Dental patients as partners in promoting quality and safety: a qualitative exploratory study

OBJECTIVE

Active patient involvement in promoting quality and safety is a priority for healthcare. We investigated how dental patients perceive their role as partners in promoting quality and safety across various dental care settings.

METHODS

Focus group sessions were conducted at three dental practice settings: an academic dental center, a community dental clinic, and a large group private practice, from October 2018-July 2019. Patients were recruited through flyers or word-of-mouth invitations. Each session lasted 2.5 h and patients completed a demographic and informational survey at the beginning. Audio recordings were transcribed, and a hybrid thematic analysis was performed by two independent reviewers using Dedoose.

RESULTS

Forty-seven participants took part in eight focus group sessions; 70.2% were females and 38.3% were aged 45-64 years. Results were organized into three major themes: patients' overall perception of dental quality and safety; patients' reaction to an adverse dental event; and patients' role in promoting quality and safety. Dental patients were willing to participate in promoting quality and safety by careful provider selection, shared decision-making, self-advocacy, and providing post-treatment provider evaluations. Their reactions towards adverse dental events varied based on the type of dental practice setting. Some factors that influenced a patient's overall perception of dental quality and safety included provider credentials, communication skills, cleanliness, and durability of dental treatment.

CONCLUSION

The type of dental practice setting affected patients' desire to work as partners in promoting dental quality and safety. Although patients acknowledged having an important role to play in their care, their willingness to participate depended on their relationship with their provider and their perception of provider receptivity to patient feedback.

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

EFFECTIVENESS OF ICE APPLICATION AT SELECTED ACUPOINT (LI-4) PRIOR TO INTRAMUSCULAR INJECTION ON LEVEL OF PAIN AMONG CHILDREN IN A SELECTED HOSPITAL, CHENNAI, TAMIL NADU, INDIA

Immunization is an effective and safest way to prevent vaccine-preventable diseases and thereby reduce morbidity and mortality in children. Injections given for immunization are the most usual ground in order to abstract agony or pain, which is the fifth vital sign leading to long-term physically and psychologically detrimental effects. A basic experimental (control group only for post-test) design using the technique of probability of simple random sampling in order to obtain sample size 105 was conducted in an Immunization Clinic at a selected PHC, Tamil Nadu, India. Ice cube was applied for about 30 seconds that is enfolded with gauze and then injected intramuscularly to administer the IM vaccine. In order to assess the pain level, an observation checklist based on Children's Hospital Eastern Ontario pain scale and Wong Baker's Faces pain scale was used. The study results manifest the higher statistical difference in the level of children's pain between the control groups and the experimental groups at a significance level of p<0.001. In order to reduce the pain level, the application of ice at LI-4 acupoint is effective. The children who are being vaccinated pass through stressful events through the application of an intramuscular injection. The findings revealed that ice application at LI-4 acupoint was very effective in pain reduction, which is a simple, safe, non-invasive, very efficient, easy-to-administer intervention and cost-effective without side effects than any other pharmacological pain intervention.

Effectiveness of Herbal, Homeopathic and Conventional Dentifrices on Dental Caries - A Double-Blind Randomised Controlled Trial

PURPOSE

To compare the effectiveness of ayurvedic, homeopathic and conventional dentifrices on plaque and saliva in terms of cariogenic bacteria, salivary pH, and plaque pH.

MATERIALS AND METHODS

This double-blinded, parallel-group, randomised controlled trial was performed at Saveetha Dental College and Hospitals, Chennai, India. The participants comprised healthy adults possessing more than 20 permanent natural teeth and having a Decayed Missing and Filled Teeth (DMFT) score, plaque index score, and gingival index score less than or equal to 2. There were 3 intervention groups: 1: herbal dentifrice (Dabur Meswak); 2: homeopathic dentifrice (Gum Forte gel); 3: fluoride dentifrice (Colgate Total). The outcome measures were as follows: plaque and saliva samples were evaluated for pH; colony counts of Streptococcus mutans and Lactobacillus at baseline, 14 and 28 days of follow-up. One-way and repeated measures ANOVA, Wilcoxon signed-rank and Kruskal Wallis tests were used to compare the mean differences of plaque and salivary pH and plaque and salivary S. mutans and Lactobacillus counts at baseline, 14 and 28 days.

RESULTS

The mean S. mutans and Lactobacillus counts in plaque and saliva decreased statistically significantly in all treatment groups at the 28-day follow-up. Mean plaque pH was not statistically significantly different at the 14-day follow-up (p-value = 0.16). On the 28th day, group 1 (7.64 ± 0.20) showed the highest increase in plaque pH followed by group 2 (7.39 ± 0.25) and group 3 (7.27 ± 0.19), which was found to be statistically significant. No statistically significant difference in mean salivary pH was observed between the three groups at the different time points.

CONCLUSION

This study reveals that the herbal dentifrice tested here was effective in reducing cariogenic bacterial count and increasing the plaque pH, thereby warranting the usage of the same.

Oral Health Behaviors for Young Low-Income Urban Children during the COVID-19 Pandemic: A Mixed Methods Analysis

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic (Nov 2020-August 2021). Survey data on oral health behaviors were collected in homes at three points before COVID-19, and via phone during COVID-19. A subset of parents and key informants from clinics and social service agencies completed in-depth interviews via video/phone. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant interviews (25 participants) and 21 family interviews were conducted. The mean child age was 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Family interviews highlighted changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in oral health services, family fear, and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Oral health behaviors for young low-income urban children during the COVID-19 pandemic: a mixed methods analysis

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic. Survey data on oral health behaviors were collected in homes at three points over one year before COVID-19, and then via phone during COVID-19. Multivariate logistic regression was used to model tooth brushing frequency. A subset of parents completed in-depth interviews via video/phone that expanded on oral health and COVID-19. Key informant interviews via video/phone were also conducted with leadership from 20 clinics and social service agencies. Interview data were transcribed and coded, and themes were extracted. COVID-19 data collection went from Nov 2020 - August 2021. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant (25 participants) and 21 parent interviews were conducted. The mean child age was approximately 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Parent interviews highlighted significant changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in their oral health services and significant family fear and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Oral community health worker-led interventions in households with average levels of psychosocial factors

Introduction

Household-level psychosocial stress levels have been linked to child tooth brushing behaviors. Community health worker (CHW) interventions that target psychosocial factors in high-risk communities have been associated with changes in health behaviors.

Aim

Observe changes in psychosocial factors over time and an association between psychosocial factors and CHW intervention dose amongst urban Chicago families.

Patients and methods

Participants (N = 420 families) were recruited from 10 community clinics and 10 Women, Infants, or Children (WIC) centers in Cook County, Illinois to participate in a clinical trial. Research staff collected participant-reported psychosocial factors (family functioning and caregiver reports of depression, anxiety, support, and social functioning) and characteristics of CHW-led oral health intervention visits (number, content, child engagement) at 0, 6, and 12 months. CHWs recorded field observations after home visits on household environment, social circumstances, stressors, and supports.

Results

Participants across the cohort reported levels of psychosocial factors consistent with average levels for the general population for nearly all measures. Psychosocial factors did not vary over time. Social functioning was the only measure reported at low levels [32.0 (6.9); 32.1 (6.7); 32.7 (6.9); mean = 50 (standard deviation)] at 0, 6, and 12 months. We did not observe a meaningful difference in social functioning scores over time by exposure to CHW-led intervention visits (control arm, 0, 1, 2, 3, and 4 visits). Field observations made by CHWs described a range of psychosocial stress related to poverty, language barriers, and immigration status.

Conclusion

The unexpectedly average and unchanging psychosocial factors over time, in the context of field observations of stress related to poverty, lack of support, immigration status, and language barriers, suggests that our study did not adequately capture the social determinants of health related to oral health behaviors or that measurement biases precluded accurate assessment. Future studies will assess psychosocial factors using a variety of instruments in an attempt to better measure psychosocial factors including social support, depression, anxiety, functioning, trauma and resilience within our urban population. We will also look at neighborhood-level factors of community distress and resilience to better apply the social ecologic model to child oral health behaviors.

Impact of type 2 diabetes on hospitalization and mortality in people with malignancy

AIM

To compare the characteristics of and outcomes for people with malignancies with and without a co-diagnosis of diabetes.

METHODS

Emergency department and hospital discharge data from a single centre for the period between 1 January 2015 and 31 December 2017 were used to identify people with a diagnosis of a malignancy and diabetes. Multivariate Cox regression models were used to estimate the effect of diabetes on all-cause mortality. A truncated negative binomial regression model was used to assess the impact of diabetes on length of hospital inpatient stay. Prentice-Williams-Peterson total time models were used to assess the effect of diabetes on number of emergency department re-presentations and inpatient re-admissions.

RESULTS

Of 7004 people identified with malignancies, 1195 (17.1%) were also diagnosed with diabetes. A diagnosis of diabetes was associated with a greater number of inpatient re-admissions [adjusted hazard ratio 1.13 (95% CI 1.03, 1.24)], a greater number of emergency department re-presentations [adjusted hazard ratio 1.13 (95% CI 1.05, 1.22)] and longer length of stay [adjusted incidence rate ratio 1.14 (95% CI 1.04, 1.25)]. A co-diagnosis of diabetes was also associated with a 48% increased risk of all-cause mortality [adjusted hazard ratio 1.48 (95% CI 1.22-1.76)].

CONCLUSIONS

People with malignancies and diabetes had significantly more emergency department presentations, more inpatient admissions, longer length of hospital stay and higher rates of all-cause mortality compared to people with a malignancy without diabetes.

Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study

INTRODUCTION

The growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking.

AIM

To outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study.

METHODS

Person-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken.

ANALYSIS

The index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective.

CONCLUSION

Completion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

Associations between the IASLC/ATS/ERS lung adenocarcinoma classification and EGFR and KRAS mutations

We sought to investigate the frequency of mutations in epidermal growth factor receptor (EGFR) and Kirsten-RAS (KRAS) by each pathological subtype for patients with resected pulmonary adenocarcinoma as defined by the IASLC/ATS/ERS classification. Histological examination determined the predominant subtype according to the IASLC/ATS/ERS classification. EGFR and KRAS mutations were determined by high-resolution melting and Sanger sequencing. Clinical data were collected from medical records and clinicians. The 178 consecutive patients consisted of 48% males, median age 68 years (range 20-87) and smoking history 78%. The tumour stage was I in 62%, II in 18% and III in 20%. The mutation rates were: EGFR 30%; KRAS 28%. The rate of EGFR mutations in the acinar predominant reference group (n=76), was 37%. The solid predominant subtype showed significantly fewer EGFR mutations [3/33 (9%), odds ratio 0.17 (0.05-0.61), p=0.007]. No differences in mutation rate were observed in other subtypes. No association was found between KRAS mutations and predominant histological subtype. Advanced stage and solid predominant subtype were negative prognostic factors. EGFR mutations can be present in adenocarcinoma of any predominant subtype, however rarely in solid predominant tumours. No association was found between KRAS mutation and the predominant histological subtype.

Capturing diagnosis-timing in ICD-coded hospital data: recommendations from the WHO ICD-11 topic advisory group on quality and safety

PURPOSE

To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data.

METHODS

As part of the World Health Organization International Classification of Diseases-11th Revision initiative, the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting.

RESULTS

The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators.

CONCLUSIONS

As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.

International variation in the definition of 'main condition' in ICD-coded health data

Hospital-based medical records are abstracted to create International Classification of Disease (ICD) coded discharge health data in many countries. The 'main condition' is not defined in a consistent manner internationally. Some countries employ a 'reason for admission' rule as the basis for the main condition, while other countries employ a 'resource use' rule. A few countries have recently transitioned from one of these approaches to the other. The definition of 'main condition' in such ICD data matters when it is used to define a disease cohort to assign diagnosis-related groups and to perform risk adjustment. We propose a method of harmonizing the international definition to enable researchers and international organizations using ICD-coded health data to aggregate or compare hospital care and outcomes across countries in a consistent manner. Inter-observer reliability of alternative harmonization approaches should be evaluated before finalizing the definition and adopting it worldwide.

Palliative care for patients with chronic obstructive pulmonary disease: exploring the landscape

Patients with chronic obstructive pulmonary disease experience a substantial symptom burden, high levels of psychosocial need and significant mortality. This epidemiological study reveals that the majority of patients are cared for in the public hospital system (64%) and generally die in hospital (72%) with a number of identifiable predictors of 6-month mortality. Our results suggest that palliative care services need to be redirected from a community-based admission focus to a model that is responsive to emergency and acute care hospital systems.

Negotiating hope with chronic obstructive pulmonary disease patients: a qualitative study of patients and healthcare professionals

BACKGROUND

The information needs of patients with chronic obstructive pulmonary disease (COPD) towards the end of life are poorly understood.

AIM

This study explored the views of patients with COPD and healthcare professionals, focusing upon information needs and treatment preferences.

METHOD

In-depth, semi-structured interviews were held with patients with COPD following admission to hospital with respiratory failure, and focus groups held with healthcare professionals from hospital and community settings.

RESULTS

Ten patients were interviewed, who had a median 4 previous hospital admissions, and had smoked for median 47 years. Five focus groups were held with 31 healthcare professionals (18 nurses, 7 doctors, 6 allied health). The theme underpinning all discussions was of tension between maintaining hope and negotiating the reality of the illness and its consequences. Within this theme, patients tended to be optimistic, viewed acute exacerbations as separate from their underlying chronic illness, and were keen for intensive treatments, including intubation if acutely unwell. They had little understanding of the complexities of decision-making around treatment escalation. Both patients and health workers believed that information around end of life should be offered routinely, but delivered in a manner that recognises and maintains a form of hope.

CONCLUSION

Patients and healthcare professionals believe information around illness course, future goals and treatment is important to care. An expanded view of hope may assist when providing such information, including when discussing goals of care in the setting of advanced illness.

Empirical aspects of linking intensive care registry data to hospital discharge data without the use of direct patient identifiers

In the field of intensive care, clinical data registries are commonly used to support clinical audit and develop evidence-based practice. However, they are often restricted to the intensive care unit episode only, limiting their ability to follow long-term patient outcomes and identify patient readmissions. Data linkage can be used to supplement existing data, but a lack of unique patient identifiers may compromise the accuracy of the linkage process. The aim of this study was to assess the quality of linking the Australia/New Zealand critical care registry to a state financial claims database using a method without direct patient identifiers and to identify possible sources of bias from this method. We used a linkage method relying on indirect patient identifiers and compared the accuracy of this method to one that also included the patient medical record number and date of birth. The overall linkage rate using the method with indirect identifiers was 92.3% compared to 94.5% using the method with direct identifiers. Factors most strongly associated with not being a correct link in the first method included patients at one study hospital, admissions in 2002 and 2003 and having a hospital length of stay of 20 days or more. Linking the Australia/New Zealand critical care without direct patient identifiers is a valid linkage method that will enable the measurement of long-term patient survival and readmissions. While some sources of bias have been identified, this method provides sufficient quality linkage that will support broad analyses designed to signal future in-depth research.

A 10-year cohort study of the burden and risk of in-hospital falls and fractures using routinely collected hospital data

OBJECTIVES

To document the burden of in-hospital falls and fractures, and to identify factors that may increase the risk of these events.

DESIGN

A retrospective cohort analysis.

SETTING

The study was set in the State of Victoria, Australia.

PARTICIPANTS

Hospital episode data collected in the Victoria Admitted Episodes Dataset, for all multiday-stay patients 18 years or more admitted to Victorian public hospitals; 1 July 1998 to 30 June 2008. Diagnoses were defined by the International Classification of Disease, 10th Revision, Australian Modification (ICD-10-AM), which includes an in-hospital diagnostic timing code. Outcome measures included rates of in-hospital falls and fractures, length of hospital stay and mortality. Variables included in risk adjustment included financial year, individual demographic and comorbidity data, and hospital characteristics.

RESULTS

There were 3,345,415 episodes: 21,250 (0.64%) in-hospital falls and 4559 (0.14%) fractures. In-hospital fall (IHF) episode rates increased over the study period, but fracture episode rates were stable. Mortality (HR 1.3, CI 1.3 to 1.5) and length of stay (median 19 days vs 5 days, p<0.0001) were increased with IHF. Risk factors for IHF included dementia (rate ratio 1.7, CI 1.6 to 1.8) and delirium (rate ratio 1.8, CI 1.6 to 2.0).

CONCLUSIONS

Routinely collected data that include a hospital diagnostic timing code offer a standard method of quantifying in-hospital falls and fractures. Unselected in-hospital falls data may be subject to reporting and documentation bias. The utility of using robust selected injuries such as IHF-related fracture as a quality-of-care indicator requires further investigation.

Invasive pneumococcal disease in Victoria: a better measurement of the true incidence

Invasive pneumococcal disease (IPD) notifications are used to monitor IPD vaccination programmes. We conducted sequential deterministic data-linkage between IPD notifications and hospitalization data in Victoria, Australia, in order to determine whether all diagnosed cases were being reported. The proportion of each relevant hospital admission ICD-10-AM code that could be linked to notified cases was calculated. Total and age-specific annual rates were calculated and compared for notified and non-notified cases. Total incidence was estimated using data-linkage results and application of a two-source capture-recapture method. The first 2 years of IPD surveillance in Victoria missed at least one-sixth of laboratory-confirmed IPD cases. Estimated annual IPD rate increased from 9.0 to 10.7/100,000 and rose even higher, to 11.5/100,000, with age-specific rates possibly reaching 90.0/100,000 children aged <2 years, when using capture-recapture. Strategies to improve notification and coding of hospitalized cases of IPD are required.

Increased case fatality rates following a first acute cardiovascular event in patients with rheumatoid arthritis

OBJECTIVE

Among patients with rheumatoid arthritis (RA), cardiovascular mortality is increased compared with the rate among unaffected peers. In this study, 30-day mortality rates following a first acute cardiovascular event (myocardial infarction or stroke) were compared between RA patients and the general population.

METHODS

All cases of a first acute cardiovascular event between July 1, 2001 and November 30, 2003 in Victoria, Australia were identified from hospital discharge data. Individuals were classified as having RA when an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification code for RA was recorded at the index admission or during the previous 5 years. Thirty-day mortality rates were determined from linkage to the state death registry.

RESULTS

A total of 29,924 patients experienced a first cardiovascular event during the study period, 359 (1.2%) of whom had RA. Thirty-day cardiovascular mortality was 17.6% in RA patients versus 10.8% in non-RA patients. In fully adjusted models, the odds ratio (OR) for cardiovascular death in RA patients following a first acute cardiovascular event was 1.6 (95% confidence interval [95% CI] 1.2-2.2). Analysis of index event subgroups revealed that this increased case fatality rate in patients with RA was accounted for almost entirely by excess deaths following myocardial infarction. The adjusted ORs for cardiovascular death in RA after myocardial infarction and stroke were 1.9 (95% CI 1.3-2.7) and 1.2 (95% CI 0.7-2.0), respectively.

CONCLUSION

RA patients have a substantially increased risk of 30-day case fatality following myocardial infarction, but not stroke, compared with non-RA patients. This higher case fatality rate is likely to contribute to the observed overall excess of cardiovascular deaths in RA populations.

Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis

Comprehensive disease management programmes for chronic disease aim to improve patient outcomes and reduce health-care utilization. Readmission rates are often used as an outcome measure of effectiveness. This study aimed to document readmission rates, and risk for early and late readmission, for patients discharged from the Royal Melbourne Hospital with a disease diagnosis of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes mellitus compared to those with other general medical conditions. Eighty five (8.6%) of patients were readmitted within 28 days and 183 (20.8%) were readmitted between 29 and 180 days. No risk factors for early readmission were identified. Patients with a primary disease diagnosis of CHF and COPD are at increased risk of late readmissions (29-180 days).

Variations in the use of adjuvant chemotherapy for node-positive colon cancer in the elderly: a population-based study

BACKGROUND

Since 1990, the recommended adjuvant therapy for patients with surgically resected node-positive colon cancer has been 5-fluorouracil (5-FU), usually in combination with leucovorin or levamisole. The purpose of this study is to assess the distribution of adjuvant 5-FU treatment in the elderly.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database provides population-based information on cancer patients, representing approximately 14% of the United States population, along with health care utilization data from Medicare claims files. We studied patients with node-positive colon cancer diagnosed between 1992 and 1996 who survived at least 120 days beyond diagnosis (N = 4998).

RESULTS

About 50% of elderly patients received 5-FU within 4 months of diagnosis. The proportion of patients treated with 5-FU increased by about 10% from 1992 to 1996. In a multiple logistic regression model, 5-FU treatment was less likely to be given to older patients (compared with those aged 65-69 years, the odds ratio (OR) [95% CI] was 0.82 [0.67-1.00] for ages 70 to 74 years, 0.47 [0.39-0.57] for ages 75 to 79, 0.17 [0.13-0.20] for ages 80 to 84, and 0.04 [0.03-0.05] for ages 85 to 88 years. Non-Hispanic black patients were less likely to be treated than non-Hispanic white patients (OR 0.46 [0.36-0.59]); patients with more than three positive lymph nodes were more likely to be treated than those with three or less, and those with comorbid conditions were less likely to be treated than those without such conditions.

CONCLUSIONS

Despite its proven efficacy in reducing colon cancer mortality, 5-FU-based chemotherapy is not widely used among apparently eligible patients over age 65. Efforts are needed to ensure that elderly and non-Hispanic black patients receive appropriate treatment.

Decision analysis of tamoxifen for the prevention of invasive breast cancer

PURPOSE

The recent Breast Cancer Prevention Trial has shown that tamoxifen may prevent invasive breast cancer. We used a Markov model to estimate the long-term effects of chemoprevention with tamoxifen on survival, quality-adjusted survival, and health care costs.

METHODS

We used a hypothetical cohort of women with breast-cancer risk similar to that of participants in the Breast Cancer Prevention Trial, and a computer-based decision analysis (Markov model and 500 Monte Carlo simulations) to model the outcomes of interest. Survival calculations were from Surveillance, Epidemiology, and End-Results (SEER) data; preference ratings from a time trade-off questionnaire administered to a group of average-risk women; and cost estimates from the Group Health Cooperative of Puget Sound and the Health Care Financing Administration. We obtained utility measures for quality-adjustment by administering a time trade-off questionnaire to a group of community-based women.

RESULTS

Use of tamoxifen prolonged the average survival of cohort members by 69 days (95% probability interval [PI] 27 to 117) for those who started use at age 35 years; 40 days (95% PI 16 to 67) for those who started use at age 50 years; and 27 days (95% PI 14 to 40) for those who started use at age 60 years. Tamoxifen extended quality-adjusted survival by 38 days (95% PI 0.1 to 82) at age 35, 25 days (95% PI 0 to 50) at age 50, and 22 days (95% PI 5 to 39) days at age 60. Chemoprevention with tamoxifen cost $46,619 (95% PI $27,928 to $98,796) per life year life saved for women who started at age 35; for women over age 50, it cost more than $50,000 per life year saved.

DISCUSSION

Tamoxifen use may improve long-term survival and quality-adjusted survival among women who are at increased risk of breast cancer, but this benefit diminishes with age. Tamoxifen is cost-effective in comparison with other cancer treatment strategies for younger women only.

The quality of life associated with prophylactic treatments for women with BRCA1/2 mutations

PURPOSE

This study was conducted to obtain and compare the preferences assigned to cancer states and prevention measures by women who had breast cancer, were at high risk for breast cancer, or had neither condition.

PATIENTS AND METHODS

We administered a time trade-off questionnaire to 21 breast cancer patients, 28 women with a personal history of multiple breast biopsies or a family history of breast cancer, and 135 women without these conditions (the reference group). We stratified the reference group into two groups aged 20 to 32 years and 33 to 50 years, respectively.

RESULTS

All four groups assigned higher preference to breast cancer than to ovarian cancer. Both reference groups preferred using a tamoxifen-like drug to having mastectomy or oophorectomy for cancer prevention; the high-risk and breast cancer groups did not. None of the four groups had a preference between prophylactic mastectomy and breast cancer. All the groups were willing to subtract more years from their life expectancy to protect offspring from genetic risk than to protect themselves. Reference group members in the 33- to 50-year age range had lower mean ratings than the breast cancer group for almost all the health states, and breast cancer patients were less willing than other respondents to trade time for health. Most of these differences were not statistically significant. The high-risk group was similar to the older reference group in time trade-off ratings.

DISCUSSION

The time trade-off-based preferences of healthy women may be used to predict the treatment preferences of women with BRCA1/2 mutations. Obtaining healthy women's ratings of treatment outcomes may help health care policy makers envision the consequences of the difficult choices that high-risk women face.

Microbial profile of neonatal infection in Coimbatore

In this study, 187 consecutive neonates suspected of having septicaemia were investigated for isolation of micro organisms. Two samples of blood were collected for isolation of aerobes and anaerobes. Cultures were positive in 75 (40%) cases. Aerobic bacteria were the major etiological agent, accounting for 93% of positives including the 8% cases showing polymicrobial etiology. Anaerobic bacteria and Candida species were isolated in 6.6% and 8% of positive cases respectively. Bacteroides fragilis (amongst anaerobic) and Staphylococcus aureus (amongst aerobic) were the predominant organisms isolated. Clinical presentations were not specifically different to distinguish aerobic from anaerobic bacteria. In the present study, 6.6% of bacteremias were due to anaerobes, hence possibility of some of the bactermias being due to anaerobes should be kept in mind while treating cases of neonatal septicaemia. For a complete microbial profile both aerobic and anaerobic cultures should be done.

Heterologously expressed inner lipoyl domain of dihydrolipoyl acetyltransferase inhibits ATP-dependent inactivation of pyruvate dehydrogenase complex. Identification of important amino acid residues

The activity of the pyruvate dehydrogenase multienzyme complex (PDC), which catalyses the oxidation of pyruvate to acetyl-CoA within the mitochondrion, is diminished in animal models of diabetes. Studies with purified PDC components have suggested that the kinases responsible for inactivating the decarboxylase catalytic subunits of the complex are most efficient in their regulatory role when they are bound to dihydrolipoyl acetyltransferase (E2) subunits, which form the structural core of the complex. We report that the addition of an exogenous E2 subdomain (inner lipoyl domain) to an intact PDC inhibits ATP-dependent inactivation of the complex. By combining molecular modelling, site-directed mutagenesis and biophysical characterizations, we have also identified two amino acid residues in this subdomain (Ile229 and Phe231) that largely determine the magnitude of this effect.

Patterns and determinants of multiple provider use in patients with acute low back pain

OBJECTIVE

To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost.

METHODS

The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up.

MAIN RESULTS

Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p < .05) associated with seeking care from multiple provider types. Age, race, gender, and education were not significant. The adjusted proportions of multiple provider type use were 14% (95% confidence interval [CI] 11%, 17%) for the private primary care provider stratum; 19% (95% CI 16%, 23%) for the chiropractic stratum; 30% (95% CI 23%, 37%) for the orthopedic stratum; and 9% (95% CI 5%, 14%) for the HMO primary care physician stratum. Cost of seeing only the index provider was $439 (95% CI $404, $475), and cost of seeing multiple provider types was $1,137 (95% CI $1,064, $1,211) based on the adjusted model.

CONCLUSIONS

Use of multiple provider types, is associated with several factors, one of which is the initial provider type. The cost of such use is significant.

Controversies in new antibiotic therapy for ambulatory patients

The care of the febrile neutropenic patient has undergone a shift in the last 10 years with the realization that neutropenic patients presenting with fever do not constitute a homogeneous group. Strategies of risk assessment have allowed the testing of novel therapies including outpatient treatment with oral and intravenous antibiotics, either in combination regimens or as monotherapy; the addition of growth factors to hasten the return of the absolute neutrophil count; and the possibility of self-initiation of antibiotics by cancer patients when they develop fever. The clinical trials data regarding these new approaches will be reviewed, and areas requiring further research will be discussed.