Development of an international glossary for clinical guidelines collaboration

OBJECTIVES

Clinical practice guidelines (CPGs) are often created through collaboration among organizations. The use of inconsistent terminology may cause poor communication and delays. This study aimed to develop a glossary of terms related to collaboration in guideline development.

STUDY DESIGN AND SETTING

A literature review of collaborative guidelines was performed to develop an initial list of terms related to guideline collaboration. The list of terms was presented to the members of the Guideline International Network Guidelines Collaboration Working Group, who provided presumptive definitions for each term and proposed additional terms to be included. The revised list was subsequently reviewed by an international, multidisciplinary panel of expert stakeholders. Recommendations received during this pre-Delphi review were implemented to augment an initial draft glossary. The glossary was then critically evaluated and refined through two rounds of Delphi surveys and a virtual consensus meeting with all panel members as Delphi participants.

RESULTS

Forty-nine experts participated in the pre-Delphi survey, and 44 participated in the two-round Delphi process. Consensus was reached for 37 terms and definitions.

CONCLUSION

Uptake and utilization of this guideline collaboration glossary by key organizations and stakeholder groups may facilitate collaboration among guideline-producing organizations by improving communication, minimizing conflicts, and increasing guideline development efficiency.

Tick exposures and alpha-gal syndrome: A systematic review of the evidence

Alpha-gal syndrome (AGS) refers to a delayed allergic reaction to galactose-α-1,3-galactose (α-Gal) that occurs following the consumption of mammalian meat or exposure to other animal-based foods and products. Increasing evidence suggests that bites from certain tick species can lead to AGS through sensitization of a person's α-Gal specific IgE levels. This systematic review aimed to summarize the published evidence on this topic to understand post-tick exposure AGS epidemiology and health outcomes. A structured search for literature in eight bibliographic databases was conducted in January, 2020. Grey literature and verification searches were also performed. The exposure of interest was tick bites, and the outcome of interest was AGS. All primary research study designs were eligible for inclusion. References were screened for relevance, and data extraction and risk-of-bias assessment were conducted on relevant studies by two independent reviewers. Data were descriptively and narratively summarized. Of 1390 references screened, 102 relevant articles (103 unique studies) were identified (published from 2009 to 2020). Most studies (76.7 %) were case report or series. These 79 studies reported on 236 post-tick exposure AGS cases from 20 different countries, mostly the United States (33.5 %), Spain (19.5 %), Sweden (18.6 %), and France (12.7 %). The mean case age was 51.3 (SD = 16.7, range 5-85, n = 229), while 68.1 % were male (n = 226). The most commonly reported symptom was urticaria (71.2 %); 51.7 % of cases reported anaphylaxis. Twenty-one observational studies were reported, mostly (95.2 %) among clinical allergy patients. The proportion of AGS cases that recalled tick bites was highly variable across these studies. Three challenge studies evaluating tick exposures and α-Gal levels in α-Gal deficient mice were identified. The existing evidence suggests tick bites lead to α-Gal-specific IgE sensitization, which can cause AGS, but further research is needed to clarify if AGS is only attributable to certain tick species and whether other vectors may trigger AGS. Additional research is needed on risk factors for AGS development, evaluation of diagnostic immunoassays, and the epidemiology and distribution of AGS in different populations. Climate change will likely lead to future cases of AGS in new regions worldwide due to the predicted alteration of suitable tick habitats.

Patient- and hospital-level predictors of vancomycin-resistant Enterococcus (VRE) bacteremia in Ontario, Canada

BACKGROUND

Data are limited on risk factors for vancomycin-resistant Enterococcus (VRE) bacteremia.

METHODS

All patients with a confirmed VRE bacteremia in Ontario, Canada, between January 2009 and December 2013 were linked to provincial healthcare administrative data sources and frequency matched to 3 controls based on age, sex, and aggregated diagnosis group. Associations between predictors and VRE bacteremia were estimated by generalized estimating equations and summarized using odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

RESULTS

In total, 217 cases and 651 controls were examined. In adjusted analyses, patient-level predictors included bone marrow transplant (OR 106.99 [95% CI 12.19-939.26]); solid organ transplant (OR 17.17 [95% CI 4.95-59.54]); any cancer (OR 8.64 [95% CI 3.88-19.21]); intensive care unit (ICU) admission (OR 6.81 [95% CI 3.53-13.13]); heart disease (OR 5.27 [95% CI 2.00-13.90]); and longer length of stay (OR 1.07 per day [95% CI 1.06-1.09]). Hospital-level predictors included hospital size (per increase in 100 beds (OR 1.26 [95% CI 1.07-1.48]) and teaching hospitals (OR 3.87 [95% CI 1.85-8.08]).

CONCLUSIONS

Patients with a bone marrow transplant, solid organ transplant, cancer, or who are admitted to the ICU are at highest risk of VRE bacteremia, particularly at large hospitals and teaching hospitals.

Influence of an independent quarterly audit on publicly reported vancomycin-resistant enterocococi bacteremia data in Ontario, Canada

BACKGROUND

All Ontario hospitals are mandated to self-report vancomycin-resistant enterocococi (VRE) bacteremias to Ontario's Ministry of Health and Long-term Care for public reporting purposes. Independent quarterly audits of publicly reported VRE bacteremias between September 2013 and June 2015 were carried out by Public Health Ontario. VRE bacteremia case-reporting errors between January 2009 and August 2013 were identified by a single retrospective audit.

METHODS

Employing a quasiexperimental pre-post study design, the relative risk of VRE bacteremia reporting errors before and after quarterly audits were modeled using Poisson regression adjusting for hospital type, case counts reported to the Ministry of Health and Long-term Care, and autocorrelation via generalized estimating equation.

RESULTS

Overall, 24.5% (126 out of 514) of VRE bacteremias were reported in error; 114 out of 367 (31%) VRE bacteremias reported before quarterly audits and 12 out of 147 (8.1%) reported after audits were found to be incorrect. In adjusted analysis, quarterly audits of VRE bacteremias were associated with significant reductions in reporting errors when compared with before quarterly auditing (relative risk, 0.17; 95% confidence interval, 0.05-0.63). Risk of reporting errors among community hospitals were greater than acute teaching hospitals of the region (relative risk, 4.39; 95% CI, 3.07-5.70).

CONCLUSIONS

This study found independent quarterly audits of publicly reported VRE bacteremias to be associated with significant reductions in reporting errors. Public reporting systems should consider adopting routine data audits and hospital-targeted training to improve data accuracy.

Predictors of Vancomycin-Resistant Enterococcus (VRE) Bacteremia in Ontario, Canada

Background

To determine predictors of vancomycin resistant enterococcus (VRE) bacteremia in Ontario, Canada.

Methods

Ontario hospitals are mandated to report VRE bacteremias to a public reporting database. All confirmed VRE bacteremias between January 2009 - December 2013 were linked to provincial health care administrative data sources. A population-based, nested case–control study was performed to determine predictors of VRE bacteremia. Cases were patients with VRE bacteremia and controls were patients with at least one hospital admission during the study period. Each case was matched with up to three controls using frequency matching on age, sex and aggregated diagnosis group. Associations between patient- and hospital-level predictors and VRE bacteremia were estimated by Generalized Estimating Equations and summarized using odds ratios (OR) (adjusted for age, sex, Charlson score, intensive care unit (ICU) admission, length of stay, hospital admission, comorbidities, hospital size and hospital type) and corresponding 95% confidence intervals (CI) in SAS.

Results

In total, 232 patients had a VRE bacteremia during the study period; 217 cases were successfully linked to administrative data sources and there were 651 controls. Mean age of cases was 61 years (SD 17) vs. 60 years for controls (SD 21). The proportion of male cases and controls was 60%. Length of stay for cases was longer than controls (median 39 days [range 1–539 days] vs. 3 days [range 1 – 136 days],
P < 0.001) and 82% of cases died within 30 days vs. 21% of controls (P < 0.001). In adjusted analyses, patient-level predictors of VRE bacteremia included: organ transplant (OR 18.93 [95% CI 8.37 – 42.79), cancer (OR 9.56 [95% CI 4.61 – 19.79]), ICU admission (OR 7.45 [95% CI 3.57 – 15.54]), heart disease (OR 5.03 [95% CI 1.92 – 13.18]) and length of stay (OR 1.08 per day [95% CI 1.03 – 1.12]); COPD (OR 3.10 [95% CI 0.86 – 11.20]) and diabetes (OR 2.35 [95% CI 0.72 – 7.64]) were not significant predictors. Hospital-level predictors included hospital size ≥800 beds (OR 10.64 [95% CI 2.34 – 48.25]) and teaching hospitals (OR 4.20 [95% CI 1.65 – 10.74]).

Conclusion

Immunocompromised and patients admitted to ICU are at highest risk of VRE bacteremia, particularly at large hospitals and teaching hospitals. These results may help inform clinical decisions and infection prevention programs.

Disclosures

All authors: No reported disclosures.

Predicting influenza vaccination uptake among health care workers: what are the key motivators?

BACKGROUND

Health care worker (HCW) vaccination was critical to protecting HCW during the H1N1 pandemic. However, vaccine uptake rates fell below recommended targets. This study examined motivators and barriers influencing HCW pH1N1 vaccination to identify modifiable factors that can improve influenza vaccine uptake.

METHODS

A cross-sectional survey was conducted at a large Canadian tertiary care hospital. HCW (N = 3,275) completed measures of demographics, vaccination history, influenza risk factors, and attitudes toward pH1N1 vaccination. Self-reported vaccination was verified with staff vaccination records. Of the total sample, 2,862 (87.4%) HCW received the pH1N1 vaccine. Multiple logistic regression analyses were used to predict HCW vaccination.

RESULTS

HCW attitudes toward vaccination significantly predicted vaccination, even after adjusting for demographics, vaccine history, and influenza risk factors. This model correctly predicted 95% (confidence interval [CI]: 0.93-0.96) of HCW vaccination. Key modifiable factors driving HCW vaccination include (1) desire to protect family members and patients, (2) belief that vaccination is important even if one is healthy, (3) confidence in vaccine safety, and (4) supervisor and physician encouragement.

CONCLUSION

This research identified fundamental reasons why HCW get vaccinated and provides direction for future influenza vaccination programs. To enhance vaccine uptake, it is important to target HCW attitudes in influenza vaccine campaigns and create a culture of vaccine promotion in the workplace, including strong messaging from supervisors and physicians.

Factors influencing pandemic influenza vaccination of healthcare workers--a systematic review

INTRODUCTION

Maintaining the health and availability of Health care workers (HCW) is an essential component of pandemic preparedness. A key to protecting HCW during the H1N1 pandemic was influenza vaccination. Numerous researchers have reported on factors influencing H1N1 vaccination behaviour in various HCW groups. This systematic review aims to inform future influenza vaccine interventions and pandemic planning processes via the examination of literature in HCW H1N1 vaccination, in order to identify factors that are (1) unique to pandemic influenza vaccination and (2) similar to seasonal influenza vaccination research.

METHODS

We conducted a comprehensive review of literature (MEDLINE, PubMed, EMBASE, PsycINFO, CINHAL, AMED, Cochrane Library, ProQuest, and grey literature sources) published between January 2005 and December 2011 to identify studies relevant to HCW pH1N1 vaccine uptake/refusal.

RESULTS

20 publications sampling HCW from different geographic regions are included in this review. H1N1 vaccine coverage was found to be variable (9-92%) across HCW populations, and self-reported vaccine status was the most frequently utilized predictor of pandemic vaccination. HCW were likely to accept the H1N1 vaccine if they perceived, (1) the H1N1 vaccine to be safe, (2) H1N1 vaccination to be effective in preventing infection to self and others (i.e. loved ones, co-workers and patients), and (3) H1N1 was a serious and severe infection. Positive cues to action, such as the access of scientific literature, trust in public health communications and messaging, and encouragement from loved ones, physicians and co-workers were also found to influence HCW H1N1 uptake. Previous seasonal influenza vaccination was found to be an important socio-demographic predictor of vaccine uptake. Factors unique to HCW pandemic vaccine behaviour are (1) lack of time and vaccine access related barriers to vaccination, (2) perceptions of novel and rapid pandemic vaccine formulation, and (3) the strong role of mass media on vaccine uptake.

CONCLUSIONS

Many of the factors that influenced HCW pandemic vaccination decisions have previously been reported in seasonal influenza vaccination literature, but some factors were unique to pandemic vaccination. Future influenza vaccine campaigns should emphasize the benefits of vaccination and highlight positive cues to vaccination, while addressing barriers to vaccine uptake in order to improve vaccine coverage among HCW populations. Since pandemic vaccination factors tend be similar among different HCW groups, successful pandemic vaccination strategies may be effective across numerous HCW populations in pandemic scenarios.