Laily
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
| | - Robert Duncan
- Department of Human Development and Family Studies, College of Health and Human Sciences, Purdue University, 1202 West State St., West Lafayette, IN 47907, USA
| | - Kaitlyn M. Gabhart
- Department of Psychology, Vanderbilt University, 230 Appleton Pl, Nashville, TN 37203, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 340 W 10th St., Indianapolis, IN 46202, USA
| | - Shannon M. Christy
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Oncological Sciences, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Anna R. Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Monica L. Kasting
- Department of Public Health, College of Health and Human Sciences, Purdue University, 820 Mitch Daniels Blvd, West Lafayette, IN 47907, USA
- Cancer Prevention and Control Program, Indiana University Simon Comprehensive Cancer Center, 535 Barnhill Dr., Indianapolis, IN 46202, USA
| |
Collapse
|
4
|
García‐Sierra R, Fernández‐Cano MI, Jiménez‐Pera M, Feijoo‐Cid M, Arreciado Marañón A. Knowledge about the best practice guidelines in the nursing degree: A non-randomized post-test design. Nurs Open 2024; 11:e2074. [PMID: 38268254 PMCID: PMC10733600 DOI: 10.1002/nop2.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 10/05/2023] [Accepted: 12/02/2023] [Indexed: 01/26/2024] Open
Abstract
AIM To compare knowledge of Nursing Degree students about Best Practice Guidelines when there are included as teaching content in a subject vs knowledge through having the usual internship experience without teaching specific guidelines contents. DESIGN Non-randomized post-test-only design with a comparison group. METHODS 143 students of the nursing degree at the Autonomous University of Barcelona were recruited. The intervention group received a classroom training in three Best Practice Guidelines with Problem-Based Learning methodology. The comparison group only attended internship, without specific guidelines contents. Knowledge was evaluated with an ad hoc post intervention questionnaire. The information was collected between 2016 and 2018. RESULTS The average score of knowledge was low, 5.1 out of 10, and differs between guides. The best results were obtained by the students with internships and that had consulted the guides on some occasions. Synchronized effort and leadership in Academia and Healthcare are needed to favour evidence-based practice. The combination of the consultation of the Best Practice Guidelines in theoretical learning combined with the practice, increases the knowledge of the Best Practice Guidelines and will favour the implementation of evidence-based practice. Some students were involved in questionnaire design.
Collapse
Affiliation(s)
- Rosa García‐Sierra
- Research Support Unit Metropolitana Nord, Primary Care Research Institut Jordi Gol (IDIAPJGol)BarcelonaSpain
- Nursing Department, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
- Multidisciplinary Research Group in Health and Society GREMSAS (2017 SGR 917)BarcelonaSpain
| | - María Isabel Fernández‐Cano
- Nursing Department, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
- Multidisciplinary Research Group in Health and Society GREMSAS (2017 SGR 917)BarcelonaSpain
| | - Miguel Jiménez‐Pera
- Nursing Department, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Maria Feijoo‐Cid
- Nursing Department, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
- Multidisciplinary Research Group in Health and Society GREMSAS (2017 SGR 917)BarcelonaSpain
| | - Antonia Arreciado Marañón
- Nursing Department, Faculty of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
- Multidisciplinary Research Group in Health and Society GREMSAS (2017 SGR 917)BarcelonaSpain
| |
Collapse
|
5
|
Nates JL, Pastores SM, Oropello JM. The authors reply. Crit Care Med 2023; 51:e276-e277. [PMID: 37971346 DOI: 10.1097/ccm.0000000000006048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Joseph L Nates
- Division of Anesthesiology and Critical Care, Department of Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen M Pastores
- Critical Care Department, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John M Oropello
- Critical Care Department, Mount Sinai Medical Center, New York, NY
| |
Collapse
|
6
|
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.
| |
Collapse
|
7
|
Boucher NA, Tucker MC, White BS, Ear B, Dubey M, Byrd KG, Williams JW, Gierisch JM. Frontline Clinician Appraisement of Research Engagement: "I feel out of touch with research". J Gen Intern Med 2023; 38:2671-2677. [PMID: 37072534 PMCID: PMC10112825 DOI: 10.1007/s11606-023-08200-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Health services research can benefit from frontline clinician input across all stages of research, yet their key perspectives are often not meaningfully engaged. OBJECTIVE How can we improve clinician engagement in research? DESIGN Convenience sampling and semi-structured interviews followed by descriptive content analysis with an inductive approach, followed by group participatory listening sessions with interviewees to further contextualize findings. PARTICIPANTS Twenty-one multidisciplinary clinicians from one healthcare system. KEY RESULTS We identified two major themes: perceptions of research (how research fits within job role) and characterizing effective engagement (what works and what does not work in frontline clinician engagement). "Perceptions of Research" encompassed three subthemes: prior research experience; desired degree of engagement; and benefits to clinicians engaging in research. "Characterizing Effective Engagement" had these subthemes: engagement barriers; engagement facilitators; and impact of clinician's racial identity. CONCLUSIONS Investing in frontline clinicians as research collaborators is beneficial to clinicians themselves, the health systems that employ them, and those for which they care. Yet, there are multiple barriers to meaningful engagement.
Collapse
Affiliation(s)
- Nathan A Boucher
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA.
- Sanford School of Public Policy, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.
- Department of Medicine (Geriatrics), School of Medicine, Duke University, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Durham, NC, USA.
| | - Matthew C Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
| | - Brandolyn S White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
| | - Belinda Ear
- Cooperative Studies Program Epidemiology Center - Durham, Durham, NC, USA
| | - Manisha Dubey
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
| | - Kaileigh G Byrd
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
| | - John W Williams
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
- Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC, USA
| | - Jennifer M Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System HSR&D, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC, USA
| |
Collapse
|
8
|
Shashar S, Ellen M, Codish S, Davidson E, Novack V. Unravelling the determinants of medical practice variation in referrals among primary care physicians: insights from a retrospective cohort study in Southern Israel. BMJ Open 2023; 13:e072837. [PMID: 37586857 PMCID: PMC10432653 DOI: 10.1136/bmjopen-2023-072837] [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: 02/23/2023] [Accepted: 07/04/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES Reducing medical practice variation (MPV) is a central theme of system improvement because it is associated with poor health outcomes, increased costs and disparities in care. This study aimed to estimate the extent to which each determinant (patient, physician, clinic) explains MPV among primary care physicians and to identify the characteristics of health services with a greater explained variance. METHODS A retrospective cohort study of primary care physicians practising in non-private clinics of Clalit Health Services in Southern Israel, for longer than a year between 2011 and 2017 and with more than 100 adult patients per practice. We assessed the variation in referral rates among 17 health services and the proportion explained by each domain (patient, physician and clinic). We used generalised linear negative binomial mixed models and the Nakagawa's R2, computing the marginal r2. RESULTS The study included 243 physicians working in 295 practices and 139 clinics. The mean-explained variance was 28.5%±10.0%, where physician characteristics explained 4.5% of the variation. The intrapractice variation (within a single physician between the years) was explained better than the interphysician (between physicians). Health services with high explained variation were blood tests characterised by both low intrapractice variation (Rs=-0.65, p value=0.005) and high referral rates (Rs=0.46, p value=0.06). CONCLUSION Over 70% of MPV is not explained by the patient, clinic and physician demographic and professional characteristics. Future research should focus on the fraction of MPV that is explained by the physicians' psychological characteristics, and thus potentially identify psychological targets for behavioural modifications aimed at reducing MPV.
Collapse
Affiliation(s)
- Sagi Shashar
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel Aviv, Israel
| | - Victor Novack
- Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| |
Collapse
|
9
|
van Opijnen MP, de Vos FYF, Nabuurs RJA, Snijders TJ, Nandoe Tewarie RDS, Taal W, Verhoeff JJC, van der Hoeven JJM, Broekman MLD. Practice variation in re-resection for recurrent glioblastoma: A nationwide survey among Dutch neuro-oncology specialists. Neurooncol Pract 2023; 10:360-369. [PMID: 37457228 PMCID: PMC10346413 DOI: 10.1093/nop/npad016] [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] [Indexed: 03/16/2024] Open
Abstract
Background Despite current best treatment options, a glioblastoma almost inevitably recurs after primary treatment. However, in the absence of clear evidence, current guidelines on recurrent glioblastoma are not well-defined. Re-resection is one of the possible treatment modalities, though it can be challenging to identify those patients who will benefit. Therefore, treatment decisions are made based on multidisciplinary discussions. This study aimed to investigate the current practice variation between neuro-oncology specialists. Methods In this nationwide study among Dutch neuro-oncology specialists, we surveyed possible practice variation. Via an online survey, 4 anonymized recurrent glioblastoma cases were presented to neurosurgeons, neuro-oncologists, medical oncologists, and radiation oncologists in The Netherlands using a standardized questionnaire on whether and why they would recommend a re-resection or not. The results were used to provide a qualitative analysis of the current practice in The Netherlands. Results The survey was filled out by 56 respondents, of which 15 (27%) were neurosurgeons, 26 (46%) neuro-oncologists, 2 (4%) medical oncologists, and 13 (23%) radiation oncologists. In 2 of the 4 cases, there appeared to be clinical equipoise. Overall, neurosurgeons tended to recommend re-resection more frequently compared to the other specialists. Neurosurgeons and radiation oncologists showed opposite recommendations in 2 cases. Conclusions This study showed that re-resection of recurrent glioblastoma is subject to practice variation both between and within neuro-oncology specialties. In the absence of unambiguous guidelines, we observed a relationship between preferred practice and specialty. Reduction of this practice variation is important; to achieve this, adequate prospective studies are essential.
Collapse
Affiliation(s)
- Mark P van Opijnen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Filip Y F de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob J A Nabuurs
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Tom J Snijders
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Walter Taal
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
10
|
Fulop NJ, Walton H, Crellin N, Georghiou T, Herlitz L, Litchfield I, Massou E, Sherlaw-Johnson C, Sidhu M, Tomini SM, Vindrola-Padros C, Ellins J, Morris S, Ng PL. A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-151. [PMID: 37800997 DOI: 10.3310/fvqw4410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Background Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary. Objective To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2). Methods A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites). Results Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls. Limitations Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups. Future work Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients. Conclusions We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered. Study registration This study is registered with the ISRCTN (14962466). Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.
Collapse
Affiliation(s)
- Naomi J Fulop
- Department of Applied Health Research, University College London, UK
| | - Holly Walton
- Department of Applied Health Research, University College London, UK
| | | | | | - Lauren Herlitz
- Department of Applied Health Research, University College London, UK
| | - Ian Litchfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Efthalia Massou
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | - Manbinder Sidhu
- Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Sonila M Tomini
- Department of Applied Health Research, University College London, UK
| | | | - Jo Ellins
- Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, UK
| | - Pei Li Ng
- Department of Applied Health Research, University College London, UK
| |
Collapse
|
11
|
Thompson C, Mebrahtu T, Skyrme S, Bloor K, Andre D, Keenan AM, Ledward A, Yang H, Randell R. The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023:1-85. [PMID: 37470324 DOI: 10.3310/grnm5147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Background Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain. Objectives Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users. Eligibility criteria Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals. Information sources Nineteen bibliographic databases searched October 2019 and February 2021. Risk of bias Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias. Synthesis of results Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design. Included studies Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not. Evidence limitations Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness. Interpretation CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required. Future work Developing nursing CDSS and primary research evaluation. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information. Registration PROSPERO [number: CRD42019147773].
Collapse
Affiliation(s)
- Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Sarah Skyrme
- School of Healthcare, University of Leeds, Leeds, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Deidre Andre
- Library Services, University of Leeds, Leeds, UK
| | | | | | - Huiqin Yang
- School of Healthcare, University of Leeds, Leeds, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
| |
Collapse
|
12
|
Viozzi I, Rovers MM, Overduin CG, ter Laan M. Stereotactic laser ablation in neuro-oncology - A survey among European neurosurgeons. BRAIN & SPINE 2023; 3:101749. [PMID: 37383437 PMCID: PMC10293215 DOI: 10.1016/j.bas.2023.101749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 06/30/2023]
Abstract
Introduction In the last decades, the application of stereotactic laser ablation (SLA) for the treatment of intracranial tumours has been growing, even though comparative trials are lacking. Our aim was to investigate the familiarity with SLA of neurosurgeons in Europe and their opinion regarding potential neuro-oncological indications. Furthermore, we investigated treatment preferences and variability for three exemplar neuro-oncological cases and willingness to refer for SLA. Material and methods A 26-questions survey was mailed to members of the EANS neuro-oncology section. We presented three clinical cases of respectively deep-seated glioblastoma, recurrent metastasis and recurrent glioblastoma. Descriptive statistics was applied to report results. Results 110 respondents completed all questions. Recurrent glioblastoma and recurrent metastases were regarded as the most feasible indications for SLA (chosen by 69% and 58% of the respondents) followed by newly diagnosed high-grade gliomas (31%). Seventy percent of respondents would refer patients for SLA. The majority of respondents would consider SLA as a treatment option for all three presented cases: 79% for the deep-seated glioblastoma case, 65% for the recurrent metastasis case and 76% for the recurrent glioblastoma case. Among respondents who wouldn't consider SLA, preference for standard treatment and lack of clinical evidence were reported as the main reasons. Conclusions Most of respondents considered SLA as a treatment option for recurrent glioblastoma, recurrent metastases and newly diagnosed deep-seated glioblastoma. At the moment the current evidence to support such a treatment is very low. Comparative prospective trials are needed to support the use of SLA and determine proper indications.
Collapse
Affiliation(s)
- Ilaria Viozzi
- Department of Neurosurgery, Radboud University Medical Center, Radboud Institute for Health Sciences, 6525 GA, Nijmegen, The Netherlands
| | - Maroeska M. Rovers
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, 6525 GA, Nijmegen, The Netherlands
| | - Christiaan G. Overduin
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, 6525 GA, Nijmegen, The Netherlands
| | - Mark ter Laan
- Department of Neurosurgery, Radboud University Medical Center, Radboud Institute for Health Sciences, 6525 GA, Nijmegen, The Netherlands
| |
Collapse
|
13
|
Trauma-Related Clinical Practice Variation in Dutch Emergency Departments. Healthcare (Basel) 2023; 11:healthcare11050748. [PMID: 36900752 PMCID: PMC10000928 DOI: 10.3390/healthcare11050748] [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: 01/25/2023] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.
Collapse
|
14
|
Giri VN, Oliver TK, Rumble RB, Friedberg JW, Miller KD, Geisel RL. ASCO Living Guidelines: The Next Frontier. J Clin Oncol 2023; 41:955-957. [PMID: 36534929 DOI: 10.1200/jco.22.02344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Veda N Giri
- Yale School of Medicine and Yale Cancer Center, New Haven, CT
| | | | | | | | | | | |
Collapse
|
15
|
Prochaska M, Meltzer D, Angelos P. When Guideline-Concordant Standardized Care Results in Healthcare Disparities. THE JOURNAL OF CLINICAL ETHICS 2023; 34:225-232. [PMID: 37831649 DOI: 10.1086/726815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
AbstractClinical red blood cell transfusion guidelines have been widely adopted in clinical practice, resulting in standardized transfusion practices in hospitalized patients with anemia. Standardization of transfusion practice has been welcomed by clinicians and health systems as a mechanism for reducing unnecessary, harmful, and costly practice variation that results in healthcare disparities. However, overzealously applied guidelines can have deleterious consequences for individual patients, ultimately resulting in and/or exacerbating healthcare disparities, rather than resolving them. This article provides empirical examples of the adverse consequences from the well-meaning attempt to standardize transfusion practice based on clinical practice guidelines and discusses the ethical implications of standardized transfusion practice.
Collapse
|
16
|
Broers DLM, Dubois L, de Lange J, Welie JVM, Brands WG, Lagas MBD, Bruers JJM, de Jongh A. How dentists and oral and maxillofacial surgeons deal with tooth extraction without a valid clinical indication. PLoS One 2023; 18:e0280288. [PMID: 36649347 PMCID: PMC9844881 DOI: 10.1371/journal.pone.0280288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES This study pertains to a secondary data analysis aimed at determining differences between oral and maxillofacial surgeons (OMFSs) and dentists handling dental extractions without an evident clinical indication. STUDY DESIGN A survey of 18 questions was conducted among 256 OMFSs in the Netherlands and a random sample of 800 dentists Respondents could answer the questions in writing or online. The data was collected in the period from November 2019 to January 2020, during which two reminders were sent. Analysis of the data took place via descriptive statistics and Chi Square test. RESULTS The response rate was 28.1% (n = 72) for OMFSs and 30.3% (n = 242) for dentists. In the past three years, 81.9% (n = 59) of the OMFSs and 68.0% (n = 164) of the dentists received a request for extraction without a clinical indication. The most common reasons were financial and severe dental fear (OMFSs: 64.9 and 50.9% vs dentists: 77.4 and 36.5%). Dentists were significantly more likely (75.6%, n = 114) than OMFS (60.7%, n = 34) to comply with their last extraction request without a clinical indication. Almost none of them regretted the extraction afterwards. As for the request itself, it was found that 17.5% (n = 10) of the OMFSs and 12.5% (n = 20) of the dentists did not check for patients' mental competency (p = 0.352). CONCLUSIONS Given that most of the interviewed dental professionals complied with non-dental extraction requests when such extractions are ethically and legally precarious, recommendations for handling such requests are greatly needed.
Collapse
Affiliation(s)
- Dyonne Liesbeth Maria Broers
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
- * E-mail:
| | - Leander Dubois
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, St Antonius Hospital, Nieuwegein/Utrecht/Woerden, The Netherlands
| | - Jan de Lange
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Isala Klinieken Zwolle, Zwolle, The Netherlands
| | - Jos Victor Marie Welie
- University College Maastricht, Maastricht University, Maastricht, The Netherlands
- St. André International Center for Ethics and Integrity, Saint-André-d’Olérargues, France
| | - Wolter Gerrit Brands
- St. André International Center for Ethics and Integrity, Saint-André-d’Olérargues, France
- Royal Dutch Dental Association (KNMT), Utrecht, The Netherlands
| | - Maria Barbara Diana Lagas
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
| | - Jan Joseph Mathieu Bruers
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
- Royal Dutch Dental Association (KNMT), Utrecht, The Netherlands
| | - Ad de Jongh
- Academic Centre for Dentistry Amsterdam, Amsterdam, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
- Research department PSYTREC, Bilthoven, The Netherlands
- School of Health Sciences, Salford University, Manchester, United Kingdom
- Institute of Health and Society, University of Worcester, Worcester, United Kingdom
- School of Psychology, Queen’s University Belfast, Belfast, Northern Ireland
| |
Collapse
|
17
|
Vreugdenhil M, Bergmans C, van Heel WJM, Rövekamp-Abels LWW, Wewerinke L, Lopes Cardozo RH, van Goudoever JB, Brus F, Akkermans MD. The effect of individualized iron supplementation on iron status in Dutch preterm infants born between 32 and 35 weeks of gestational age: evaluation of a local guideline. J Matern Fetal Neonatal Med 2022; 35:10279-10286. [PMID: 36229041 DOI: 10.1080/14767058.2022.2122796] [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: 01/20/2023]
Abstract
OBJECTIVE Iron deficiency (ID) and iron deficiency anemia (IDA) in early life are associated with adverse effects. Preterm infants are at risk for developing ID(A). Considering that not every preterm infant develops ID(A) and the potential risk of iron overload, indiscriminate iron supplementation in late preterm infants is debatable. This study aimed to evaluate the effect of a locally implemented guideline regarding individualized iron supplementation on the prevalence of ID(A) at the postnatal age of 4-6 months in Dutch preterm infants born between 32 and 35 weeks of gestational age (GA). METHODS An observational study comparing the prevalence of ID(A) at the postnatal age of 4-6 months in Dutch preterm infants born between 32 and 35 weeks of GA before (i.e. PRE-guideline group) and after (i.e. POST-guideline group) implementation of the local guideline. RESULTS Out of 372 eligible preterm infants, 110 were included (i.e. 72 and 38 in the PRE- and POST-guideline group, respectively). ID- and IDA-prevalence rates at 4-6 months of age in the PRE-guideline group were 36.1% and 13.9%, respectively, and in the POST-guideline group, 21.1% and 7.9%, respectively, resulting in a significant decrease in ID-prevalence of 15% and IDA-prevalence of 6%. No indication of iron overload was found. CONCLUSION An individualized iron supplementation guideline for preterm infants born between 32 and 35 weeks GA reduces ID(A) at the postnatal age of 4-6 months without indication of iron overload.
Collapse
Affiliation(s)
- Mirjam Vreugdenhil
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Carlijn Bergmans
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands.,Department of Pediatrics/Neonatology, Amsterdam University Medical Centers, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Willemijn J M van Heel
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Lyanne W W Rövekamp-Abels
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Leo Wewerinke
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Rob H Lopes Cardozo
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Johannes B van Goudoever
- Department of Pediatrics/Neonatology, Amsterdam University Medical Centers, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Frank Brus
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Marjolijn D Akkermans
- Department of Pediatrics/Neonatology, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| |
Collapse
|
18
|
Javed S, Kang WD, Black C, Chorath K, Johal J, Huh BK. Clinical practice guidelines for the management of patients with chronic regional pain syndrome: a systematic appraisal using the AGREE II instrument. Pain Manag 2022; 12:951-960. [PMID: 36193759 DOI: 10.2217/pmt-2022-0046] [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: 11/21/2022] Open
Abstract
Aim: Chronic regional pain syndrome (CRPS) is a debilitating, painful condition of limbs that often arises after an injury and is associated with significant morbidity. Materials & methods: The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, used to assess the quality of clinical practice guidelines (CPGs), was used to evaluate seven CRPS management guideline. Results: Out of the seven CPGs evaluated using the AGREE II instrument, only one from Royal College of Physicians was found to have high-quality consensus guidelines for diagnosis and management of CRPS. Conclusion: Future CPGs should be backed by systematic literature searches, focus on guidelines clinical translation into clinical practice and applicability to the desired patient population.
Collapse
Affiliation(s)
- Saba Javed
- Department of Pain Medicine, MD Anderson Cancer Center Houston, TX, USA
| | | | | | | | | | - Billy K Huh
- Department of Pain Medicine, MD Anderson Cancer Center Houston, TX, USA
| |
Collapse
|
19
|
Gerritse MBE, Smeets CFA, Heesakkers JPFA, Lagro-Janssen ALM, van der Vaart CH, de Vries M, Kluivers KB. Physicians’ perspectives on using a patient decision aid in female stress urinary incontinence. Int Urogynecol J 2022:10.1007/s00192-022-05344-w. [DOI: 10.1007/s00192-022-05344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/09/2022] [Indexed: 10/14/2022]
Abstract
Abstract
Introduction and hypothesis
A treatment choice for female stress urinary incontinence (SUI) is preference sensitive for both patients and physicians. Multiple treatment options are available, with none being superior to any other. The decision-making process can be supported by a patient decision aid (PDA). We aimed to assess physicians’ perceptions concerning the use of a PDA.
Methods
In a mixed methods study, urologists, gynecologists and general practitioners in the Netherlands were asked to fill out a web-based questionnaire. Questions were based on the Tailored Implementation for Chronic Diseases checklist using the following domains: guideline factors, individual health professional factors, professional interactions, incentives and resources, and capacity for organizational change. Participants were asked to grade statements using a five-point Likert scale and to answer open questions on facilitators of and barriers to implementation of a PDA. Outcomes of statement rating were quantitatively analyzed and thematic analysis was performed on the outcomes regarding facilitators and barriers.
Results
The response rate was 11%, with a total of 120 participants completing the questionnaire. Ninety-two of the physicians (77%) would use a PDA in female SUI. Evidence-based and unbiased content, the ability to support shared decision making, and patient empowerment are identified as main facilitators. Barriers are the expected prolonged time investment and the possible difficulty using the PDA in less health-literate patient populations.
Conclusions
The majority of physicians would use a PDA for female SUI. We identified facilitators and barriers that can be used when developing and implementing such a PDA.
Collapse
|
20
|
Dairi MS. Physicians' Knowledge and Practices Regarding Asthma: A Cross-Sectional Study in Saudi Arabia. Int J Gen Med 2022; 15:6671-6680. [PMID: 36016985 PMCID: PMC9397430 DOI: 10.2147/ijgm.s369306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to explore the characteristics of knowledge and practice of physicians towards asthma in Saudi Arabia. Methods An online cross-sectional study was conducted in Saudi Arabia between 28 August and 10 November 2021. Convenience sampling technique was applied in this study through social media websites. Previously developed 10-items questionnaire was used to assess the knowledge about asthma among the participating physicians. Descriptive statistics were used to describe the participants’ demographic characteristics. Binary logistic regression analysis was conducted to identify factors associated with being adherent to asthma practices guidelines. Results Overall, participants’ knowledge was moderate. The average percentage of physicians who reported practicing asthma management based on recommended guidelines 63.7%. Younger age (30–34 years) and having a work experience of (6–10 years) were significant predictors of being adherent to asthma practices guidelines (OR: 1.96 (95% CI: 1.21–3.17) (p=0.006) and OR: 1.67 (95% CI 1.05–2.67) (p=0.031), receptively). Conclusion This study showed that the percentage of physicians who reported practicing asthma management based on recommended guidelines in Saudi Arabia are moderate. Future studies to investigate factors associated with improvement in knowledge about asthma and adherence to guidelines are needed.
Collapse
Affiliation(s)
- Mohammad S Dairi
- Department of Internal Medicine, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| |
Collapse
|
21
|
Kocken PL, van Kesteren NMC, van Zoonen R, Reijneveld SA. Availability and implementation of guidelines in European child primary health care: how can we improve? Eur J Public Health 2022; 32:670-676. [PMID: 36006035 PMCID: PMC9527973 DOI: 10.1093/eurpub/ckac114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU). METHODS We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care. RESULTS According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability. CONCLUSIONS Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.
Collapse
Affiliation(s)
- Paul L Kocken
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Sijmen A Reijneveld
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Hussain WA, Bondi DS, Shah P, Morgan SE, Sriram S, Schreiber MD. Implementation of an Inhaled Nitric Oxide Weaning Protocol and Stewardship in a Level 4 NICU to Decrease Inappropriate Use. J Pediatr Pharmacol Ther 2022; 27:284-291. [PMID: 35350163 DOI: 10.5863/1551-6776-27.3.284] [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: 04/15/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension in newborns, with limited data regarding weaning. Our institution implemented a multidisciplinary iNO weaning protocol and stewardship to reduce inappropriate use of iNO. The objective of this study was to evaluate our institutional iNO usage before and after implementation. METHODS Single-center study comparing a retrospective control group to a prospective cohort after implementation of an iNO weaning protocol. All infants in the neonatal intensive care unit (NICU) who received iNO during the study timeframe were included. The primary outcome was duration of iNO per course. RESULTS A total of 47 courses of iNO occurred during the pre-protocol timeframe compared with 37 courses in the post-protocol timeframe. Median iNO usage per course was 149 hours (IQR, 63-243) in the pre-protocol group versus 59 hours (IQR, 37-122) in the post-protocol group (p = 0.008). Length of stay was significantly longer in the pre-protocol group (p = 0.02), likely related to significantly longer ventilator days in the pre-protocol group (p = 0.02). Compliance with initiation of weaning when recommended per the protocol was 72%, and the incidence of successful weaning was 74%. CONCLUSIONS The implementation of an iNO weaning protocol in the NICU significantly decreased iNO usage by approximately 60% with no notable negative effects.
Collapse
Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics (WAH), Loyola University Medical Center, Maywood, IL
| | - Deborah S Bondi
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Pooja Shah
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Sherwin E Morgan
- Department of Respiratory Care Services (SEM), University of Chicago Medicine, Chicago, IL
| | - Sudhir Sriram
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Michael D Schreiber
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| |
Collapse
|
24
|
Roifman I, Han L, Fang J, Chu A, Austin P, Ko DT, Douglas P, Wijeysundera H. Patient, physician and geographic predictors of cardiac stress testing strategy in Ontario, Canada: a population-based study. BMJ Open 2022; 12:e059199. [PMID: 35273065 PMCID: PMC8915339 DOI: 10.1136/bmjopen-2021-059199] [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] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain. DESIGN Retrospective cohort study. SETTING Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018. PARTICIPANTS 103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain. PRIMARY AND SECONDARY OUTCOME MEASURES To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo). RESULTS There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT. CONCLUSIONS We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.
Collapse
Affiliation(s)
- Idan Roifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | | | - Peter Austin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Pamela Douglas
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Harindra Wijeysundera
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| |
Collapse
|
25
|
Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
Collapse
|
26
|
Iltis AS, Mehta M, Sawinski D. Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease. HEC Forum 2021:10.1007/s10730-021-09463-7. [PMID: 34617168 DOI: 10.1007/s10730-021-09463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.
Collapse
Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | - Maya Mehta
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| | - Deirdre Sawinski
- Renal Electrolyte, and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
27
|
Korownyk CS, Allan GM, McCormack J, Lindblad AJ, Horvey S, Kolber MR. Successes, lessons and opportunities: 15-year follow-up of an integrated evidence-based medicine curriculum. BMJ Evid Based Med 2021; 26:241-245. [PMID: 33355249 PMCID: PMC8479748 DOI: 10.1136/bmjebm-2020-111393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 01/17/2023]
Abstract
In 2005, the Department of Family Medicine at the University of Alberta introduced an evidence-based practice curriculum into the 2-year Family Medicine Residency Program. The curriculum was based on best available evidence, had multiple components and was comprehensive in its approach. It prioritised preappraised summary evidence over in-depth evidence appraisal. This paper describes the lessons learnt over the past 15 years including components that were eventually discontinued. We also discuss additions to the programme including the development of accessible, preappraised, summarised resources. We review the difficulties associated with evaluation and the incorporation of evidence-based practice into all aspects of residency training. Future directions are discussed including the incorporation of shared decision-making at the point of care.
Collapse
Affiliation(s)
- Christina S Korownyk
- Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - G Michael Allan
- Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- College of Family Physicians of Canada, Mississauga, Ontario, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adrienne J Lindblad
- Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- College of Family Physicians of Canada, Mississauga, Ontario, Canada
| | - Samantha Horvey
- Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael R Kolber
- Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
28
|
Koppes DM, van Hees MSF, Koenders VM, Oudijk MA, Bekker MN, Franssen MTM, Smits LJ, Hermens R, van Kuijk SMJ, Scheepers HC. Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study. J Perinat Med 2021; 49:783-790. [PMID: 34049425 DOI: 10.1515/jpm-2021-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/26/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights to make an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications. METHODS In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages. RESULTS A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation (SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen. CONCLUSIONS Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.
Collapse
Affiliation(s)
- Dorothea M Koppes
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Merel S F van Hees
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | | | - Martijn A Oudijk
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maureen T M Franssen
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Luc J Smits
- Department of Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Rosella Hermens
- Scientific Centre for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Hubertina C Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
29
|
Coppola A, Black S, Endacott R. How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study. Scand J Trauma Resusc Emerg Med 2021; 29:138. [PMID: 34530872 PMCID: PMC8447587 DOI: 10.1186/s13049-021-00946-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. DESIGN AND METHODS An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. RESULTS Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. CONCLUSION Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.
Collapse
Affiliation(s)
- Ali Coppola
- MClinRes Research Paramedic, South Western Ambulance Service NHS Foundation Trust, Abbey Court, Eagle Way, Exeter, UK.
| | - Sarah Black
- Head of Research, Audit and Quality Improvement, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Ruth Endacott
- School of Nursing and Midwifery (Faculty of Health: Medicine, Dentistry and Human Sciences), University of Plymouth, Plymouth, UK
- School of Nursing and Midwifery, (Faculty of Medicine, Nursing and Health Sciences), Monash University, Melbourne, Australia
| |
Collapse
|
30
|
van Kalleveen MW, Dykstra TC, de Meij TGJ, Plötz FB. Guideline adherence and clinical relevance of laboratory investigations during follow-up in paediatric coeliac disease: A Dutch single-centre cohort study. Acta Paediatr 2021; 110:2641-2647. [PMID: 34081815 DOI: 10.1111/apa.15967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 01/21/2023]
Abstract
AIM Dutch national guidelines on follow-up of paediatric celiac disease (CD) are available. The primary aim was to evaluate guideline adherence by paediatricians during follow-up. The secondary aim was to determine the clinical relevance and diagnostic yield of routine laboratory tests suggested by these guidelines. METHODS A retrospective, single-centre, cohort study was performed in paediatric CD patients who visited Tergooi Hospital, the Netherlands, between January 2017 and December 2019, with follow-up of at least twelve months after diagnosis. We analysed guideline adherence, number of outpatient visits and all laboratory data. RESULTS We included 91 CD children with a median follow-up of 4.0 years (range 1-16 years) and 162 follow-up visits. Strict adherence amongst paediatricians during follow-up was 8.0% (13/162 cases). A total of 1570 laboratory tests were performed of which 45.4% (713/1570) was in strict compliance with the Dutch national guidelines. Clinically relevant deviations were observed in 5.3% of requested laboratory tests. CONCLUSION Strict guideless adherence amongst paediatricians in follow-up of paediatric CD was low and the clinical relevance of the suggested routine laboratory tests is limited. This underlines the increasing notion that evidence-based guidelines on follow-up of CD are warranted.
Collapse
Affiliation(s)
- Michael W. van Kalleveen
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
- Department of Gastroenterology and Hepatology Leiden University Medical Centre Leiden The Netherlands
| | - Tim C. Dykstra
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
| | - Tim G. J. de Meij
- Department of Paediatric Gastroenterology Amsterdam UMC Amsterdam The Netherlands
| | - Frans B. Plötz
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
- Department of Paediatrics Amsterdam UMC Emma Children’s Hospital University of Amsterdam Amsterdam The Netherlands
| |
Collapse
|
31
|
Sanders M, Fiscella K, Hill E, Ogedegbe O, Cassells A, Tobin JN, Williams S, Veazie P. Motivation to move fast, motivation to wait and see: The association of prevention and promotion focus with clinicians' implementation of the JNC-7 hypertension treatment guidelines. J Clin Hypertens (Greenwich) 2021; 23:1752-1757. [PMID: 34374204 PMCID: PMC8463494 DOI: 10.1111/jch.14332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/27/2022]
Abstract
Roughly half of the adults in the United States are diagnosed with hypertension (HTN). Unfortunately, less than one‐third have their condition under control. Clinicians generally have positive regard for the use of HTN guidelines to achieve HTN treatment goals; however, actual uptake remains low. Factors underpinning clinician variation in practice are poorly understood. To understand the relationship between clinicians’ personal motivation to complete goals and their uptake of the Joint National Commission's HTN guidelines. The authors used Regulatory Focus Theory (RFT, ie, prevention and promotion focus), an empirically supported motivational theory, as a guiding framework to examine the relationship. The authors hypothesized that clinicians with high prevention focus would report following guidelines more often and have shorter follow‐up visit intervals for patients with uncontrolled blood pressure. Clinicians (n = 27) caring for adult patients diagnosed with HTN (n = 8605) in Federally Qualified Health Centers (n = 8). Clinicians’ prevention and promotion focus scores and the number of days between visits for their patients with uncontrolled systolic blood pressure (SBP) (≥ 140 mm Hg). Consistent with RFT, 60% of prevention focused clinicians reported they always followed the monthly visit guideline for the patients with uncontrolled blood pressure, compared with 38% of promotion focused clinicians (p = .254). The unadjusted probability of returning for a follow‐up visit within 30 days was greater among patients whose clinician was higher in prevention focus (p = .009), but there was no evidence at the 0.05 significance level in our adjusted model. These findings provide some limited evidence that RFT is a useful framework to understand clinician adherence to HTN treatment guidelines.
Collapse
Affiliation(s)
- Mechelle Sanders
- Department of Family Medicine, University of Rochester, Rochester, New York, USA
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester, Rochester, New York, USA
| | - Elaine Hill
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | | | - Andrea Cassells
- Clinical Directors Network Inc, Rockefeller Univ, New York, New York, USA
| | - Jonathan N Tobin
- Clinical Directors Network Inc, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Peter Veazie
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| |
Collapse
|
32
|
Reducing bruising and pain through enhancement of subcutaneous anticoagulant injection techniques: a best practice implementation project. JBI Evid Implement 2021; 19:94-104. [PMID: 33570337 DOI: 10.1097/xeb.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Subcutaneous delivery of anticoagulant therapy is a common treatment modality across multiple medical disciplines. However, postinjection complications of bruising and pain continues to be a problem that has the propensity to affect patients physically and psychologically. A review of literature revealed a set of recommended injection techniques that have shown to improve these clinical outcomes. OBJECTIVES The project aims to utilize an evidence implementation framework to introduce evidence-based injection technique, for the reduction of postinjection complications. METHODS A best practice implementation project was administered across three adult- cardiology and cardio-thoracic general wards in Singapore from March 2018 to February 2019. The Joanna Briggs Institute (JBI)'s framework of evidence implementation was utilized to enable change. A baseline audit was carried out to ascertain existing injection practices. Guided by the latest evidence, a new subcutaneous injection workflow was created and disseminated. Follow-up audits were held at 1 and 8-month postimplementation to assess compliance to the new subcutaneous injection workflow and the sustainment of change. Data were consolidated and analysed with the aid of JBI Practical Application of Clinical Evidence System. Barriers to change were also identified and addressed with the aid of JBI's Getting Research into Practice tool. RESULTS A large variation of subcutaneous injection techniques was observed at the baseline audit. At 1-month postimplementation, overall compliance with the new subcutaneous injection workflow was assessed to be 73.3%. Criteria 2 and 3 of the JBI Practical Application of Clinical Evidence System audit criteria improved from the baseline values (9.1-80%; 0-93.3%). At 8-month postimplementation, compliance rate remained high (83%) following strategies to reinforce and sustain change. Participants complied to Criteria 1 at all stages of the project. Correspondingly, the incidence of bruising reduced from baseline, with a relative risk reduction of 52% (1 month) and 29% (8 months). Median pain also decreased from the baseline, with an improvement from 2.0 (1.0-3.0) to 0.0 (0.0-1.0). CONCLUSION Introduction and sustainment of change requires careful planning and execution. JBI's framework of evidence implementation is an effective model to guide this process. This project also highlighted the value of continuous learning, clinical update and practice standardization. This is especially important in the current climate of nursing mobility worldwide and the associated practice variations based on nursing education and experience.
Collapse
|
33
|
Shah J, Nwogu C, Vivian E, John ES, Kedia P, Sellers B, Cler L, Acharya P, Tarnasky P. The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care". Pancreas 2021; 50:293-299. [PMID: 33835958 DOI: 10.1097/mpa.0000000000001758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP). METHODS This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured. RESULTS The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001). CONCLUSIONS The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.
Collapse
Affiliation(s)
- Jimmy Shah
- From the Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas
| | - Christiana Nwogu
- From the Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas
| | - Elaina Vivian
- From the Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas
| | - Elizabeth S John
- From the Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas
| | | | | | - Leslie Cler
- Internal Medicine and Hospital Administration, Methodist Dallas Medical Center
| | - Priyanka Acharya
- Clinical Research Institute, Methodist Health System, Dallas, TX
| | | |
Collapse
|
34
|
Gaube S, Suresh H, Raue M, Merritt A, Berkowitz SJ, Lermer E, Coughlin JF, Guttag JV, Colak E, Ghassemi M. Do as AI say: susceptibility in deployment of clinical decision-aids. NPJ Digit Med 2021; 4:31. [PMID: 33608629 PMCID: PMC7896064 DOI: 10.1038/s41746-021-00385-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023] Open
Abstract
Artificial intelligence (AI) models for decision support have been developed for clinical settings such as radiology, but little work evaluates the potential impact of such systems. In this study, physicians received chest X-rays and diagnostic advice, some of which was inaccurate, and were asked to evaluate advice quality and make diagnoses. All advice was generated by human experts, but some was labeled as coming from an AI system. As a group, radiologists rated advice as lower quality when it appeared to come from an AI system; physicians with less task-expertise did not. Diagnostic accuracy was significantly worse when participants received inaccurate advice, regardless of the purported source. This work raises important considerations for how advice, AI and non-AI, should be deployed in clinical environments.
Collapse
Affiliation(s)
- Susanne Gaube
- Department of Psychology, University of Regensburg, Regensburg, Germany. .,MIT AgeLab, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Harini Suresh
- MIT Computer Science & Artificial Intelligence Lab, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Martina Raue
- MIT AgeLab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Seth J Berkowitz
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eva Lermer
- LMU Center for Leadership and People Management, LMU Munich, Munich, Germany.,FOM University of Applied Sciences for Economics & Management, Munich, Germany
| | - Joseph F Coughlin
- MIT AgeLab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - John V Guttag
- MIT Computer Science & Artificial Intelligence Lab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Errol Colak
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Marzyeh Ghassemi
- Departments of Computer Science and Medicine, University of Toronto, Toronto, Canada.,Vector Institute, Toronto, Canada
| |
Collapse
|
35
|
Chorath K, Garza L, Tarriela A, Luu N, Rajasekaran K, Moreira A. Clinical practice guidelines on newborn hearing screening: A systematic quality appraisal using the AGREE II instrument. Int J Pediatr Otorhinolaryngol 2021; 141:110504. [PMID: 33229031 DOI: 10.1016/j.ijporl.2020.110504] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Several guidelines and consensus statements have been produced and disseminated for the detection and management of newborn hearing loss. However, to date, the quality and methodologic rigor of these screening and management protocols have not been appraised. OBJECTIVE To identify and evaluate existing guidelines and consensus statements for the detection and management of neonatal hearing loss. METHODS A comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources was conducted until August 2020. The quality of these guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered satisfactory quality if they scored >60%, and intraclass correlation coefficients (ICC) were calculated to assess agreement among the appraisers. RESULTS Twelve guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality', and the remaining were 'average' or 'low quality'. The 'Scope and Purpose' domain achieved the highest mean score (91.3% ± 5.8%), and lowest was 'Rigor of Development' (35.8% ± 19.1%). ICC analysis showed good to very good agreement across all domains (0.63-0.95). CONCLUSION These findings highlight the variability in methodologic quality of guidelines and consensus statement for the detection and management of neonatal hearing loss. These results may help to improve the reporting of future guidelines and guide the selection and use of these guidelines in clinical practice.
Collapse
Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Luis Garza
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, USA
| | - Aina Tarriela
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, USA
| | - Neil Luu
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, USA
| |
Collapse
|
36
|
Luu NN, Chorath KT, May BR, Bhuiyan N, Moreira AG, Rajasekaran K. Clinical practice guidelines in idiopathic facial paralysis: systematic review using the appraisal of guidelines for research and evaluation (AGREE II) instrument. J Neurol 2021; 268:1847-1856. [PMID: 33389026 DOI: 10.1007/s00415-020-10345-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/19/2020] [Accepted: 12/04/2020] [Indexed: 12/18/2022]
Abstract
Bell's palsy, or idiopathic facial paralysis, is a peripheral facial palsy of unknown cause that presents as sudden, unilateral weakness of the muscles of the face. Prompt treatment of Bell's palsy is critical in order for patients to achieve complete recovery of facial function. Delays in diagnosis and management can result in permanent facial defects. A number of clinical practice guidelines (CPG) exist to guide clinical decision-making in patients presenting with idiopathic facial paralysis. However, to date, there has been no comprehensive review of the methodological rigor and quality of these CPGs. Thus, the objective of the authors is to appraise the existing CPGs to ensure safe and effective practices. A total of eight guidelines met the inclusion criteria and were appraised. Only two CPGs achieved an overall rating of 'High', having five or more quality domains scoring > 60%. Across the CPGs, the domains of rigor of development, stakeholder involvement, and applicability has the lowest overall scores with 48.1%, 43.9%, and 43.1%, respectively. Based on the AGREE II instrument, the methodological rigor and quality of CPGs for Bell's palsy is low to average. In particular, future guidelines for Bell's palsy should look to the quality domains of rigor of development, stakeholder involvement, and applicability as the greatest opportunities for improvement.
Collapse
Affiliation(s)
- Neil N Luu
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut St, 18th Floor, Philadelphia, PA, 19010, USA
| | - Kevin T Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut St, 18th Floor, Philadelphia, PA, 19010, USA
| | - Brandon R May
- University of Texas Health Science Center-San Antonio, Texas, USA
| | - Nuvid Bhuiyan
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut St, 18th Floor, Philadelphia, PA, 19010, USA
| | - Alvaro G Moreira
- University of Texas Health Science Center-San Antonio, Texas, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut St, 18th Floor, Philadelphia, PA, 19010, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
37
|
Korupolu R, Stampas A, Jimenez I, Cruz D, Di Giusto M, Verduzco-Gutierrez M, Davis M. Mechanical ventilation and weaning practices for adults with spinal cord injury - An international survey. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm-000124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
38
|
Litchfield I, Moiemen N, Greenfield S. Barriers to Evidence-Based Treatment of Serious Burns: The Impact of Implicit Bias on Clinician Perceptions of Patient Adherence. J Burn Care Res 2020; 41:1297-1300. [PMID: 32645716 DOI: 10.1093/jbcr/iraa114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The underlying assumption of modern evidence-based practice is that treatment decisions made by healthcare providers are based solely on the best available scientific data. However, the connection between evidence informed care guidelines and the provision of care remains ambiguous. In reality, a number of contextual and nonclinical factors can also play a role, among which is the implicit bias that affects the way in which we approach or treat others based on irrelevant, individual characteristics despite conscious efforts to treat everyone equally. Influenced by the social and demographic characteristics of patients, this bias and its associated perceptions have been shown to affect clinical decision making and access to care across multiple conditions and settings. This summary article offers an introduction to how the phenomenon of implicit bias can impact on treatment compliance in multiple care contexts, its potential presence and impact in burns care and describes some of the strategies which offer possible solutions to reducing the disconnect between the conscious attempts to deliver equitable care and the discrepancies in care delivery that remain.
Collapse
Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | - Naiem Moiemen
- Plastic & Burns Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Birmingham
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| |
Collapse
|
39
|
Herzik KA, Barnett MJ, Thanh DM, Doroudgar S, Ip EJ. Glyburide Use in Older Adults: Pharmacy Claims Data Analysis of a Regional Healthcare Organization. J Am Geriatr Soc 2020; 68:2354-2358. [DOI: 10.1111/jgs.16723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kristen A. Herzik
- Department of Clinical Sciences Touro University California College of Pharmacy Vallejo California USA
- Department of Pharmacy Sharp Memorial Hospital San Diego California USA
- Department of Pharmacy Sharp Grossmont Hospital La Mesa California USA
| | - Mitchell J. Barnett
- Department of Clinical Sciences Touro University California College of Pharmacy Vallejo California USA
| | - Danielle M. Thanh
- Department of Clinical Sciences Touro University California College of Pharmacy Vallejo California USA
- Department of Pharmacy Stanford Health Care Stanford California USA
| | - Shadi Doroudgar
- Department of Clinical Sciences Touro University California College of Pharmacy Vallejo California USA
| | - Eric J. Ip
- Department of Clinical Sciences Touro University California College of Pharmacy Vallejo California USA
- Department of Medicine Stanford University School of Medicine Stanford California USA
| |
Collapse
|
40
|
Fisher SJ, Margerison LN, Jonker L. Development and cohort study of an audit approach to evaluate patient management in family practice in the UK: the 7S tool. Fam Pract 2020; 37:98-102. [PMID: 31529031 DOI: 10.1093/fampra/cmz053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In the UK, there is increased pressure on general practitioners' time due to an increase in (elderly) population and a shortage of general practitioners. This means that time has to be used efficiently, whilst optimizing adherence to consistent, appropriate and timely provision of care. OBJECTIVE(S) Create an audit tool that assists general practitioners and family practice staff to evaluate if patients are managed as effectively as possible, and to test the usefulness of this tool in a family practice. METHODS The '7S' audit tool has seven outcome elements; these broadly stand for what the actual and desired patient contact outcome was, or should have been. Terms include 'surgery', 'speak' and 'specific other' for an appointment at the practice, by telephone or with a dedicated specialist such as a practice nurse or phlebotomist, respectively. RESULTS A very small, rural, general practice in the UK was audited using the 7S tool. Five hundred patient contacts were reviewed by an independent general practitioner and the decision made if the mode of contact was appropriate or not for each case; in one of the three cases, the choice of care provision was inappropriate and chronic disease cases contributed most to this. General practitioners instigated the majority of poor patient management choices, and chronic disease patients were frequently seen in suboptimal settings. CONCLUSIONS Inefficiencies in the management of patients in family practice can be identified with the 7S audit tool, thereby producing evidence for staff education and service reconfiguration.
Collapse
Affiliation(s)
| | | | - Leon Jonker
- Science and Innovation Manager, Cumbria Partnership NHS Foundation Trust, Carlisle, UK
| |
Collapse
|
41
|
Covelli A, Facey M, Kennedy E, Brezden-Masley C, Gupta AA, Greenblatt E, Baxter NN. Clinicians' Perspectives on Barriers to Discussing Infertility and Fertility Preservation With Young Women With Cancer. JAMA Netw Open 2019; 2:e1914511. [PMID: 31693121 PMCID: PMC6865261 DOI: 10.1001/jamanetworkopen.2019.14511] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/15/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Infertility can be a devastating adverse effect of cancer treatment for young women. Fertility preservation may be an important and influential factor in treatment decisions. Despite American Society of Clinical Oncology guidelines recommending discussion around potential infertility with patients, nearly 50% of young women with cancer remain uninformed. Objective To understand and describe from clinicians' perspectives the barriers to discussing infertility and fertility preservation with young women with cancer. Design, Setting, and Participants This qualitative study used purposeful, maximum variation, and snowball sampling strategies to recruit 22 clinicians from cancer centers and community hospitals in 5 Canadian provinces, 5 practice areas, and 12 practice sites. Eligibility criteria included clinicians who regularly treat young women with cancer who might need fertility preservation. Telephone interviews that lasted between 30 to 75 minutes were conducted between May and November 2014 using a semistructured interview guide. Thematic analysis was used to discern the nature of barriers, and the Cabana framework was used to organize and interpret these findings. Analysis was conducted from May 2014 until May 2015. Main Outcomes and Measures Clinician perspectives on what influences their nonadherence to American Society of Clinical Oncology guidelines, which recommend discussing fertility preservation with patients. Results A total of 22 clinicians were interviewed, including 8 medical oncologists, 4 surgical oncologists, 4 fertility specialists, 3 hematology and oncology specialists, and 3 nurse practitioners or clinician nurse specialists. Seventeen clinicians were women and 5 clinicians were men; the median (range) time in practice was 10 (0.67-37) years. Analysis suggested that clinicians' unfamiliarity with infertility risks, fertility preservation technologies, referral processes, and procedures, as well as environmental factors and their perceptions of fertility preservation, influenced their practices regarding fertility discussions. Conclusions and Relevance The findings of this qualitative study suggest that the individual and environmental challenges that clinicians experience might negatively affect their willingness and ability to raise fertility-related issues with young women with cancer. Multiple strategies are needed to address these challenges to improve overall care of young women with cancer.
Collapse
Affiliation(s)
- Andrea Covelli
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marcia Facey
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Abha A Gupta
- Department of Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ellen Greenblatt
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
42
|
Regional trends in In-hospital Cardiac Arrest following sepsis-related admissions and subsequent mortality. Resuscitation 2019; 143:35-41. [DOI: 10.1016/j.resuscitation.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/19/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
|
43
|
Ugolini C, Lippi Bruni M, Leucci AC, Fiorentini G, Berti E, Nobilio L, Moro ML. Disease management in diabetes care: When involving GPs improves patient compliance and health outcomes. Health Policy 2019; 123:955-962. [PMID: 31481267 DOI: 10.1016/j.healthpol.2019.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/13/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022]
Abstract
Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study, we use clinical data from the Diabetes Register of one large Local Health Authority (LHAs) in Italy's Emilia-Romagna Region for the period 2012-2015. Firstly, we investigate whether GPs' participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Secondly, we test whether the monitoring activities prescribed for diabetics by the Regional diabetes guidelines have a positive impact on patients' health outcomes and increase appropriateness in health care utilization. Our results show that such a Program, which aims to increase GPs' involvement and cooperation in following the Regional guidelines, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, Regional policies have succeeded in promoting better health outcomes and improved appropriateness of health care utilization.
Collapse
Affiliation(s)
- Cristina Ugolini
- Department of Economics and CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Italy.
| | - Matteo Lippi Bruni
- Department of Economics and CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Italy
| | - Anna Caterina Leucci
- CRIFSP-School of Advanced Studies in Health Policies, University of Bologna, Italy
| | - Gianluca Fiorentini
- Department of Economics and CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Italy
| | - Elena Berti
- Regional Agency for Health and Social Care, Emilia-Romagna Region - ASSR, Italy
| | - Lucia Nobilio
- Regional Agency for Health and Social Care, Emilia-Romagna Region - ASSR, Italy
| | - Maria Luisa Moro
- Regional Agency for Health and Social Care, Emilia-Romagna Region - ASSR, Italy
| |
Collapse
|
44
|
Cabañero-Martínez MJ, Ramos-Pichardo JD, Velasco-Álvarez ML, García-Sanjuán S, Lillo-Crespo M, Cabrero-García J. Availability and perceived usefulness of guidelines and protocols for subcutaneous hydration in palliative care settings. J Clin Nurs 2019; 28:4012-4020. [PMID: 31410903 DOI: 10.1111/jocn.15036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 06/25/2019] [Accepted: 08/04/2019] [Indexed: 01/21/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the availability of, adherence to, and perceived usefulness of guidelines and protocols for managing hydration and subcutaneous hydration in palliative care settings. BACKGROUND Hydration at the end of life and the use of a subcutaneous route to hydrate generate some controversy among health professionals for different reasons. Having guidelines and protocols to assist in decision-making and to follow a standard procedure may be relevant in clinical practice. DESIGN Cross-sectional telephone survey, with closed-ended and open-ended questions designed specifically for this study. METHODS Data were obtained from 327 professionals, each from a different palliative care service. Mean, standard deviation, minimum and maximum were calculated for continuous variables; frequency distributions were obtained for categorical variables. A qualitative content analysis was performed on the open-ended questions. The article adheres to the STROBE guidelines for reporting observational studies. RESULTS Only 24.8% of the participants had guidelines available to assist in making decisions regarding hydration, and 55.6% claimed to follow them 'always or almost always'. Of the participants, 38.8% had subcutaneous hydration protocols available, while 78.7% stated that they 'always or almost always' followed these protocols. The remaining participants considered the protocols as useful tools despite not having them available. CONCLUSIONS Only 25% of the participants' services had guidelines for hydration, and less than 40% had protocols for subcutaneous hydration. However, adherence was high, especially in cases where protocols existed. Among the participants who did not have guidelines and protocols, attitudes were mostly favourable, but mainly as a reference and support for an individualised clinical practice. RELEVANCE TO CLINICAL PRACTICE Guidelines and protocols on hydration in palliative care may be more useful as a solid reference and support for individualised practice than as instruments for standardising care. From this perspective, their development and availability in palliative care services are recommended.
Collapse
|
45
|
Cook DA, Durning SJ, Sherbino J, Gruppen LD. Management Reasoning: Implications for Health Professions Educators and a Research Agenda. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1310-1316. [PMID: 31460922 DOI: 10.1097/acm.0000000000002768] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Substantial research has illuminated the clinical reasoning processes involved in diagnosis (diagnostic reasoning). Far less is known about the processes entailed in patient management (management reasoning), including decisions about treatment, further testing, follow-up visits, and allocation of limited resources. The authors' purpose is to articulate key differences between diagnostic and management reasoning, implications for health professions education, and areas of needed research.Diagnostic reasoning focuses primarily on classification (i.e., assigning meaningful labels to a pattern of symptoms, signs, and test results). Management reasoning involves negotiation of a plan and ongoing monitoring/adjustment of that plan. A diagnosis can usually be established as correct or incorrect, whereas there are typically multiple reasonable management approaches. Patient preferences, clinician attitudes, clinical contexts, and logistical constraints should not influence diagnosis, whereas management nearly always involves prioritization among such factors. Diagnostic classifications do not necessarily require direct patient interaction, whereas management prioritizations require communication and negotiation. Diagnoses can be defined at a single time point (given enough information), whereas management decisions are expected to evolve over time. Finally, management is typically more complex than diagnosis.Management reasoning may require educational approaches distinct from those used for diagnostic reasoning, including teaching distinct skills (e.g., negotiating with patients, tolerating uncertainty, and monitoring treatment) and developing assessments that account for underlying reasoning processes and multiple acceptable solutions.Areas of needed research include if and how cognitive processes differ for management and diagnostic reasoning, how and when management reasoning abilities develop, and how to support management reasoning in clinical practice.
Collapse
Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director of education science, Office of Applied Scholarship and Education Science, and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: http://orcid.org/0000-0003-2383-4633. S.J. Durning is professor of medicine and director, Division of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland. J. Sherbino is assistant dean, Health Professions Education Research, Faculty of Health Sciences, and professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. L.D. Gruppen is professor, Department of Learning Health Sciences, and director, Master of Health Professions Education Program, University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | |
Collapse
|
46
|
Gachau S, Owuor N, Njagi EN, Ayieko P, English M. Analysis of Hierarchical Routine Data With Covariate Missingness: Effects of Audit & Feedback on Clinicians' Prescribed Pediatric Pneumonia Care in Kenyan Hospitals. Front Public Health 2019; 7:198. [PMID: 31380338 PMCID: PMC6646705 DOI: 10.3389/fpubh.2019.00198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/02/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Routine clinical data are widely used in many countries to monitor quality of care. A limitation of routine data is missing information which occurs due to lack of documentation of care processes by health care providers, poor record keeping, or limited health care technology at facility level. Our objective was to address missing covariates while properly accounting for hierarchical structure in routine pediatric pneumonia care. Methods: We analyzed routine data collected during a cluster randomized trial to investigating the effect of audit and feedback (A&F) over time on inpatient pneumonia care among children admitted in 12 Kenyan hospitals between March and November 2016. Six hospitals in the intervention arm received enhance A&F on classification and treatment of pneumonia cases in addition to a standard A&F report on general inpatient pediatric care. The remaining six in control arm received standard A&F alone. We derived and analyzed a composite outcome known as Pediatric Admission Quality of Care (PAQC) score. In our analysis, we adjusted for patients, clinician and hospital level factors. Missing data occurred in patient and clinician level variables. We did multiple imputation of missing covariates within the joint model imputation framework. We fitted proportion odds random effects model and generalized estimating equation (GEE) models to the data before and after multilevel multiple imputation. Results: Overall, 2,299 children aged 2 to 59 months were admitted with childhood pneumonia in 12 hospitals during the trial period. 2,127 (92%) of the children (level 1) were admitted by 378 clinicians across the 12 hospitals. Enhanced A&F led to improved inpatient pediatric pneumonia care over time compared to standard A&F. Female clinicians and hospitals with low admission workload were associated with higher uptake of the new pneumonia guidelines during the trial period. In both random effects and marginal model, parameter estimates were biased and inefficient under complete case analysis. Conclusions: Enhanced A&F improved the uptake of WHO recommended pediatric pneumonia guidelines over time compared to standard audit and feedback. When imputing missing data, it is important to account for the hierarchical structure to ensure compatibility with analysis models of interest to alleviate bias.
Collapse
Affiliation(s)
- Susan Gachau
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Nelson Owuor
- School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Edmund Njeru Njagi
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philip Ayieko
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
47
|
Baumann AA, Mutabazi V, Brown AL, Hooley C, Reeds D, Ingabire C, Ndahindwa V, Nishimwe A, Cade WT, de Las Fuentes L, Proctor EK, Karengera S, Schecthman KB, Goss CW, Yarasheski K, Newsome B, Mutimura E, Davila-Roman VG. Dissemination and Implementation Program in Hypertension in Rwanda: Report on Initial Training and Evaluation. Glob Heart 2019; 14:135-141. [PMID: 31324367 PMCID: PMC6816501 DOI: 10.1016/j.gheart.2019.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for late-phase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control. OBJECTIVES To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTN-CVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions. METHODS A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered. RESULTS Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001). CONCLUSIONS Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.
Collapse
Affiliation(s)
- Ana A Baumann
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Angela L Brown
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Cole Hooley
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Dominic Reeds
- Division of Geriatrics and Nutritional Science, Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO, USA
| | - Cecile Ingabire
- School of Nursing and Midwifery, University of Rwanda, Kigali, Rwanda
| | - Vedaste Ndahindwa
- School of Nursing and Midwifery, University of Rwanda, Kigali, Rwanda
| | - Aurore Nishimwe
- School of Health Sciences, University of Rwanda, Kigali, Rwanda
| | - W Todd Cade
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa de Las Fuentes
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA; Divisions of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Enola K Proctor
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Stephen Karengera
- Regional Alliance for Sustainable Development, Kigali, Rwanda; EAC RCE-VIHSCM, College of Medicine and Heath Sciences, University of Rwanda, Kigali, Rwanda
| | - Kenneth B Schecthman
- Divisions of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles W Goss
- Divisions of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Brad Newsome
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Eugene Mutimura
- Regional Alliance for Sustainable Development, Kigali, Rwanda
| | - Victor G Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
48
|
Abstract
Background Pelvic pain (PP) is a debilitating condition that is challenging to manage. Despite differences in suspected etiologies of different PP conditions, common clinical signs and symptoms make it appropriate to group these diagnoses. The presence of neuro-musculoskeletal impairments in PP suggests that physical therapists are ideally situated to be included as part of the health care team managing this condition; however, little information is available to guide physical therapist management of PP. Objectives As a first step to developing management guidelines, we sought to determine common interventions currently used by physical therapists to manage PP. Study Design Descriptive survey. Methods A modified Delphi approach was used to identify broad categories of interventions that were then used to build a survey. Purposeful selection with snowball recruiting methods was used to collect responses from practitioners. Frequency data were collected for survey responses. Chi-square analysis determined associations among responses based on practitioner training. Results A total of 984 responses from 17 different countries were analyzed. The primary responses were from physical therapists in the USA and Canada. The majority of respondents were board-certified clinical specialists. More than 80% of physical therapist respondents indicated that they "frequently used" education, exercise, and manual therapy for patients with PP. The most common interventions considered effective but not frequently used were cognitive-behavioral therapy, dry needling, acupuncture, topical medications, and internal pelvic manual therapy techniques. Geographical differences in patterns of usespecific manual therapy and exercise interventions were noted. Differences were also noted on the basis of the levels of advanced postprofessional training. Conclusion Physical therapists routinely use education, manual therapy, and exercise to manage pelvic pain conditions.
Collapse
|
49
|
Schreuder K, Maduro J, Spronk P, Bijker N, Poortmans P, van Dalen T, Struikmans H, Siesling S. Variation in the Use of Boost Irradiation in Breast-Conserving Therapy in the Netherlands: The Effect of a National Guideline and Cofounding Factors. Clin Oncol (R Coll Radiol) 2019; 31:250-259. [DOI: 10.1016/j.clon.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 12/25/2022]
|
50
|
Noels EC, Wakkee M, van den Bos RR, Bindels PJE, Nijsten T, Lugtenberg M. Substitution of low-risk skin cancer hospital care towards primary care: A qualitative study on views of general practitioners and dermatologists. PLoS One 2019; 14:e0213595. [PMID: 30889211 PMCID: PMC6424446 DOI: 10.1371/journal.pone.0213595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/25/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution. METHODS A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi. RESULTS GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs' education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients' trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction. CONCLUSIONS GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs' skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.
Collapse
Affiliation(s)
- E. C. Noels
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M. Wakkee
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - R. R. van den Bos
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P. J. E. Bindels
- Department of General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T. Nijsten
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - M. Lugtenberg
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|