Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

ABSTRACT

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

LEVEL OF EVIDENCE

Consensus algorithm from the Western Trauma Association, Level V.

Quality management of cutaneous melanoma: impact on short-term outcomes and costs

Promoting standardization and quality assurance (QA) may guarantee better outcomes for patients and ensure a better allocation of healthcare system resources. The present study tested the association between process quality indicators of the clinical pathway for melanoma and both patient short-term mortality and budget utilization. Specific indicators were selected to assess quality of processes in different phases of the pathway as well as the pathway as a whole. Cox regression models were run for each phase to test the association between adherence to the quality indicator and overall mortality. A Tobit regression analysis was used to identify any association between adherence to the quality indicators and total costs over the two years after melanoma was diagnosed. This retrospective cohort study concerned 1,222 incident cases of melanoma in the Veneto Region (north-east of Italy). Adherence to the clinical pathway as a whole was associated with a significant decrease in risk of death (HR= 0.40; 95% CI: 0,19 -0,77). Adherence to quality processes in the diagnostic phase (HR= 0.55 95% CI: 0.31- 0.95) and surgical phase (HR= 0.33 95% CI: 0.16- 0.61) significantly reduced the hazard risk. Tobit regression revealed a significant increase in overall costs for patients who adhered to the whole pathway in comparison with those who did not (β= 2,393.24; p= 0.013). This study suggests that adherence to the quality of management of clinical pathways modifies short-term survival as well as mean cost of care for patients with cutaneous melanoma. Physicians should be encouraged to improve their compliance with clinical care pathways for their melanoma patients, and steadily growing associated costs emphasize the need for policy makers to invest exclusively in treatments of proven efficacy.

Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease

Find AGA's NASH Clinical Care Pathway App for iOS and Android mobile devices at nash.gastro.org. Scan this QR code to be taken directly to the website.Nonalcoholic fatty liver disease (NAFLD) is becoming increasingly common, currently affecting approximately 37% of US adults. NAFLD is most often managed in primary care or endocrine clinics, where clinicians must determine which patients might benefit from secondary care to address hepatic manifestations, comorbid metabolic traits, and cardiovascular risks of the disease. Because NAFLD is largely asymptomatic, and because optimal timing of treatment depends on accurate staging of fibrosis risk, screening at the primary care level is critical, together with consistent, timely, evidence-based, widely accessible, and testable management processes. To achieve these goals, the American Gastroenterological Association assembled a multidisciplinary panel of experts to develop a Clinical Care Pathway providing explicit guidance on the screening, diagnosis, and treatment of NAFLD. This article describes the NAFLD Clinical Care Pathway they developed and provides a rationale supporting proposed steps to assist clinicians in diagnosing and managing NAFLD with clinically significant fibrosis (stage F2-F4) based on the best available evidence. This Pathway is intended to be applicable in any setting where care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study

BACKGROUND

Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process.

METHODS

We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis.

RESULTS

Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians.

INTERPRETATION

These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis

AIMS

Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers.

METHODS

We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models.

RESULTS

A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91).

CONCLUSIONS

Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Care maps are an effective tool for optimizing quality of care of infectious diseases in a resource-constrained short-stay ambulatory care setting

ABSTRACT

Care maps (CMs), which are innovative, comprehensive, educational, and simple medical tools, were developed for 6 common diseases, including heart failure, stroke, hyperglycemia, urinary tract infection, dengue infection, and upper gastrointestinal bleeding, were implemented in a short-stay ambulatory ward. This study aimed to investigate the effectiveness of and level of clinician satisfaction with CMs in an ambulatory care setting.A retrospective chart review study comparing the quality of care between before and after CM implementation was conducted. The medical records of patients who were admitted to a short-stay ambulatory ward in a tertiary referral center were reviewed. Demographic data, severity of disease, quality of care, length of stay (LOS), admission cost, and CM user satisfaction were collected and recorded.The medical records of 1116 patients were evaluated. Of those, 589 and 527 patients were from before (non-CM group) and after CM (CM group) implementation, respectively. There were no significant differences between groups for age, gender, or disease-specific severity the median (interquartile range) total and essential quality scores were significantly higher in the CM group than in the non-CM group [total quality score 85.3 (75.0-92.9) vs 61.1 (50.0-75.0); P < .001, and essential quality scores 90.0 (75.0-100.0) vs 60.0 (40.6-80.0); P < .0001, respectively]. All aspects of quality of care were significantly improved between before and after CM implementation. Overall median LOS was significantly decreased from 3.8 (2.5-5.7) to 3.0 (2.0-4.9) days, but there was no significant decrease for admission cost. However, CMs were able to significantly reduce both LOS and admission cost in the infectious disease-related subgroup. Most CM users reported satisfaction with CMs.CMs were shown to be an effective tool for improving the quality of care in patients with ambulatory infectious diseases. In that patient subgroup, LOS and admission cost were both significantly reduced compared to pre-CM implementation.

Do Antimicrobial Resistance Patterns Matter? An Algorithm for the Treatment of Patients With Impetigo

BACKGROUND

Impetigo, a highly contagious bacterial skin infection commonly occurring in young children, but adults may also be affected. The superficial skin infection is mainly caused by Staphylococcus aureus (S. aureus) and less frequently by Streptococcus pyogenes (S. pyogenes). Antimicrobial resistance has become a worldwide concern and needs to be addressed when selecting treatment for impetigo patients. An evidence-based impetigo treatment algorithm was developed to address the treatment of impetigo for pediatric and adult populations.

METHODS

An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists employed a modified Delphi technique to develop the impetigo treatment algorithm. Treatment recommendations were evidence-based, taking into account antimicrobial stewardship and the increasing resistance to oral and topical antibiotics.

RESULTS

The algorithm includes education and prevention of impetigo, diagnosis and classification, treatment measures, and follow-up and distinguishes between localized and widespread or epidemic outbreaks of impetigo. The panel adopted the definition of localized impetigo of fewer than ten lesions and smaller than 36 cm2 area affected in patients of two months and up with no compromised immune status. Resistance to oral and topical antibiotics prescribed for the treatment of impetigo such as mupirocin, retapamulin, fusidic acid, have been widely reported.

CONCLUSIONS

When prescribing antibiotics, it is essential to know the local trends in antibiotic resistance. Ozenoxacin cream 1% is highly effective against S. pyogenes and S. aureus, including methycyllin-susceptible and resistant strains (MRSA), and may be a suitable option for localized impetigo.J Drugs Dermatol. 2021;20(2):134-142. doi:10.36849/JDD.5475 THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

Adherence to guidelines in the management of urolithiasis: are there differences among distinct patient care settings?

INTRODUCTION

Urolithiasis is a common diagnosis in urology. New technologies offer a variety of diagnostic and therapy and consequently display a financial burden on healthcare systems. Hence, clinical practice guidelines (CPG) are essential to implement evidence-based medicine and assure a standard of care considering limited resources. To date, there is no evidence of the use and adherence to CPG on urolithiasis.

MATERIAL AND METHODS

Therefore, we performed a cross-sectional study to analyze the use of CPG on urolithiasis. Data collection was carried out by a questionnaire given to 400 German urologists. The survey included use and adherence to guidelines, evaluation of the clinical situation, therapy spectrum, and workplace. In total, 150 (37%) questionnaires were received and included in our survey. Statistics were performed by SPSS using Chi-quadrat test/Fisher's exact test.

RESULTS

In our study, urologists were office based, hospital affiliated, non-academic, or academic centers in 53%, 32%, 16% and 5%, respectively. In 74% and 70%, urologists adhere to CPG in diagnostic and therapy. Interestingly, workplace and therapy spectrum determines the use of different CPG (p = 0.01; p = 0.022). Academic urologists were more likely to use international CPG of EAU (40%), while outpatient urologists significantly orientated on national CPG (46%). 86% of urologists with high volume of urolithiasis practice interventions in contrast to 53% in low volume (p = 0.001). More than 80% of urologists use short versions and app version of CPG.

CONCLUSION

We firstly describe compliance and the use of CPG on urolithiasis. EAU and DGU present the most commonly used CPG. Short version and app version of CPG find frequent clinical utilization.

Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model

BACKGROUND

Diabetes-related foot ulcers give rise to considerable morbidity, generate a high monetary cost for health and social care services and precede the majority of diabetes-related lower extremity amputations. There are many clinical prediction rules in existence to assess risk of foot ulceration but few have been subject to validation.

OBJECTIVES

Our objectives were to produce an evidence-based clinical pathway for risk assessment and management of the foot in people with diabetes mellitus to estimate cost-effective monitoring intervals and to perform cost-effectiveness analyses and a value-of-information analysis.

DESIGN

We developed and validated a prognostic model using predictive modelling, calibration and discrimination techniques. An overview of systematic reviews already completed was followed by a review of randomised controlled trials of interventions to prevent foot ulceration in diabetes mellitus. A review of the health economic literature was followed by the construction of an economic model, an analysis of the transitional probability of moving from one foot risk state to another, an assessment of cost-effectiveness and a value-of-information analysis.

INTERVENTIONS

The effects of simple and complex interventions and different monitoring intervals for the clinical prediction rules were evaluated.

MAIN OUTCOME MEASURE

The main outcome was the incidence of foot ulceration. We compared the new clinical prediction rules in conjunction with the most effective preventative interventions at different monitoring intervals with a 'treat-all' strategy.

DATA SOURCES

Data from an electronic health record for 26,154 people with diabetes mellitus in one Scottish health board were used to estimate the monitoring interval. The Prediction Of Diabetic foot UlcerationS (PODUS) data set was used to develop and validate the clinical prediction rule.

REVIEW METHODS

We searched for eligible randomised controlled trials of interventions using search strategies created for Ovid® (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Randomised controlled trials in progress were identified via the International Standard Randomised Controlled Trial Number Registry and systematic reviews were identified via PROSPERO. Databases were searched from inception to February 2019.

RESULTS

The clinical prediction rule was found to accurately assess the risk of foot ulceration. Digital infrared thermometry, complex interventions and therapeutic footwear with offloading devices were found to be effective in preventing foot ulcers. The risk of developing a foot ulcer did not change over time for most people. We found that interventions to prevent foot ulceration may be cost-effective but there is uncertainty about this. Digital infrared thermometry and therapeutic footwear with offloading devices may be cost-effective when used to treat all people with diabetes mellitus regardless of their ulcer risk.

LIMITATIONS

The threats to the validity of the results in some randomised controlled trials in the review and the large number of missing data in the electronic health record mean that there is uncertainty in our estimates.

CONCLUSIONS

There is evidence that interventions to prevent foot ulceration are effective but it is not clear who would benefit most from receiving the interventions. The ulceration risk does not change over an 8-year period for most people with diabetes mellitus. A change in the monitoring interval from annually to every 2 years for those at low risk would be acceptable.

FUTURE WORK RECOMMENDATIONS

Improving the completeness of electronic health records and sharing data would help improve our knowledge about the most clinically effective and cost-effective approaches to prevent foot ulceration in diabetes mellitus.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016052324.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 62. See the NIHR Journals Library website for further project information.

Coronavirus Disease Model to Inform Transmission-Reducing Measures and Health System Preparedness, Australia

The ability of health systems to cope with coronavirus disease (COVID-19) cases is of major concern. In preparation, we used clinical pathway models to estimate healthcare requirements for COVID-19 patients in the context of broader public health measures in Australia. An age- and risk-stratified transmission model of COVID-19 demonstrated that an unmitigated epidemic would dramatically exceed the capacity of the health system of Australia over a prolonged period. Case isolation and contact quarantine alone are insufficient to constrain healthcare needs within feasible levels of expansion of health sector capacity. Overlaid social restrictions must be applied over the course of the epidemic to ensure systems do not become overwhelmed and essential health sector functions, including care of COVID-19 patients, can be maintained. Attention to the full pathway of clinical care is needed, along with ongoing strengthening of capacity.

Clinical risk score to predict in-hospital mortality in COVID-19 patients: a retrospective cohort study

OBJECTIVES

Several physiological abnormalities that develop during COVID-19 are associated with increased mortality. In the present study, we aimed to develop a clinical risk score to predict the in-hospital mortality in COVID-19 patients, based on a set of variables available soon after the hospitalisation triage.

SETTING

Retrospective cohort study of 516 patients consecutively admitted for COVID-19 to two Italian tertiary hospitals located in Northern and Central Italy were collected from 22 February 2020 (date of first admission) to 10 April 2020.

PARTICIPANTS

Consecutive patients≥18 years admitted for COVID-19.

MAIN OUTCOME MEASURES

Simple clinical and laboratory findings readily available after triage were compared by patients' survival status ('dead' vs 'alive'), with the objective of identifying baseline variables associated with mortality. These were used to build a COVID-19 in-hospital mortality risk score (COVID-19MRS).

RESULTS

Mean age was 67±13 years (mean±SD), and 66.9% were male. Using Cox regression analysis, tertiles of increasing age (≥75, upper vs <62 years, lower: HR 7.92; p<0.001) and number of chronic diseases (≥4 vs 0-1: HR 2.09; p=0.007), respiratory rate (HR 1.04 per unit increase; p=0.001), PaO2/FiO2 (HR 0.995 per unit increase; p<0.001), serum creatinine (HR 1.34 per unit increase; p<0.001) and platelet count (HR 0.995 per unit increase; p=0.001) were predictors of mortality. All six predictors were used to build the COVID-19MRS (Area Under the Curve 0.90, 95% CI 0.87 to 0.93), which proved to be highly accurate in stratifying patients at low, intermediate and high risk of in-hospital death (p<0.001).

CONCLUSIONS

The COVID-19MRS is a rapid, operator-independent and inexpensive clinical tool that objectively predicts mortality in patients with COVID-19. The score could be helpful from triage to guide earlier assignment of COVID-19 patients to the most appropriate level of care.

Survivors' Perceptions of Quality of Colorectal Cancer Care by Sexual Orientation

OBJECTIVE

The objective of this study was to assess sexual minority and heterosexual survivors' perceived quality of cancer care and identify demographic, clinical, and psychosocial characteristics associated with patient-centered quality of care.

MATERIALS AND METHODS

Four cancer registries provided data on 17,849 individuals who were diagnosed with stage I, II, or III colorectal cancer an average of 3 years prior and resided in predetermined diverse geographic areas. A questionnaire, which queried about sexual orientation and other eligibility criteria was mailed to all cancer survivors. Of these, 480 eligible survivors participated in a telephone survey. Quality of cancer care was defined by 3 measures of interpersonal care (physician communication, nursing care, and coordination of care) and by rating cancer care as excellent. We used generalized linear models and logistic regression with forward selection to obtain models that best explained each quality of care measure.

RESULTS

Sexual minority survivors rated physician communication, nursing care, and coordination of care similarly to heterosexual survivors, yet a significantly higher percentage of sexual minority survivors rated the overall quality of their cancer care as excellent (59% vs. 49%). Sexual minority survivors' greater likelihood of reporting excellent care remained unchanged after adjusting for demographic, clinical, and psychosocial characteristics.

CONCLUSIONS

Sexual minority survivors' ratings of quality of colorectal cancer care were comparable or even higher than heterosexual survivors. Sexual minority survivors' reports of excellent care were not explained by their interpersonal care experiences.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

Narrow excision margins are appropriate for Merkel cell carcinoma when combined with adjuvant radiation: Analysis of 188 cases of localized disease and proposed management algorithm

BACKGROUND

Merkel cell carcinoma (MCC) management typically includes surgery with or without adjuvant radiation therapy (aRT). Major challenges include determining surgical margin size and whether aRT is indicated.

OBJECTIVE

To assess the association of aRT, surgical margin size, and MCC local recurrence.

METHODS

Analysis of 188 MCC cases presenting without clinical nodal involvement.

RESULTS

aRT-treated patients tended to have higher-risk tumors (larger diameter, positive microscopic margins, immunosuppression) yet had fewer local recurrences (LRs) than patients treated with surgery only (1% vs 15%; P = .001). For patients who underwent surgery alone, 7 of 35 (20%) treated with narrow margins (defined as ≤1.0 cm) developed LR, whereas 0 of 13 patients treated with surgical margins greater than 1.0 cm developed LR (P = .049). For aRT-treated patients, local control was excellent regardless of surgical margin size; only 1% experienced recurrence in each group (1 of 70 with narrow margins ≤1 cm and 1 of 70 with margins >1 cm; P = .56).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Among patients treated with aRT, local control was superb even if significant risk factors were present and margins were narrow. We propose an algorithm for managing primary MCC that integrates risk factors and optimizes local control while minimizing morbidity.

Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews

BACKGROUND

The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation.

RESEARCH QUESTION

What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS?

STUDY DESIGN AND METHODS

We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines.

RESULTS

Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery.

INTERPRETATION

This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.

[How information on a patient's social status is gathered. An anthropological analysis of the discourses employed in private medical practice]

BACKGROUND

A number of studies have highlighted differences and even discrimination in health care offer according to social category, and shown that they contribute to the production of inequality. On the other hand, when the health care system treats every patient equally, and does not take personal difficulties into consideration, some authors have suggested inequality "by omission". That is why public health actors at different levels have recommended systematic collection of information on patients' social status. The objective of this article is to analyze data gathering on patients' socio-economic condition and its repercussions.

METHODS

The survey is based on more than 50 semi-structured face-to-face interviews with doctors and dentists in private practice. Their answers were subjected to socio-anthropological analysis.

RESULTS

While some practitioners collect information on patients' social status proactively by systematic interrogation, others proceed indirectly and in accordance with subjective criteria. Quite often, patient status remains ignored, usually due to lack of interest, and less frequently because practitioners wish to guard against any risk of stigmatizing underprivileged patients. Different rationales may explain these attitudes: need to prioritize relevant information, wish to observe equity and equality, determination to refrain from social labeling, desire to protect patient self-esteem and to reinforce the practitioner-patient relationship. When identification does occur, it is essentially justified by a desire to adapt the care pathway to potential socio-economic obstacles.

CONCLUSION

When a patient's social situation is sought out by private doctors and dentists, they are mainly concerned with customizing care pathways by taking financial impediments into close consideration. In most cases, their justifications for asking questions are subjective; by doing so, they inadvertently introduce arbitrariness in an area where the French state endeavors to produce social justice via provisions such as "CMU" ("universal", across the board health coverage). Systematic questioning on a patient's social status can represent a form of supplementary if unconscious symbolic violence toward frequently disqualified persons; what is more, it runs the risk of inducing stereotypes and manifesting prejudice. Only when contextualized does such questioning seem appropriate. On the other hand, when a practitioner misses out on social issues liable to impede care and treatment, he will probably have no "second chance" to address these concerns. Some practitioners have emphasized a need for suitable timing and contextualizing of questions on a patient's social status, and for putting them forward in a climate of trust.

A care pathway for the cardiovascular complications of COVID-19: Insights from an institutional response

The infection caused by severe acute respiratory syndrome coronavirus-2, or COVID-19, can result in myocardial injury, heart failure, and arrhythmias. In addition to the viral infection itself, investigational therapies for the infection can interact with the cardiovascular system. As cardiologists and cardiovascular service lines will be heavily involved in the care of patients with COVID-19, our division organized an approach to manage these complications, attempting to balance resource utilization and risk to personnel with optimal cardiovascular care. The model presented can provide a framework for other institutions to organize their own approaches and can be adapted to local constraints, resource availability, and emerging knowledge.

Stop Doing Needless Things! Saving Healthcare Resources During COVID-19 and Beyond

The COVID-19 outbreak is putting tremendous strain on the US healthcare system, with a direct impact on medical professionals, hospital systems, and physical resources. While comprehensive public health and regulatory efforts are essential to overcome this crisis, it is important to recognize this moment as an opportunity to provide more intelligent and more efficient care in spite of increasing patient volumes and fewer resources. Specifically, we must limit unnecessary and wasteful medical practices and improve the delivery of those services which enhance the quality of patient care. In doing so, we will increase availability of the critical resources required for the provision of high-quality care to those in greatest need both now and in the future.

The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing

INTRODUCTION

Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services.

METHODS

A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports.

FINDINGS

There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

Surgery as a Viable Alternative First-Line Treatment for Prolactinoma Patients. A Systematic Review and Meta-Analysis

CONTEXT

The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas.

OBJECTIVE

To compare clinical outcomes after dopamine agonist withdrawal and transsphenoidal surgery in prolactinoma patients.

METHODS

Eight databases were searched up to July 13, 2018. Primary outcome was disease remission after drug withdrawal or surgery. Secondary outcomes were biochemical control and side effects during dopamine agonist treatment and postoperative complications. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions. Robustness of results was assessed by sensitivity analyses.

RESULTS

A total of 1469 articles were screened: 55 (10 low risk of bias) on medical treatment (n = 3564 patients) and 25 (12 low risk of bias) on transsphenoidal surgery (n = 1836 patients). Long-term disease remission after dopamine agonist withdrawal was 34% (95% confidence interval [CI], 26-46) and 67% (95% CI, 60-74) after surgery. Subgroup analysis of microprolactinomas showed 36% (95% CI, 21-52) disease remission after dopamine agonist withdrawal, and 83% (95% CI, 76-90) after surgery. Biochemical control was achieved in 81% (95% CI, 75-87) of patients during dopamine agonists with side effects in 26% (95% CI, 13-41). Transsphenoidal surgery resulted in 0% mortality, 2% (95% CI, 0-5) permanent diabetes insipidus, and 3% (95% CI, 2-5) cerebrospinal fluid leakage. Multiple sensitivity analyses yielded similar results.

CONCLUSIONS

In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonists.

[The interplay between isolation and precariousness, and hospitalization duration in French Guiana]

BACKGROUND

French Guiana faces singular health challenges: poverty, isolation, structural lag, difficulties in attracting health professionals. Hospital stays exceed the recommended durations. The present study aimed to model the impact of precariousness and geographic isolation on the hospital duration performance indicator and to recalculate the indicator after incrementing severity by 1 unit when patients were socially precarious.

METHODS

Cayenne hospital data for 2017 were used to model the hospital duration performance indicator (IP-DMS) using quantile regression to study the impact of geographic and social explanatory variables. This indicator was computed hypothesizing a 1 unit increment of severity for precarious patients and by excluding patients from isolated regions.

RESULTS

Most excess hospitalization days were linked to precariousness: the sojourns of precarious patients represented 47% of activity but generated 71% of excess days in hospital. Quantile regression models showed that after adjustment for potential confounders, patients from western French Guiana and Eastern French Guiana, precarious patients and the interactions terms between residence location and precariousness were significantly associated with IP-DMS increases. Recalculating the IP-DMSafter exclusion of patients from the interior and after increasing severity by 1 notch if the patient was precarious led to IP-DMS levels close to 1.

CONCLUSION

The results show the nonlinear relationship between the IP-DMS and geographical isolation, poverty, and their interaction. These contextual variables must be taken into account when choosing the target IP-DMS value for French Guiana, which conditions funding and number of hospital beds allowed in a context of rapid demographic growth.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol

BACKGROUND

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.

METHODS

The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.

DISCUSSION

Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.

TRIAL REGISTRATION

Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

Ischemic stroke: clinical pathway impact

PURPOSE

A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data.

DESIGN/METHODOLOGY/APPROACH

Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients' (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included.

FINDINGS

An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p=0.85) and no statistically significant differences in 30-day mortality.

RESEARCH LIMITATIONS/IMPLICATIONS

The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome.

ORIGINALITY/VALUE

Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

Staff perceptions of prescription and over-the-counter drug dependence services in England: a qualitative study

BACKGROUND

Dependence to prescription and over-the-counter (OTC) drugs represents an increasing public health and clinical problem both in England and internationally. However, relatively little is known about those affected, particularly in relation to their management at drug dependence treatment centres. This study aimed to explore the views and experiences of health care professionals (HCPs) working in formal drug treatment services in relation to supporting clients with prescription and OTC drug dependence.

METHODS

An exploratory, qualitative design was used involving semi-structured telephone interviews. 15 staff were recruited using purposive sampling to represent a variety of different professional roles, funding (NHS, charity and local government) and geographical locations across England. Transcribed interviews were analysed using Braun and Clarke's six stage thematic analysis.

RESULTS

Current services were considered to be inappropriate for the treatment of OTC and prescription drug dependence, which was perceived to be a significantly under-recognised issue affecting a range of individuals but particularly those taking opioid analgesics. Negativity around current treatment services involved concerns that these were more suited for illicit drug users and this was exacerbated by a lack of specific resources, funding and commissioning. There was a perceived variation in service provision in different areas and a further concern about the lack of formal treatment guidelines and care pathways. Participants felt there to be stigma for affected clients in both the diagnosis of OTC or prescription drug dependence and also attendance at drug treatment centres which adversely impacted service engagement. Suggested service improvements included commissioning new specific services in general practices and pain management clinics, developing national guidelines and care pathways to ensure equal access to treatment and increasing awareness amongst the public and HCPs.

CONCLUSIONS

This study reveals considerable negativity and concern about current treatment services for prescription and OTC drug dependence in England from the perspective of those working in such services. Policy and practice improvement are suggested to improve outcomes for this neglected group in relation to increasing funding, guidelines and awareness.

Improving people's access to community-based back pain treatment through an inclusive design approach

Back pain is a very common health problem and affects people across the world. This study applies an Inclusive Design approach to a community-based back pain service to understand the challenges, in relation to patients' capabilities, that can affect their access to the service. It consisted of three steps: i) online surveys and interviews with physiotherapists and collected patients' personal online care stories to gather insight into their experiences within the back pain care journeys; ii) estimated services' demands made on patients when they access the service and identified the related challenges and iii) proposed recommendations that could address the challenges for patients to access the service. The study suggests an Inclusive Design approach could help identify capability-related challenges such as vision and memory which could affect people's access to back pain treatment. In addition, the application of the approach also uncovered some non-capability-related challenges.

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review

OBJECTIVES

In urological cancers, sex disparity exists for survival, with women doing worse than men. Suboptimal evaluation of presenting symptoms may contribute.

DESIGN

We performed a systematic review examining factors affecting the quality of the diagnostic process of patients presenting with symptoms of bladder or kidney cancer.

DATA SOURCES

We searched Medline, Embase and the Cochrane Library from 1 January 2000 to 13 June 2019.

ELIGIBLE CRITERIA

We focused on one of the six domains of quality of healthcare: timeliness, and examined the quality of the diagnostic process more broadly, by assessing whether guideline-concordant history, examination, tests and referrals were performed. Studies describing the factors that affect the timeliness or quality of the assessment of urinary tract infections, haematuria and lower urinary tract symptoms in the context of bladder or kidney cancer, were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by two authors. Due to the heterogeneity of study design and outcomes, the results could not be pooled. A narrative synthesis was performed.

RESULTS

28 studies met review criteria, representing 583 636 people from 9 high-income countries. Studies were based in primary care (n=8), specialty care (n=12), or both (n=8). Up to two-thirds of patients with haematuria received no further evaluation in the 6 months after their initial visit. Urinary tract infections, nephrolithiasis and benign prostatic conditions before cancer diagnosis were associated with diagnostic delay. Women were more likely to experience diagnostic delay than men. Patients who first saw a urologist were less likely to experience delayed evaluation and cancer diagnosis.

CONCLUSIONS

Women, and patients with non-cancerous urological diagnoses just prior to their cancer diagnosis, were more likely to experience lower quality diagnostic processes. Risk prediction tools, and improving guideline ambiguity, may improve outcomes and reduce sex disparity in survival for these cancers.

Variation in the practice of discontinuing mechanical ventilation in critically ill adults: study protocol for an international prospective observational study

INTRODUCTION

Research supports the use of specific strategies to discontinue mechanical ventilation (MV) in critically ill patients. Little is known about how clinicians actually wean and discontinue MV in practice or the association between different discontinuation strategies and outcomes. The primary objective of this study is to describe international practices in the use of (1) daily screening for readiness to discontinue MV, (2) modes of MV used before initial discontinuation attempts, (3) weaning and spontaneous breathing trial (SBT) protocols, (4) SBT techniques and (5) sedation and mobilisation practices to facilitate weaning and discontinuation. The secondary objectives are to identify patient characteristics and time-dependent factors associated with use of selected strategies, investigate associations between SBT outcome (failure vs success) and outcomes, explore differences between patients who undergo an SBT early versus later in their intensive care unit (ICU) stay, and investigate the associations between different SBT techniques and humidification strategies on outcomes.

METHODS AND ANALYSIS

We will conduct an international, prospective, observational study of MV discontinuation practices among critically ill adults who receive invasive MV for at least 24 hours at approximately 150 ICUs in six geographic regions (Canada, USA, UK, Europe, India and Australia/New Zealand). Research personnel at participating ICUs will collect demographic data, data to characterise the initial strategy or event that facilitated discontinuation of MV (direct extubation, direct tracheostomy, initial successful SBT, initial failed SBT or death before any attempt could be made), clinical outcomes and site information. We aim to collect data on at least 10 non-death discontinuation events in each ICU (at least 1500 non-death discontinuation events).

ETHICS AND DISSEMINATION

This study received Research Ethics Approval from St. Michael's Hospital (11-024) Research ethics approval will be sought from all participating sites. The results will be disseminated through publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03955874.

Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review

OBJECTIVE

Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion.

DESIGN

Systematic review.

DATA SOURCES

Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature.

ELIGIBILITY CRITERIA

All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively.

RESULTS

The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the 'meso' level of a whole systems approach.

CONCLUSION

It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways.

PROSPERO REGISTRATION NUMBER

CRD42016035510.

Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework

BACKGROUND

Management of rectal cancer has become more complex with multimodality therapy (neoadjuvant chemoradiotherapy and surgery) and this has led to the need to organize multidisciplinary teams. The aim of this study was to report on the planning, implementation and evaluation of an integrated care pathway for neoadjuvant treatment of middle and lower rectal cancer.

DESIGN AND SETTING

This was a cross-sectional post-implementation study that was carried out at a public university cancer center.

METHODS

The Framework for Program Evaluation in Public Health of the Centers for Disease Control and Prevention (CDC) was used to identify resources and activities; link results from activities and outcomes with expected goals; and originate indicators and outcome measurements.

RESULTS

The logic model identified four activities: stakeholders' engagement, clinical pathway development, information technology improvements and training programs; and three categories of outcomes: access to care, effectiveness and organizational outcomes. The measurements involved 218 patients, among whom 66.3% had their first consultation within 15 days after admission; 75.2% underwent surgery < 14 weeks after the end of neoadjuvant treatment and 72.7% completed the treatment in < 189 days. There was 100% adherence to the protocol for the regimen of 5-fluorouracil and leucovorin.

CONCLUSIONS

The logic model was useful for evaluating the implementation of the integrated care pathways and for identifying measurements to be made in future outcome studies.

Utilizing Quality Improvement Methods to Examine the Radiation Therapy Pathway for Patients Requiring Palliative Radiation Therapy at a Community Cancer Center

BACKGROUND

At a community cancer center, during weekly quality improvement huddles, the radiation therapy team expressed stress and frustration with the pretreatment pathway for patients requiring palliative radiotherapy. As the department was meeting provincial targets with respect to wait times, it was unknown why the consensus around the department reflected discomfort and stress.

METHODS

Four radiation therapists formed a quality improvement project team, intent on utilizing a data-driven improvement cycle to investigate and address opportunities to improve the discomfort around this pretreatment pathway. After defining the process and identifying the customers (the health care providers operating in this pathway), the team conducted interviews with each person, transcribing answers verbatim, and grouping results by discipline. Utilizing the interview themes, each discipline identified one or two priorities to measure, as well as metrics to capture the magnitude and prevalence of these priorities.

RESULTS

Each discipline's priorities were measured and analyzed. The identified issues brought forward at the weekly quality improvement huddles were not as prevalent as expected. Minor changes were implemented for priority issues.

CONCLUSION

The team focused on the four principles of quality improvement: the patient, team, process, and data to address the expressed discomfort around this specific radiation therapy pathway. The results dispelled some of the myths among teams and provided solutions to areas where minor improvements were required. Utilizing the data, an evidence-informed timeline was validated, encouraging task deadlines to be more evenly distributed across the pathway. Plans to monitor this pathway are being established. The team was successful in contributing to a growing culture of continuous improvement at this community cancer center.

Shortened cataract surgery by standardisation of the perioperative protocol according to the Joint Commission International accreditation: a retrospective observational study

OBJECTIVES

To investigate the impact of standardisation of the perioperative protocol based on the Joint Commission International (JCI) accreditation guidelines for operating time in cataract surgery.

DESIGN

Retrospective observational study.

SETTING

Single centre in Japan.

PARTICIPANTS

Between March 2014 and June 2016, 3127 patients underwent cataract surgery under topical anaesthesia including 2581 and 546 patients before and after JCI accreditation, respectively.

PRIMARY AND SECONDARY OUTCOMES

We compared three time periods, comprising the preprocedure/surgery time (pre-PT), PT and post-PT, and total PT (TPT) of cataract surgery between patients before and after JCI accreditation, by regression analysis adjusted for age, sex and cataract surgery-associated confounders.

RESULTS

The main outcomes were pre-PT, PT, post-PT and TPT. Pre-PT (19.8±10.5 vs 13.9±8.5 min, p<0.001) and post-PT (3.5±4.6 vs 2.6±2.1 min, p<0.001) significantly decreased after JCI accreditation, while PT did not significantly change (16.8±6.7 vs 16.2±6.3 min, p=0.065). Consequently, TPT decreased on average by 7.3 min per person after JCI accreditation (40.1±13.4 vs 32.8±10.9 min, p<0.001). After adjusting for confounders, pre-PT (β=-5.82 min, 95% CI -6.75 to -4.88), PT (β=-0.76 min, 95% CI -1.34 to -1.71), post-PT (β=-0.85 min, 95% CI -1.24 to -0.45) and TPT (β=-7.43 min, 95% CI -8.61 to -6.24) were significantly shortened after JCI accreditation.

CONCLUSION

Perioperative protocol standardisation, based on JCI accreditation, shortened TPT in cataract surgery under local anaesthesia.

Pain Sensitization, Breastfeeding Effectiveness, and Parental Preferences by Antibiotic Route in Suspected Neonatal Sepsis

OBJECTIVES

Intravenous (IV) and intramuscular (IM) antibiotics have comparable efficacy in treating neonates undergoing sepsis evaluations. There are no clinical data favoring the use of either route regarding newborn pain and parental preferences. We hypothesized that pain associated with IM injections would worsen breastfeeding effectiveness and decrease parental satisfaction, making IV catheters the preferred route.

METHODS

This prospective cohort study took place in an academic institution with nurseries in 2 separate hospitals, 1 providing IV antibiotics, and the other, IM antibiotics. Newborns receiving 48 hours of antibiotics were compared by using objective pain and breastfeeding scores and parental surveys.

RESULTS

In 185 newborns studied, pain scores on a 7-point scale were up to 3.4 points higher in the IM compared with the IV group (P < .001). Slopes of repeated pain scores were 0.42 ± 0.08 and -0.01 ± 0.11 in the IM and IV groups, respectively (P = .002). Breastfeeding scores were similar between groups. Parents in the IV group were less likely to perceive discomfort with antibiotic administration (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.06-0.74) but more likely to perceive interference with breastfeeding (OR 26; 95% CI 6.4-108) and bonding (OR 101; 95% CI 17-590) and more likely to prefer changing to the alternate route (OR 6.9; 95% CI 2.3-20).

CONCLUSIONS

IM antibiotics in newborns are associated with pain sensitization and greater pain than IV dosing. Despite accurately recognizing newborn pain with the IM route, parents preferred this to the IV route, which was perceived to interfere with breastfeeding and bonding.

US care pathways: continued focus on oncology and outstanding challenges

OBJECTIVES

To update an ongoing assessment of care pathway development, implementation, and evaluation, and to evaluate the emerging relationship between care pathways and other components of value-based care.

STUDY DESIGN

Targeted literature review followed by an online survey and in-depth interviews.

METHODS

The PubMed/Cochrane databases and gray literature were searched for publications on care pathways (January 1, 2014, to March 3, 2017); a supplemental targeted search was completed in October 2017. Qualitative data were collected via an online survey and semistructured, in-depth interviews with payers, providers, pathway vendors, and opinion leaders.

RESULTS

A total of 112 articles or posters were identified in recently published research. The survey and interviews included 32 and 19 respondents, respectively. Care pathways are increasingly driven by providers and provider networks. Overall, we found increased awareness of and adherence to codified best practices or standards, and prioritization of high-quality evidence during development. Research findings suggest stronger links between outcomes-based measures and both physician reimbursement and care pathway evaluation. Integration with other value-based care initiatives, including alternative payment models, is also gradually emerging.

CONCLUSIONS

This study identified growing use of high standards of evidence and adoption of other best practices in the development, implementation, and evaluation of care pathways. As the influence of care pathways on patient care continues to expand, additional efforts are needed to increase transparency, disclose conflicts of interest, engage with patients, effectively align care pathways with improvements in patient outcomes, and integrate efficiently with other value-based care initiatives.

Identifying key factors leading to the optimal care pathway for patients with ST-segment elevation myocardial infarction: Results from the RESCAMIP registry

BACKGROUND

In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible.

AIM

To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway.

METHODS

RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included.

RESULTS

Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65).

CONCLUSIONS

The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND

Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.

METHODS

We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973.

FINDINGS

Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28).

INTERPRETATION

No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care.

FUNDING

National Institute for Health Research Health Services and Delivery Research Programme.

Perceptions about the implementation of physiotherapist prescribing in Australia: a national survey of Australian physiotherapists

OBJECTIVES

To explore: (1) the views of Australian physiotherapists regarding potential implementation of non-medical prescribing in Australia, (2) how the geographical location and health sector in which a clinician works may influence their perceptions and (3) the perceptions of Australian physiotherapists about how physiotherapist prescribing might impact the care that the profession can provide.

DESIGN

A cross-sectional descriptive survey using open and closed questions.

SETTING

Participants completed an online questionnaire.

PARTICIPANTS

883 Australian Health Professionals Registration Authority (AHPRA)-registered physiotherapists, working across all states and territories.

OUTCOME MEASURES

An online questionnaire was developed by a panel of subject experts and pretested (n=10) for internal consistency. A hyperlink to the questionnaire was emailed to all members of the Australian Physiotherapy Association. A reminder email was sent 4 weeks later. Quantitative data were analysed descriptively, with use of absolute risk reductions (ARRs) and 95% CIs to determine the likelihood that health sector or geographical location were associated with specific views. Thematic analysis enabled synthesis of the qualitative data.

RESULTS

79.0% participants felt that physiotherapist prescribing should be introduced in Australia, with 71.2% wanting to train as prescribers. Clinical governance, risk management, regulation of clinicians and the development of an education framework were identified as priorities for implementation. Participants working in the private sector were significantly more likely to train as prescribers than those in the public sector (ARR 9.9%; 95% CI 3.5 to 16.4) or educational/research institutions (ARR 23.3%; 95% CI 12.8 to 33.8), with city dwellers significantly more likely to train compared with physiotherapists in remote regions (ARR 19.8%; 95% CI 0.8 to 39.2). Physiotherapist prescribing was predicted to improve efficiency of healthcare delivery, access to medicines and reductions in healthcare costs.

CONCLUSIONS

AHPRA-registered physiotherapists perceive that the introduction of autonomous physiotherapist prescribing would be beneficial for the Australian population and should be introduced. Decision makers should consider the results of this survey in conjunction with cost-benefit and risk analysis when planning the introduction of physiotherapist prescribing.

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

INTRODUCTION

Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.

METHODS

A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.

RESULTS

Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.

CONCLUSION

While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

From Diagnostic-Therapeutic Pathways to Real-World Data: A Multicenter Prospective Study on Upfront Treatment for EGFR-Positive Non-Small Cell Lung Cancer (MOST Study)

INTRODUCTION

Gefitinib, erlotinib, and afatinib represent the approved first-line options for epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC). Because pivotal trials frequently lack external validity, real-world data may help to depict the diagnostic-therapeutic pathway and treatment outcome in clinical practice.

METHODS

MOST is a multicenter observational study promoted by the Veneto Oncology Network, aiming at monitoring the diagnostic-therapeutic pathway of patients with nonsquamous EGFR-mutant NSCLC. We reported treatment outcome in terms of median time to treatment failure (mTTF) and assessed the impact of each agent on the expense of the regional health system, comparing it with a prediction based on the pivotal trials.

RESULTS

An EGFR mutation test was performed in 447 enrolled patients, of whom 124 had EGFR mutation and who received gefitinib (n = 69, 55%), erlotinib (n = 33, 27%), or afatinib (n = 22, 18%) as first-line treatment. Because erlotinib was administered within a clinical trial to 15 patients, final analysis was limited to 109 patients. mTTF was 15.3 months, regardless of the type of tyrosine kinase inhibitor (TKI) used. In the MOST study, the budget impact analysis showed a total expense of €3,238,602.17, whereas the cost estimation according to median progression-free survival from pivotal phase III trials was €1,813,557.88.

CONCLUSION

Good regional adherence and compliance to the diagnostic-therapeutic pathway defined for patients with nonsquamous NSCLC was shown. mTTF did not significantly differ among the three targeted TKIs. Our budget impact analysis suggests the potential application of real-world data in the process of drug price negotiation.

IMPLICATIONS FOR PRACTICE

The MOST study is a real-world data collection reporting a multicenter adherence and compliance to diagnostic-therapeutic pathways defined for patients with epidermal growth factor receptor-mutant non-small cell lung cancer. This represents an essential element of evidence-based medicine, providing information on patients and situations that may be challenging to assess using only data from randomized controlled trials, e.g., turn-around time of diagnostic tests, treatment compliance and persistence, guideline adherence, challenging-to-treat populations, drug safety, comparative effectiveness, and cost effectiveness. This study may be of interest to various stakeholders (patients, clinicians, and payers), providing a meaningful picture of the value of a given therapy in routine clinical practice.