Question banks: credit? Or debit? A qualitative exploration of their use among medical students

BACKGROUND

Online question banks are the most widely used education resource amongst medical students. Despite this there is an absence of literature outlining how and why they are used by students. Drawing on Deci and Ryan's self-determination theory, our study aimed to explore why and how early-stage medical students use question banks in their learning and revision strategies.

METHODS

The study was conducted at Newcastle University Medical School (United Kingdom and Malaysia). Purposive, convenience and snowball sampling of year two students were employed. Ten interviews were conducted. Thematic analysis was undertaken iteratively, enabling exploration of nascent themes. Data collection ceased when no new perspectives were identified.

RESULTS

Students' motivation to use question banks was predominantly driven by extrinsic motivators, with high-stakes exams and fear of failure being central. Their convenience and perceived efficiency promoted autonomy and thus motivation. Rapid feedback cycles and design features consistent with gamification were deterrents to intrinsic motivation. Potentially detrimental patterns of question bank use were evident: cueing, avoidance and memorising. Scepticism regarding veracity of question bank content was absent.

CONCLUSIONS

We call on educators to provide students with guidance about potential pitfalls associated with question banks and to reflect on potential inequity of access to these resources.

'That's someone's grandma': Teaching person-centred care in a frailty context

BACKGROUND

The ability to provide person-centred care (PCC) is an essential skill for doctors and requires therapeutic empathy. We sought to evaluate a novel teaching approach to understand how medical students' personal reflections on an older person impact their views about PCC and frailty.

APPROACH

We designed a teaching session where students prepared an image and story about an older person they knew. Given the innovative nature of this, we set it in the context of a Plan Do Study Act cycle to ensure evaluation and continuous improvement at each stage. Students' contributions were discussed in a supportive environment, weaving together stories about individuals with the impacts of ageing they experienced. We evaluated the teaching with a pre- and post-session 'frailty' word cloud and an online focus group.

EVALUATION

Word cloud analysis showed a shift in the words students used when considering 'frailty', from words associated with illness and vulnerability to those associated with character and experience. Focus group themes supported these findings. Students expressed a change in their perception of frailty to consider 'the person behind the patient', which, unexpectedly, led to them also seeing 'the person behind the medical student'. The session stimulated student reflection on challenges that may impact on delivery of truly person-centred care.

IMPLICATIONS

This flexible teaching technique was an effective stimulus for medical students to consider the person behind the patient. Future work could consider how to promote retention of empathy as medical students make the transition to working as a doctor.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Prevalence and determinants of chronic respiratory diseases in adults in rural Sudan

BACKGROUND: Chronic respiratory diseases (CRDs) greatly contribute to worldwide mortality. Despite new data emerging from Africa, prevalence estimates and determinants of CRDs in rural settings are limited. This study sought to extend the existing research conducted in urban Sudan by conducting a rural comparison.METHODS: Participants aged ≥18 years (n = 1,850), living in rural Gezira State completed pre-and post-bronchodilator spirometry and a questionnaire. Prevalence of respiratory symptoms and spirometric abnormalities were reported. Regression analyses were used to identify risk factors for CRDs.RESULTS: Prevalence of chronic airflow obstruction (CAO) was 4.1% overall and 5.5% in those aged ≥40 years. Reversibility was seen in 6.4%. Low forced vital capacity (FVC) was seen in 58.5%, and at least one respiratory symptom was present in 40.7% of the participants. CAO was more common among people aged 60-69 years (OR 2.07, 95% CI 1.13-3.82) and less common among highly educated participants (OR 0.50, 95% CI 0.27-0.93). Being underweight was associated with lower FVC (OR 3.07, 95% CI 2.24-4.20).CONCLUSIONS: A substantial burden of CRD exists among adults in rural Sudan. Investment in CRD prevention and management strategies is needed.

Co-design to deliver service improvement: What does this mean and how can we do it? A qualitative study with upper gastrointestinal cancer patients and professionals

BACKGROUND

There is strategic objective to incorporate the principles and practice of co-design into routine service development and improvement.

AIM

The aim was to explore the concept and feasibility of service co-design with patients and health professionals with regards to the upper gastrointestinal (UGI) cancer care pathway.

METHODS AND RESULTS

Qualitative telephone interviews and face-to-face focus groups in one region of England. Twenty patients completed interviews. Nine patients and ten professionals formed two focus groups. Patients were referred through the urgent (two week) GP referral route and were within six months of receiving their first treatment for an UGI cancer. Professionals were working as service planners and providers of the UGI cancer care pathway. Thematic analysis was undertaken. Six themes emerged: Responsibilities and expectations, Knowledge and understanding, Valuing patient input, Building relationships, Environment for co-design activities, Impact and effectiveness. Based on the themes a checklist has been created to provide practical suggestions for both professionals and patients on approaching co-design for service improvement.

CONCLUSION

This study offers policy and practice partners a clearer understanding of co-design and factors to consider when approaching co-design in real life settings.

A mixed methods evaluation of Multiple Mini Interviews for entry into the Bachelor of Midwifery

BACKGROUND

Multiple-mini interviews (MMI) are increasingly used as part of the admission process into healthcare degrees. Evaluations have found MMIs to be a fair assessment tool in terms of reliability and validity and viewed positively by those involved in the MMI process. The use of MMIs in midwifery is novel and evaluation is lacking.

AIM

To evaluate the use of MMIs as part of the admission process for the Bachelor of Midwifery in one Australian university.

METHODS

A basic convergent mixed methods study design was utilised. Data included linked data sets, Likert scale responses to survey questions, focus groups and open-ended survey questions. Integration took place at the interpretation and reporting stage.

FINDINGS

Participants viewed the MMI experience positively. The study confirmed the reliability of the MMIs as an assessment tool. Most variance in MMI scores was attributed to the candidate at 31.4 % with the interviewer and the interview station having less influence on the MMI score at 11 % and 6.4 % variance. Older applicants on average achieved higher MMI scores, and those who spoke a language other than English at home or were first in family to attend university had lower on average MMI scores. Being born overseas did not impact an applicant's MMI score. The overall experience was seen as fair, offering further opportunity to gain entry into the Bachelor of Midwifery.

CONCLUSION

MMIs were viewed positively and findings support the use of MMIs as part of an admissions process for the Bachelor of Midwifery.

How do patients make decisions in the context of a multidisciplinary team: an ethnographic study of four head and neck cancer centres in the north of England

OBJECTIVES

To describe how patients are engaged with cancer decisions in the context of multidisciplinary team (MDT) and how MDT recommendations are operationalised in the context of a shared decision.

DESIGN

Ethnographic qualitative study.

SETTING

Four head and neck cancer centres in the north of England.

PARTICIPANTS

Patients with a diagnosis of new or recurrent head and neck cancer; non-participant observation of 35 MDT meetings and 37 MDT clinics, informal interviews, and formal, semistructured interviews with 20 patients and 9 MDT staff members.

METHODS

Ethnographic methods including non-participant observation of MDT meetings and clinic appointments, informal interviews, field notes and formal semistructured interviews with patients and MDT members.

RESULTS

MDT discussions often conclude with a firm recommendation for treatment. When delivered to a patient in clinic, this recommendation is often accepted by the patient, but this response may result from the disempowered position in which they find themselves. While patient behaviour may thus appear to endorse clinicians' views that a paternalistic approach is desired by patients (creating a 'cycle of paternalism'), the rigidity of the MDT treatment recommendation can act as a barrier to discussion of options and the exploration of patient values.

CONCLUSIONS

The current model of MDT decision-making does not support shared decision-making and may actively undermine it. A model should be developed whereby the individual patient perspective has more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient. In order to achieve these objectives, a new model of MDT working is required.

Enhancing national audit through addressing the quality improvement capabilities of feedback recipients: a multi-phase intervention development study

Background

National audits are a common, but variably effective, intervention to improve services. This study aimed to design an intervention to increase the effectiveness of national audit.

Methods

We used interviews, documentary analysis, observations, co-design and stakeholder engagement methods. The intervention was described in an intervention manual and illustrated using a logic model. Phase 1 described the current hospital response to a national audit. Phase 2 identified potential enhancements. Phase 3 developed a strategy to implement the enhancements. Phase 4 explored the feasibility of the intervention alongside the National Audit of Dementia and refined the intervention. Phase 5 adapted the intervention to a second national audit (National Diabetes Audit). Phase 6 explored the feasibility and fidelity of the intervention alongside the National Diabetes Audit and used the findings to further refine the intervention.

Results

The developed intervention is a quality improvement collaborative (QIC), containing virtual educational workshop, virtual outreach for local team leads and virtual facilitation of a learning collaborative delivered after feedback has been received. The QIC aims to support national audit recipients to undertake improvement actions tailored to their local context. The target audience is clinical and clinical governance leaders. We found that actions from national audit were constrained by what the clinical lead perceived they deliver personally, these actions were not aligned to identified influences upon performance. We found that the hospital response could be enhanced by targeting low baseline performance, identifying and addressing influences upon to performance, developing trust and credibility, addressing recipient priorities, presenting meaningful comparisons, developing a conceptual model, involving stakeholders and considering the opportunity cost. Phase 3 found that an educational workshop and outreach strategy could support implementation of the enhancements through developing coherence and cognitive participation. We found feasibility could be increased by revising the content, re-naming the intervention, amending activities to address time commitment, incorporating a more structured analysis of influences, supporting collaboration and developing local feedback mechanisms. Phase 5 found adaptation to a second national audit involved reflecting differences in the clinical topic, context and contractual requirements. We found that the behaviour change techniques identified in the manual were delivered by facilitators. Participants reported positive attitudes towards the intervention and that the intervention was appropriate.

Conclusions

The QIC supports local teams to tailor their actions to local context and develop change commitment. Future work will evaluate the effectiveness of the intervention as an adjunct to the National Diabetes Audit.

Implementing shared decision-making in UK: Progress 2017-2022

Shared decision making has been on the policy agenda in the UK for at least twelve years, but it lacked a comprehensive approach to delivery. That has changed over the past five years, and we can now see significant progress across all aspects of a comprehensive approach, including leadership at policy, professional and patient levels; infrastructure developments, including the provision of training, tools and campaigns; and practice improvements, such as demonstrations, measurement and coordination. All these initiatives were necessary, but the last, central coordination, would appear to be key to success.

Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina

Background

Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI.

Methods

A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and ‘alpha’ tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis.

Results

CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms.

Conclusions

CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01882-x.

Twelve tips for small group teaching 2.0 - Rebooted for remote and HyFlex learning

Small group teaching (SGT) is not just the delivery of teaching to a small number of learners - it is, instead, underpinned by learner-learner interaction, discussion, and collaboration. The advent of readily available technology, combined with the need to maintain learner and teacher safety during the COVID-19 pandemic, has led to a surge in remote learning, and significant increases in synchronous hybrid learning environments, also known as HyFlex learning, in which some learners join remotely and others do so in-person. Teaching in this manner brings new challenges and opportunities and, when compared to face-to-face SGT, requires teachers to employ a complementary repertoire of skills. Against this backdrop, and with the pressing need to up-skill teachers in this domain, we take a fresh look at previously published tips for SGT and reboot these strategies in the context of remote and HyFlex SGT. The challenges of adapting these tips in a changed environment will be considered, and refashioned strategies for their application will be offered.

Temporal changes in anticoagulant prescribing and atrial fibrillation: results of interrupted time-series analysis of openly available routine data in England

Introduction

The use of anticoagulants for stroke prevention in patients with atrial fibrillation (AF) has been increasing in England in the recent years (1, 2). The changes in practice coincided with several developments in the area of anticoagulants and AF, including: the emergence of evidence supporting anticoagulant use for stroke prevention in AF, changes in guideline recommendations, and the licensing of direct oral anticoagulants (DOACs) as an alternative to warfarin, which was the mainstay of stroke prevention in AF. Currently, there are four DOACs available for use: dabigatran, rivaroxaban, apixaban, and edoxaban. Recent analyses of time trends of anticoagulant prescribing in England showed an increase in DOACs prescribing and a decrease in warfarin prescribing (1, 2). However, more recent exploration of recent anticoagulant prescribing trends is needed.

Aim

To explore the changes in anticoagulant prescribing for AF in England.

Methods

Interrupted time-series analysis (ITSA) of openly available data on anticoagulant prescribing and AF. Separate analyses were conducted for data from Sentinel Stroke National Audit Programme (SSNAP) and Quality and Outcomes Framework (QOF). The timeframe of the analysis and the length of time intervals depended on the characteristics of each dataset.

Results

Analysis of data from SSNAP showed that the proportion of stroke patients who have a diagnosis of AF who were taking an anticoagulant alone prior to admission increased from 32.51% in the third quarter of 2013 to 62.63% in the third quarter of 2020; this coincided with a decreased proportion of stroke patients who have a diagnosis of AF taking antiplatelets alone from 37.10% to 8.31% during the same period. Analysed QOF data on anticoagulants and AF included information about AF prevalence in QOF datasets, the eligibility of patients with AF for anticoagulant based on stroke risk assessment, and the use of anticoagulants among eligible patients. Prevalence of AF in England in QOF datasets increased from 1.52% in 2012/2013 to 2.05% in 2019/2020 (ITSA gradient=0.08, p-value<.001, 95% confidence interval: 0.07- 0.09). The proportion of patients with AF who are considered eligible for anticoagulation per all patients with AF in QOF datasets increased from 44.95% in 2012/2013 to 80.87% in 2019/2020; there was an increase by 25.24% between 2014/2015 and 2015/2016 which corresponds to modifying risk assessment scores to include additional criteria. The proportion of eligible patients with AF being prescribed anticoagulants also increased in the period between 2012/2013 and 2019/2020 (ITSA gradient = 1.98, p-value<.001, 95% confidence interval: 1.52- 2.44).

Conclusion

The analysis of data from different sources identified an increase in anticoagulant prescribing for patients with AF in England, which is likely to translate into health gains. However, the use of aggregate data in the analysis did not allow for detailed inspection of patient characteristics, and individual anticoagulants were not specified in the datasets. Therefore, quantitative analyses of primary care data of individual anticoagulant prescribing for different patient groups with AF are needed to further understand whether additional improvements are possible in the prevention of complications from atrial fibrillation.

References

(1) Adderley NJ, Ryan R, Nirantharakumar K, Marshall T. Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016. Heart. 2019;105(1):27-33.

(2) Loo SY, Dell’Aniello S, Huiart L, Renoux C. Trends in the prescription of novel oral anticoagulants in UK primary care. British Journal of Clinical Pharmacology. 2017;83(9):2096-106.

836 DIEP Flap Monitoring Adherence

Aim

The popularity of Deep Epigastric Perforator (DIEP) free flaps for breast reconstruction after mastectomies have increased due to their natural aesthetic results and reliability. Free flaps require strict post-operative monitoring by nursing staff during the early post-operative period where they should notify the surgeons to anticipate vascular compromise in order to salvage the flap. To ensure success the DIEP guidelines were introduced to Morriston Hospital, Swansea. This was a first cycle closed loop re-audit.

Method

Interventions from initial audit were implemented in 2018. Retrospective analysis of patient notes over an 8-month period (August 2019- March 2020) and compared with DIEP checklist. Clinical notes, nursing cartex and flap observations and medication charts were reviewed.

Results

100% had bear huggers, antiemetics (87% in 2018), correct thromboprophylaxis (75% in 2018) and laxatives (37% in 2018). 100% had senior reviews daily post op (75% in 2018). 100% had flap observations performed as guidelines immediately post op.

Conclusions

This was a successful re-audit showing significant improvements in adherence rates amongst the surgical and nursing staff in the plastic surgery department. Implementation of the DIEP operation note template may help maintain such adherence amongst staff.

The mental health of Australian medical practitioners during Covid-19

OBJECTIVES

To ascertain whether doctors were experiencing higher rates of distress during Covid-19 and whether this was impacted by demographic factors. Our hypotheses were that being a junior doctor, having a previous mental health diagnosis and treating Covid-19 positive patients would predict higher rates of distress.

METHODS

Cross-sectional survey conducted via Survey Monkey. Voluntary participants were recruited from the mailing list of a national-based referral service for doctors to psychiatrists. Distress was measured using the Kessler Psychological Distress Scale (K10). Demographic factors were analysed for predictive value of a higher rating on the K10. Areas of concern in relation to Covid-19 and preference for support services were measured on a Likert scale and compared to levels of distress.

RESULTS

The rate of very high distress was 15%. Being a junior doctor and having a previous mental health diagnosis were predictive factors of a higher K10 score. K10 was not affected by likelihood of contact with Covid-19-positive patients. Social isolation had a larger impact on mental health in the context of a previous psychiatric diagnosis. Face-to-face assessments were preferred.

CONCLUSIONS

Rates of distress in doctors have been higher than baseline during Covid-19. Some groups have been particularly vulnerable.

Development and piloting of four decision aids for implantable cardioverter-defibrillators in different media formats

BACKGROUND

Using DAs for preference-sensitive decisions is an evidence-based way to improve patient-centered decisions. Reimbursement mandates have increased the need for DAs in ICD care, although none have been formally evaluated. The objectives were to develop and pilot implantable cardioverter-defibrillator (ICD) decision aids (DAs) for patients considering primary prevention ICDs.

METHODS

Development Phase: An expert panel, including patients and physicians, iteratively developed four DAs: a one-page Option Grid^TM conversation aid, a four-page in-depth paper tool, a 17-minute video, and an interactive website. Trial Phase: At three sites, patients with heart failure who were eligible for primary prevention ICDs were randomly assigned 2:1 to intervention (received DAs) or control (usual care). We conducted a mixed-methods evaluation exploring acceptability and feasibility.

RESULTS

Twenty-one eligible patients enrolled (15 intervention). Most intervention participants found the DAs to be unbiased (67%), helpful (89%), and would recommend them to others (100%). The pilot was feasible at all sites; however, using clinic staff to identify eligible patients was more efficient than chart review. Although the main goals were to measure acceptability and feasibility, intervention participants trended towards increased concordance between longevity values and ICD decisions (71% concordant vs. 29%, p = .06). Participants preferred the in-depth paper tool and video DAs. Access to a nurse during the decision-making window encouraged questions and improved participant-perceived confidence.

CONCLUSIONS

Participants felt the DAs provided helpful, balanced information that they would recommend to other patients. Further exploration of this larger context of DA use and strategies to promote independent use related to electrophysiology (EP) visits are needed.

Prevalence and characteristics of women with borderline personality pathology referred to a perinatal consultation liaison service

OBJECTIVE

To examine the prevalence and characteristics of pregnant women with borderline personality pathology (defined as borderline personality disorder and borderline personality traits) referred to a perinatal consultation-liaison psychiatry service.

METHOD

Socio-demographic and clinical data, and diagnoses made according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria were recorded for all women referred to and seen by the perinatal consultation-liaison psychiatry service over an 18-month period. Data were analysed using descriptive statistics and logistic regression analysis.

RESULTS

A total of 318 women were seen. The most common diagnoses found were depressive disorder (25.5%) and anxiety disorder (15.1%). Borderline personality disorder was found in 10.1% of women and almost one in five women had two or more borderline personality traits (19.5%). When compared to women with other diagnoses, women with borderline personality pathology had higher rates of unplanned pregnancy, being unpartnered, substance use during pregnancy and higher rates of child safety services involvement as a child or in a previous pregnancy. Over 40% of women with borderline personality pathology were referred to child safety services in the current pregnancy and a diagnosis of borderline personality pathology increased the risk of child safety services involvement by almost sixfold (odds ratio: 5.5; 95% confidence interval = [1.50, 20.17]).

CONCLUSION

The prevalence of borderline personality pathology in antenatal women identified at antenatal screening and the recognition that women with borderline personality pathology are 'high-risk' caregivers argue for borderline personality pathology to be recognised as a high priority for investment in service development.

The impact of Multiple Mini Interviews on the attrition and academic outcomes of midwifery students

BACKGROUND

Admission to the Bachelor of Midwifery (BMid) in Australia has traditionally been based on academic ranking. The BMid is a high demand course offered to a limited number of students and therefore choosing applicants who complete the degree is important. Multiple Mini Interviews (MMIs) are used to assess non-cognitive skills and select students into healthcare degrees. One university in Australia has introduced MMIs as part of the application process for the BMid.

AIM

Compare attrition rates and Grade Point Average (GPA) scores between students admitted into the BMid using both academic ranking and MMIs, to those admitted on academic ranking alone.

METHODS

A basic convergent mixed methods design, using an explanatory unidirectional framework to integrate data. Attrition rates, GPA, and multiple mini interview scores (2013-2019), were linked and compared for before and after the use of MMI's. Focus groups with students, interviewers, and hospital-based educators, explored stakeholder experiences. Open-ended questions from an applicant survey were added to the qualitative data set, which was analysed thematically.

FINDINGS

Students who enrolled via the MMI's had significantly lower attrition rates than those enrolled before MMI's were introduced. GPA scores were significantly higher for students who enrolled via the MMI's. Integration of data found MMI's identified students passionate to undertake midwifery, and that success at the interviews increased students' confidence to successfully complete their studies.

CONCLUSION

MMI's as part of the entry process into the BMid enabled identification of applicants more likely to remain in the course and succeed in their studies.

Chondroid syringoma: an unusual presentation in a 7-year-old boy

Coined in 1961 by Hirsch and Helwig, the term chondroid syringoma refers to a rare mixed tumour of subcutaneous tissue. Histologically, these tumours are almost identical to pleomorphic adenomas, arising from salivary glands. With the obvious difference being the presence of sweat gland tissue (syringoma) within a matrix of cartilage (chondroid). These mixed tumours remain scarce throughout the world, with an incidence of less than 0.098%. The vast majority of cases are reported in middle-aged and older adults, where they typically present as painless swellings in the head and neck, which gradually grow in size.

Are We Improving? Update and Critical Appraisal of the Reporting of Decision Process and Quality Measures in Trials Evaluating Patient Decision Aids

Background

In 2014, a systematic review found large gaps in the quality of reporting of measures used in 86 published trials evaluating the effectiveness of patient decision aids (PtDAs). The purpose of this study was to update that review.

Methods

We examined measures of decision making used in 49 randomized controlled trials included in the 2014 and 2017 Cochrane Collaboration systematic review of PtDAs. Data on development of the measures, reliability, validity, responsiveness, precision, interpretability, feasibility, and acceptability were independently abstracted by 2 paired reviewers.

Results

Information from 273 measures was abstracted, and 109 of these covered the core domains of decision processes (n = 55) and decision quality including informed choice/knowledge (n = 48) and values-choice concordance (n = 12). Very few studies reported data on the performance and clinical sensibility of measures, with reliability (23%) and validity (6%) being the most common. Studies using new measures were less likely to include information about their psychometric performance compared with previously published measures.

Limitations

The review was limited to reporting of measures in studies included in the Cochrane review and did not consult prior publications.

Conclusion

There continues to be very little reported about the development or performance of measures used to evaluate the effectiveness of PtDAs in published trials. Minimum reporting standards have been published, and efforts to require investigators to use them are needed.

Factors influencing oral anticoagulant prescribing decisions for patients with atrial fibrillation: a systematic review of qualitative and quantitative evidence

Introduction

Despite their efficacy in reducing stroke risk in patients with atrial fibrillation (AF), oral anticoagulants (OACs) remain under-prescribed [1]. Until recently, warfarin has been the dominant OAC. The introduction of direct oral anticoagulants (DOACs) led to changes in anticoagulant prescribing patterns, with an increase in OAC prescribing and a shift towards DOACs [2]. Treatment decisions for OACs are complicated, and require a discussion between clinicians and patients when deciding on a treatment [1].

Aim

To investigate the main factors that influence initial and ongoing OAC prescribing decisions for patients with AF according to patient and health professional views.

Methods

A systematic review was conducted according to the Toolkit for Mixed-Methods Reviews, and was registered on PROSPERO: CRD42019145406. Medline, CINAHL, Scopus, EMBASE, Web of Knowledge and PsychInfo were searched in August, 2019. Primary qualitative and quantitative studies, published between 2009 and 2019, exploring patient and health professional perceptions, views and experiences of OACs in AF were included. McMaster critical appraisal tool for quantitative studies and Critical Appraisal Skills Programme (CASP) checklist for qualitative studies were used for quality assessment. The review followed a convergent integrated approach to data extraction and analysis, which involves extracting and analysing results of quantitative and qualitative studies at the same time using the same method. A data extraction form was adapted from Joanna-Briggs Institute (JBI) mixed-methods extraction form. Study author interpretation of quantitative data was summarised as qualitative statements which were coded together with primary qualitative data using NVIVO 12 software; codes were applied to each sentence in the findings, and were grouped into a hierarchical tree structure

Results

The systematic review included 62 papers (58 studies) discussing clinical and non-clinical factors influencing decisions to initiate OACs, the choice between warfarin and DOACs, and the choice between individual OACs. The balance of stroke and bleeding risks was the most influential when making the decision to initiate anticoagulation according to both patients and health professionals. Convenience-related factors, such as monitoring requirements, dosing regimens, and interactions impacted the choice between warfarin and DOACs, whereas, reversibility and dosing regimen influenced the choice between individual medications according to the views of both groups. Health professional specialty and years of experience affected all aspects of treatments, with specialists and senior clinicians more willing to initiate anticoagulation and choose DOACs. Even though health professionals often expressed that patient views were considered when deciding on a treatment, patients generally said that they followed their physician’s recommendations without questioning.

Conclusion

The review revealed similarities and differences across patient and professional views, experiences, and preferences of anticoagulation. The main discrepancies were related to the decision-making process, and whether patient views are being considered when prescribing. Combining quantitative and qualitative evidence helped explore a wide range of views of OAC and AF, however the review only included published research papers in English, which might have led to exclusion of valuable evidence. More research is needed to explore the factors driving the choice between OACs, especially the choice between individual DOACs.

References

1. Noseworthy PA, Brito JP, Kunneman M, Hargraves IG, Zeballos-Palacios C, Montori VM, Ting HH. Shared decision-making in atrial fibrillation: navigating complex issues in partnership with the patient. Journal of Interventional Cardiac Electrophysiology. 2019;56(2):159–163.

2. Loo, S.Y., Dell'Aniello, S., Huiart, L. and Renoux, C. Trends in the prescription of novel oral anticoagulants in UK primary care. British Journal of Clinical Pharmacology. 2017; 83(9): 2096–2106.

Opportunities to enhance ward audit: a multi-site qualitative study

BACKGROUND

Hospitals in many countries are encouraged to develop audits to assess and improve the quality of care. Ward audit is a specific form of audit and feedback that is commonly used but little studied. The aim of this study is to describe the content and application of hospital ward audit in order to identify potential enhancements to such audits.

METHODS

Multiple qualitative methods were used to study a diversity sample of four English National Health Service organisations over a 16-month period. We undertook semi-structured interviews (n = 32), documentary analysis (n = 44) and 25 h of observations of healthcare workers involved in the design and implementation of ward audit. Data were analysed using framework analysis. Findings were presented iteratively to stakeholders who used them to develop a description of the content and delivery of ward audit.

RESULTS

Ward audit consisted of seven stages: impetus; method; preparation of staff; assessing practice; analysis; feedback; and decide on action to improve. Two key stages were the monthly assessment of practice using case note data extraction, and the resulting feedback to clinical staff, ward managers, matrons and directors of nursing. At three organisations, the case note data were extracted by staff and there was evidence that this resulted in misrepresentation of the clinical performance audited. The misrepresentation appeared to be associated with the anticipation of punitive feedback from directors of nursing and matrons, as well as time pressures and a lack clarity about the method of audit data collection. Punitive feedback was reported to occur if no data were collected, if data demonstrated poor performance or if performance did not improve.

CONCLUSIONS

Organisations invest considerable clinical resources in ward audit, but such audits may have unintended, potentially negative, consequences due to the impacts from punitive feedback. We discuss potential enhancements to ward audit (e.g. providing feedback recipients with suggested actions for improvement) and discuss implications for theory. There is a need to reduce the use of punitive feedback.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions

BACKGROUND

Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process.

REVIEW QUESTION

What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD?

METHODS

A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements.

RESULTS

Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning.

CONCLUSION

Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts.

PATIENT INVOLVEMENT

Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

Patient experiences of the urgent cancer referral pathway-Can the NHS do better? Semi-structured interviews with patients with upper gastrointestinal cancer

Background

Timeliness is viewed as a key feature of health‐care quality. Internationally, this is challenging. In England, cancer waiting time targets are currently not being met. For example, between 2015 and 2018 only 71% of patients with upper gastrointestinal (UGI) cancer started treatment within the recommended 62 days of referral.

Objective

We explored patients’ experiences to identify areas for service improvement.

Design

Semi‐structured interviews were conducted.

Setting and participants

Twenty patients who were referred through the urgent (two‐week) GP referral route and were within six months of receiving first treatment were recruited.

Data analysis

Data from the interviews were analysed thematically.

Results

Four themes were developed: organization of care; diagnosis; support; and views and expectations of the NHS. Patients described cross‐cutting issues such as complex and varied pathways and uncertainty about what would happen next. They felt daunted by the intensity and speed of investigations. They were presented with a recommended course of action rather than options and had little involvement in decision making. They were grateful for care, reluctant to complain and resigned to the status quo.

Discussion and conclusions

In order to meet patient needs, the NHS needs to improve communication and streamline pathways. Future cancer pathways also need to be designed to support shared decision making, be truly person‐centred and informed by patient experience.

The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study

Background

Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing.

Objective

This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients.

Methods

A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher’s exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively.

Results

The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66).

Conclusion

In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.

Shared decision-making for ICDs: a regional collaborative initiative

The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision- making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.

Interventions to reduce inequalities in avoidable hospital admissions: explanatory framework and systematic review protocol

INTRODUCTION

Internationally there is pressure to contain costs due to rising numbers of hospital admissions. Alongside age, socioeconomic disadvantage is the strongest risk factor for avoidable hospital admission. This equity-focussed systematic review is required for policymakers to understand what has been shown to work to reduce inequalities in hospital admissions, what does not work and where the current gaps in the evidence-base are.

METHODS AND ANALYSIS

An initial framework shows how interventions are hypothesised to reduce socioeconomic inequalities in avoidable hospital admissions. Studies will be included if the intervention focusses exclusively on socioeconomically disadvantaged populations or if the study reports differential effects by socioeconomic status (education, income, occupation, social class, deprivation, poverty or an area-based proxy for deprivation derived from place of residence) with respect to hospital admission or readmission (overall or condition-specific for those classified as ambulatory care sensitive). Studies involving individuals of any age, undertaken in OECD (Organisation for Economic Co-operation and Development) countries, published from 2000 to 29^th February 2020 in any language will be included. Electronic searches will include MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform. Electronic searches will be supplemented with full citation searches of included studies, website searches and retrieval of relevant unpublished information. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Narrative synthesis will be conducted and also meta-analysis where possible. The main analysis will examine the effectiveness of interventions at reducing socioeconomic inequalities in hospital admissions. Interventions will be characterised by their domain of action and approach to addressing inequalities. For included studies, contextual information on where, for whom and how these interventions are organised, implemented and delivered will be examined where possible.

ETHICS AND DISSEMINATION

Ethical approval was not required for this protocol. The research will be disseminated via peer-reviewed publication, conferences and an open-access policy-orientated paper.

PROSPERO REGISTRATION NUMBER

CRD42019153666.

Impetus to change: a multi-site qualitative exploration of the national audit of dementia

BACKGROUND

National audit is a key strategy used to improve care for patients with dementia. Audit and feedback has been shown to be effective, but with variation in how much it improves care. Both evidence and theory identify active ingredients associated with effectiveness of audit and feedback. It is unclear to what extent national audit is consistent with evidence- and theory-based audit and feedback best practice.

METHODS

We explored how the national audit of dementia is undertaken in order to identify opportunities to enhance its impact upon the improvement of care for people with dementia. We undertook a multi-method qualitative exploration of the national audit of dementia at six hospitals within four diverse English National Health Service organisations. Inductive framework analysis of 32 semi-structured interviews, documentary analysis (n = 39) and 44 h of observations (n = 36) was undertaken. Findings were presented iteratively to a stakeholder group until a stable description of the audit and feedback process was produced.

RESULTS

Each organisation invested considerable resources in the audit. The audit results were dependent upon the interpretation by case note reviewers who extracted the data. The national report was read by a small number of people in each organisation, who translated it into an internal report and action plan. The internal report was presented at specialty- and organisation-level committees. The internal report did not include information that was important to how committee members collectively decided whether and how to improve performance. Participants reported that the national audit findings may not reach clinicians who were not part of the specialty or organisation-level committees.

CONCLUSIONS

There is considerable organisational commitment to the national audit of dementia. We describe potential evidence- and theory-informed enhancements to the enactment of the audit to improve the local response to performance feedback in the national audit. The enhancements relate to the content and delivery of the feedback from the national audit provider, support for the clinicians leading the organisational response to the feedback, and the feedback provided within the organisation.

The Evidence-Based Development of an Intervention to Improve Clinical Health Literacy Practice

Low health literacy is an issue with high prevalence in the UK and internationally. It has a social gradient with higher prevalence in lower social groups and is linked with higher rates of long-term health conditions, lower self-rated health, and greater difficulty self-managing long-term health conditions. Improved medical services and practitioner awareness of a patient's health literacy can help to address these issues. An intervention was developed to improve General Practitioner and Practice Nurse health literacy skills and practice. A feasibility study was undertaken to examine and improve the elements of the intervention. The intervention had two parts: educating primary care doctors and nurses about identifying and enhancing health literacy (patient capacity to get hold of, understand and apply information for health) to improve their health literacy practice, and implementation of on-screen 'pop-up' notifications that alerted General Practitioners (GPs) and nurses when seeing a patient at risk of low health literacy. Rapid reviews of the literature were undertaken to optimise the intervention. Four General Practices were recruited, and the intervention was then applied to doctors and nurses through training followed by alerts via the practice clinical IT system. After the intervention, focus groups were held with participating practitioners and a patient and carer group to further develop the intervention. The rapid literature reviews identified (i) key elements for effectiveness of doctors and nurse training including multi-component training, role-play, learner reflection, and identification of barriers to changing practice and (ii) key elements for effectiveness of alerts on clinical computer systems including 'stand-alone' notification, automatically generated and prominent display of advice, linkage with practitioner education, and use of notifications within a targeted environment. The findings from the post-hoc focus groups indicated that practitioner awareness and skills had improved as a result of the training and that the clinical alerts reminded them to incorporate this into their clinical practice. Suggested improvements to the training included more information on health literacy and how the clinical alerts were generated, and more practical role playing including initiating discussions on health literacy with patients. It was suggested that the wording of the clinical alert be improved to emphasise its purpose in improving practitioner skills. The feasibility study improved the intervention, increasing its potential usefulness and acceptability in clinical practice. Future studies will explore the impact on clinical care through a pilot and a randomised controlled trial.

Inequalities in rural communities: adapting national deprivation indices for rural settings

Background

Deprivation indices have been widely used in healthcare research and planning in the United Kingdom. Existing indices, however, are dominated by characteristics of urban populations that may be less relevant in capturing the nature of rural deprivation. We explore if deprivation indices can be modified to make them more sensitive to displaying rural disadvantage in England.

Methods

The analysis focussed on the 2011 Carstairs Index (Carstairs2011) and the 2010 English Index of Multiple Deprivation (IMD2010). We removed all urban areas as identified by the Office for National Statistics Rural–Urban Area Classifications and mapped the Carstairs2011 and IMD2010 across the remaining rural areas using rural-specific quintiles.

Results

Our method was effective in displaying much greater heterogeneity in rural areas than was apparent in the original indices. We received positive feedback from Directors of Public Health who confirmed that the observed patterns mirror their experiences and first-hand knowledge on the ground.

Conclusions

Our maps of Carstairs2011 and IMD2010 for rural areas might strengthen the evidence base for rural planning and service provision. The modified deprivation indices, however, were not specifically formulated for rural populations and further work is needed to explore alternative input variables to produce a more rural-specific measure of deprivation.

Are Patient Decision Aids Used in Clinical Practice after Rigorous Evaluation? A Survey of Trial Authors

Background. Patient decision aids (PtDAs) are effective interventions to support patient involvement in health care decisions, but there is little use in practice. Our study aimed to determine subsequent PtDA use in clinical practice following published randomized controlled trials. Design. A descriptive study using an e-mail-embedded questionnaire survey targeting authors of 133 trials included in Cochrane Reviews of PtDAs (106 authors). We classified PtDA level of use as a) implementation, defined as integrating within care processes; b) dissemination to target users with planned strategies; and c) diffusion, defined as passive, unplanned spread. We conducted content analysis to identify barriers and enablers guided by the Ottawa Model of Research Use. Results. Ninety-eight authors responded (92.5%) on 108 trialed PtDAs. Reported levels of use were implementation (n = 29; 28%), dissemination to target user(s) (n = 9; 9%), and diffusion (n = 7; 7%); 57 (55%) reported no uptake, and 1 had no response (1%). Barriers to use in clinical practice were identified at the level of researchers (e.g., lack of posttrial plan), PtDAs (e.g., outdated, delivery mechanism), clinicians (e.g., disagreed with PtDA use), and practice environment (e.g., infrastructure support; funding). Enablers were online delivery, organizational endorsement (e.g., professional organization, charity, government), and design for and integration into the care process. Limitations. Self-report bias and potential for recall bias. Conclusions. Only 44% of PtDA trial authors indicated some level of subsequent use following their trial. The most commonly reported barriers were lack of funding, outdated PtDAs, and clinician disagreement with PtDA use. To improve subsequent use, researchers should codesign PtDAs with end users to ensure fit with clinical practice and develop an implementation plan. National systems (e.g., platforms, endorsement, funding) can enable use.

"About sixty per cent I want to do it": Health researchers' attitudes to, and experiences of, patient and public involvement (PPI)-A qualitative interview study

Background

Funders, policy‐makers and research organizations increasingly expect health researchers in the UK to involve patients and members of the public in research. It has been stated that it makes research “more effective, more credible and often more cost efficient.” However, the evidence base for this assertion is evolving and can be limited. There has been little research into how health researchers feel about involving people, how they go about it, how they manage formal policy rhetoric, and what happens in practice.

Objective

To explore researchers’ experiences and perceptions of patient and public involvement (PPI).

Methods

Semi‐structured interview study of 36 health researchers (both clinical and non‐clinical), with data collection and thematic analysis informed by the theoretical domains framework.

Results

In the course of our analysis, we developed four themes that encapsulate the participants’ experiences and perceptions of PPI. Participants expressed ambivalence, cynicism and enthusiasm about PPI, an activity that creates emotional labour, which is both rewarding and burdensome and requires practical and social support. It is operationalized in an academic context influenced by power and incentives.

Discussion and conclusions

Researchers’ experiences and attitudes towards patient and public involvement are a key factor in the successful embedding of involvement within the wider research culture. We call for a culture change that supports the development of effective organizational approach to support involvement.

Equestrian-related injuries, predictors of fatalities, and the impact on the public health system in Sweden

OBJECTIVES

Horse riding is a popular activity but has also been found to lead to many injuries and even fatalities. No reduction in the numbers of those being admitted to hospital for equestrian-related injuries have been seen in Sweden in recent years. The aim of this work was to examine injuries, fatalities, and predictors of fatalities in equestrian-related activities and to investigate the cost of these injuries to the public health system.

STUDY DESIGN

The study is a retrospective analysis of hospital data.

METHODS

National Swedish hospital and mortality registers were retrospectively examined, inclusive of the years 1997-2014. Logistic regression was used to examine the predictors of fatal injuries, and cost of hospital treatment was considered.

RESULTS

Over the study period, there were an observed 29,850 injured cases and 51 fatalities. Women comprized almost 90% of those injured and 70% of fatalities. The average age was 26.8 years (range 0-91, standard deviation [SD] = 16.1) for injured and 43 years (range 7-78 years, SD = 20.5) for fatal cases. Men dominated both injured and fatal samples in the older age ranges (Fatal: >50 years; Injured: >70 years), although overall numbers were small. Injuries to the head contributed more than any other body region for both injured and fatal cases, and fractures were the most frequently seen injury type. A chi-squared analysis confirmed that injury type and injured body region were not independent of age. Logistic regression examining the association between fatality and age, gender, home region, and year of injury, indicating trends over time, found that there was an increase of 5.1% in the odds of fatality for every year increase in age of the patient and men had 2.2 times higher odds to be in the fatal sample than women. The conservative estimated cost of injury was 1800 Euro per injury event, equating to over 3 million Euro per year.

CONCLUSION

Equestrian-related injury events present a major public health concern. Observed decreases in fatalities suggest improved health care, yet head injury and fatality rates are still high, indicating a need for further intervention. The type of injury changes with the age group, and a better understanding of injury patterns with age is needed to identify protective measures for the different user groups.

Validation of the Arabic version of the Social Communication Questionnaire

Validated screening and diagnostic tools for autism spectrum disorder for use in Arabic-speaking individuals are scarce. This study validated the Arabic version of the Social Communication Questionnaire. The total study sample included 206 children with autism spectrum disorder and 206 typically developing children (73.8% male; mean age: 8.5 (standard deviation = 2.6) years). The mean Social Communication Questionnaire total score was significantly higher in autism spectrum disorder children than in typically developing children (p < 0.0001). Scores on the three Social Communication Questionnaire subscales also differed significantly between the groups (p < 0.001). Of the 39 items, 37 were endorsed significantly more often in the autism spectrum disorder group. The total Social Communication Questionnaire score did not vary by age or gender. Internal consistency was excellent (alpha = 0.92). In the receiver operating characteristic analysis, the area under the curve for the total score showed excellent discrimination between autism spectrum disorder and typically developing children (area under the curve = 0.95; 95% confidence interval: 0.93–0.97). The areas under the curve for the scale subscores were 0.923 (95% confidence interval: 0.898–0.949) for the social interaction score, 0.872 (95% confidence interval: 0.838–0.905) for the communication score, and 0.856 (95% confidence interval: 0.819–0.893) for the repetitive behaviors score. The findings support the use of the Arabic Social Communication Questionnaire to successfully differentiate children with clinically diagnosed autism spectrum disorder using the established cutoff value for the English version.

2178. Detection of Key Potential Healthcare Pathogens Using Periodic Point Prevalence Surveillance

Background

Surveillance for asymptomatic carriage of multidrug-resistant (MDR) pathogens is useful to determine the burden of these organisms and help guide infection prevention strategy. We currently perform surveillance cultures for Gram-negative multidrug-resistant pathogens (GNMDR) in the ICUs on a monthly basis. We added a quarterly point prevalence survey to all hospital units for these and other key pathogens over one year to determine whether our program should expand beyond the ICU and include other organisms.

Methods

Rectal samples were collected quarterly for 1 year starting June 2016 at NorthShore University HealthSystem, a four-hospital, 789 bed system. All hospitalized patients present on the day of the point prevalence testing had a double-headed rectal swab collected. One swab was plated to VACC agar (Remel) for culture of GNMDR and VRE, and the second was plated to CCFAHT (Anaerobe Systems) for C. difficile (Cdif) culture. All samples were collected on a specified day at each of our 4 hospitals, one hospital per week, and sent to the central microbiology lab for processing. Testing for GNMDR included the following pathogens: Carbapenem-resistant Enterobacteriaceae (CRE), ESBLs, and Gram negative organisms susceptible to ≤2 drug classes.

Results

A total of 987 surveillance samples were collected. The number of patients with MDR in the ICU vs. non-ICU units is described in Table 1. There was an 11% greater difference in the percentage of patients colonized with GNMDR and Cdif in non-ICU patients compared with ICU patients (P = 0.006). An important discovery was three patients colonized with CRE outside the ICU that were previously unknown. The burden of ESBL, VRE and Cdif carriage was also greater outside the ICU.

Conclusion

The point prevalence surveillance uncovered a significant amount of MDRs in our non-ICU units, particularly three CREs that were previously unknown. These results suggest there is a large burden of MDR organisms outside the ICU.

Disclosures

All authors: No reported disclosures.

2407. Emerging Piperacillin/Tazobactam Resistance in Escherichia coli and Klebsiella sp

Background

Piperacillin / tazobactam (P/T) plays an important role in the empirical therapy of many infections. While Enterobacteraciae resistance to P/T remains relatively low in our institution we have identified an increasing number of E. coli and Klebsiella sp. isolates with intermediate susceptibility or resistance to P/T (P/T-R). We report the increasing prevalence of P/T-R among E. coli and Klebsiella sp., antimicrobial usage, and attempts to document the mechanism of resistance in these isolates.

Methods

Antimicrobial susceptibility results using Kirby Bauer disk diffusion method for E. coli and Klebsiella sp. from all clinical sites (hospitalized patients) were reviewed from January 2006 through December 2016. Duplicates were excluded. Antimicrobial use was expressed as the number of hospital days on antimicrobials per 1000 hospital days. Whole genome sequencing was performed on a subset of isolates identified as P/T-R in order to identify a mechanism of resistance.

Results

From 2006 through 2016 we identified 126,422 E. coli and Klebsiella sp. isolates; 978 were P/T-R (0.78%). Of these 336 were extended spectrum β lactamase (ESBL) producers. Of the 642 non ESBL- P/T-R, 179 (27.8%) retained susceptibility to all cephalosporins tested. Figure 1 shows the distribution of P/T-R isolates and total antibiotic and P/T use in hospitalized patients. Whole genome sequencing of 4 isolates (K. pneumoniae from blood; n = 3 and E. coli from urine; n = 1) showed the presence of Class A β-lactamase genes; SHV (n = 3) and TEM (n = 1). All isolates showed the presence genes for outer membrane porins and protein efflux pumps; however, there were no detectable mutations that could explain the phenotypic susceptibility profile seen in these isolates.

Conclusion

We describe a novel phenotypic resistance pattern to P/T in E. coli and Klebsiella sp. which doubled in incidence from 2013 to 2016. This is concurrent with increasing P/T and overall antimicrobial use during the same time period. While a porin mutation has been described in similar strains, we have not been able to demonstrate this mechanism of resistance to date. Clinicians should be aware of this emerging resistance pattern when prescribing empiric antimicrobials.

Disclosures

All authors: No reported disclosures.

A New Era in Pathology Consultation: The MyPathologist Electronic Consultation Tool

Pathologists and laboratory scientists provide valuable guidance on laboratory utilization, test ordering, interpretation, and quality control provided that clinical staff can easily access the laboratory team. To encourage consultation between clinicians with laboratory scientists and pathologists, we developed an easily accessible electronic tool termed "MyPathologist," placed on the homepage of our electronic health record system. Over its 2-year pilot, utilization of this consultation tool climbed as we continued to publicize it and incorporated education into housestaff onboarding and electronic health record training. Physician satisfaction with the tool was high. Additionally, this became the primary source of consults to our residency call service. Evaluation of MyPathologist questions received during its pilot period showed that more than half the questions were of significant educational value to the residents, often focusing on results interpretation, appropriate test ordering, and quality control. MyPathologist is a novel electronic tool for pathology consultation within our electronic health record and also represents an avenue for educating residents, improving utilization of the laboratory, and improving patient care.

Interventions for increasing the use of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review.

OBJECTIVES

To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs.

AUTHORS' CONCLUSIONS

It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Standards for UNiversal reporting of patient Decision Aid Evaluation studies: the development of SUNDAE Checklist

BACKGROUND

Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs.

METHODS

An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three in-person meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist.

RESULTS

The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/117 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies.

CONCLUSION

The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist.

Explanation and elaboration of the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) guidelines: examples of reporting SUNDAE items from patient decision aid evaluation literature

This Explanation and Elaboration (E&E) article expands on the 26 items in the Standards for UNiversal reporting of Decision Aid Evaluations guidelines. The E&E provides a rationale for each item and includes examples for how each item has been reported in published papers evaluating patient decision aids. The E&E focuses on items key to reporting studies evaluating patient decision aids and is intended to be illustrative rather than restrictive. Authors and reviewers may wish to use the E&E broadly to inform structuring of patient decision aid evaluation reports, or use it as a reference to obtain details about how to report individual checklist items.