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Islam S, Bangdiwala SI. Accounting for center-level effects in multicenter randomized controlled trials. Trials 2024; 25:390. [PMID: 38886750 PMCID: PMC11184780 DOI: 10.1186/s13063-024-08202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
Investigators often conduct randomized controlled trials (RCTs) at multiple centers/sites when determining the effect of a treatment or an intervention. Diversifying recruitment across multiple institutions allows investigators to make recruitment go faster within a shorter timeframe and allows generalizing the study results across diverse populations. Despite having a common study protocol across multiple centers, the eligible participants may be heterogeneous, site policies and practices may vary, and the investigators' experience, training, and expertise may also vary across sites. These factors may contribute to the heterogeneity in effect estimates across centers. As a result, we usually observe some degree of heterogeneity in effect estimates across centers, despite all centers following the same study protocol. During the analysis of such a trial, investigators typically ignore center effects, but some have suggested considering centers as fixed or random effects in the model. It is not clear how considering the effects of centers, either as fixed or random effects, impacts the test of the primary hypothesis. In this article, we first review the practice of accounting for center effects in the analyses of published RCTs and illustrate the extent of heterogeneity observed in a few preexisting multicenter RCTs. To determine the impact of heterogeneity on the test of a primary hypothesis of an RCT, we considered continuous and binary outcomes and the corresponding appropriate model, namely, a simple linear regression model for a continuous outcome and a logistic regression model for the binary outcome. For each model type, we considered three methods: (a) ignore the center effect, (b) account for centers as fixed effects, or (c) account for centers as random effects. Based on simulation studies of these models, we then examine whether considering the center as a fixed or random effect in the model helps to preserve or reduce the type I and type II error rates during the analysis phase of an RCT. Finally, we outline the threshold at which center-level effects are negligible and thus negligible and provide recommendations on when it may be necessary to account for center effects during the analyses of multicenter randomized controlled trials.
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Affiliation(s)
- Shofiqul Islam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Shrikant I Bangdiwala
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Statistics, Population Health Research Institute, Hamilton, Canada
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2
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Ofori S, Rayner D, Mikhail D, Borges FK, Marcucci MM, Conen D, Mbuagbaw L, Devereaux PJ. Barriers and facilitators to perioperative smoking cessation: A scoping review. PLoS One 2024; 19:e0298233. [PMID: 38861527 PMCID: PMC11166293 DOI: 10.1371/journal.pone.0298233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 01/19/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVE Smoking cessation interventions are underutilized in the surgical setting. We aimed to systematically identify the barriers and facilitators to smoking cessation in the surgical setting. METHODS Following the Joanna Briggs Institute (JBI) framework for scoping reviews, we searched 5 databases (MEDLINE, Embase, Cochrane CENTRAL, CINAHL, and PsycINFO) for quantitative or qualitative studies published in English (since 2000) evaluating barriers and facilitators to perioperative smoking cessation interventions. Data were analyzed using thematic analysis and mapped to the theoretical domains framework (TDF). RESULTS From 31 studies, we identified 23 unique barriers and 13 facilitators mapped to 11 of the 14 TDF domains. The barriers were within the domains of knowledge (e.g., inadequate knowledge of smoking cessation interventions) in 23 (74.2%) studies; environmental context and resources (e.g., lack of time to deliver smoking cessation interventions) in 19 (61.3%) studies; beliefs about capabilities (e.g., belief that patients are nervous about surgery/diagnosis) in 14 (45.2%) studies; and social/professional role and identity (e.g., surgeons do not believe it is their role to provide smoking cessation interventions) in 8 (25.8%) studies. Facilitators were mainly within the domains of environmental context and resources (e.g., provision of quit smoking advice as routine surgical care) in 15 (48.4%) studies, reinforcement (e.g., surgery itself as a motivator to kickstart quit attempts) in 8 (25.8%) studies, and skills (e.g., smoking cessation training and awareness of guidelines) in 5 (16.2%) studies. CONCLUSION The identified barriers and facilitators are actionable targets for future studies aimed at translating evidence informed smoking cessation interventions into practice in perioperative settings. More research is needed to evaluate how targeting these barriers and facilitators will impact smoking outcomes.
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Affiliation(s)
- Sandra Ofori
- Department of Medicine, McMaster University Canada, Hamilton, Canada
| | - Daniel Rayner
- Department of Health Research Methods, Evidence and Impact, McMaster University Canada, Hamilton, Canada
| | - David Mikhail
- Department of Health Sciences, McMaster University Canada, Hamilton, Canada
| | - Flavia K. Borges
- Department of Medicine, McMaster University Canada, Hamilton, Canada
| | - Maura M. Marcucci
- Department of Medicine, McMaster University Canada, Hamilton, Canada
| | - David Conen
- Department of Medicine, McMaster University Canada, Hamilton, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - P. J. Devereaux
- Department of Medicine, McMaster University Canada, Hamilton, Canada
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Grygorian A, Montano D, Shojaa M, Ferencak M, Schmitz N. Digital Health Interventions and Patient Safety in Abdominal Surgery: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e248555. [PMID: 38669018 PMCID: PMC11053376 DOI: 10.1001/jamanetworkopen.2024.8555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/28/2024] [Indexed: 04/29/2024] Open
Abstract
Importance Over the past 2 decades, several digital technology applications have been used to improve clinical outcomes after abdominal surgery. The extent to which these telemedicine interventions are associated with improved patient safety outcomes has not been assessed in systematic and meta-analytic reviews. Objective To estimate the implications of telemedicine interventions for complication and readmission rates in a population of patients with abdominal surgery. Data Sources PubMed, Cochrane Library, and Web of Science databases were queried to identify relevant randomized clinical trials (RCTs) and nonrandomized studies published from inception through February 2023 that compared perioperative telemedicine interventions with conventional care and reported at least 1 patient safety outcome. Study Selection Two reviewers independently screened the titles and abstracts to exclude irrelevant studies as well as assessed the full-text articles for eligibility. After exclusions, 11 RCTs and 8 cohort studies were included in the systematic review and meta-analysis and 7 were included in the narrative review. Data Extraction and Synthesis Data were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline and assessed for risk of bias by 2 reviewers. Meta-analytic estimates were obtained in random-effects models. Main Outcomes and Measures Number of complications, emergency department (ED) visits, and readmissions. Results A total of 19 studies (11 RCTs and 8 cohort studies) with 10 536 patients were included. The pooled risk ratio (RR) estimates associated with ED visits (RR, 0.78; 95% CI, 0.65-0.94) and readmissions (RR, 0.67; 95% CI, 0.58-0.78) favored the telemedicine group. There was no significant difference in the risk of complications between patients in the telemedicine and conventional care groups (RR, 1.05; 95% CI, 0.77-1.43). Conclusions and Relevance Findings of this systematic review and meta-analysis suggest that perioperative telehealth interventions are associated with reduced risk of readmissions and ED visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.
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Affiliation(s)
- Artem Grygorian
- Faculty of Medicine, Department of Population-Based Medicine, Tuebingen University, Tuebingen, Germany
| | - Diego Montano
- Faculty of Medicine, Department of Population-Based Medicine, Tuebingen University, Tuebingen, Germany
| | - Mahdieh Shojaa
- Faculty of Medicine, Department of Population-Based Medicine, Tuebingen University, Tuebingen, Germany
| | - Maximilian Ferencak
- Faculty of Medicine, Department of Population-Based Medicine, Tuebingen University, Tuebingen, Germany
| | - Norbert Schmitz
- Faculty of Medicine, Department of Population-Based Medicine, Tuebingen University, Tuebingen, Germany
- Faculty of Medicine, Department of Psychiatry, McGill University, Montreal, Québec, Canada
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4
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Ip VHY, Uppal V, Kwofie K, Shah U, Wong PBY. Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations. Can J Anaesth 2024:10.1007/s12630-024-02699-0. [PMID: 38504037 DOI: 10.1007/s12630-024-02699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.
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Affiliation(s)
- Vivian H Y Ip
- Department of Anesthesia, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ushma Shah
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
| | - Patrick B Y Wong
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 501 Smyth Rd, CCW 1401, Ottawa, ON, K1H 8L6, Canada.
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Sadri H, Fraser ND. The role of innovative technologies in reducing health system inequity. Healthc Manage Forum 2024; 37:101-107. [PMID: 37861228 DOI: 10.1177/08404704231207509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
The scarcity of Health Human Resources (HHR), regional disparities, and decentralized healthcare systems have profoundly affected health equity in Canada. Adequate HHR allocation is essential for equitable healthcare delivery, and the COVID-19 pandemic has revealed the importance of resilient and culturally diverse organizational HHR. Geography and infrastructure shortcomings aggravate healthcare equity. This study examines the role of innovative technologies in reducing inequity and provides four practice-based examples in different therapeutic areas. Long-term solutions such as collaborative networks, infrastructure improvements, and effective HHR planning can mitigate current challenges. However, in the short and medium terms, advanced medical technologies, digital health, and artificial intelligence can reduce health inequities by improving access, reducing disparities, optimizing resource utilization, and providing skill development opportunities for healthcare professionals.
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Affiliation(s)
| | - Neil D Fraser
- Independent MedTech Consultant, Toronto, Ontario, Canada
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Pham C, Poorzargar K, Panesar D, Lee K, Wong J, Parotto M, Chung F. Video plethysmography for contactless blood pressure and heart rate measurement in perioperative care. J Clin Monit Comput 2024; 38:121-130. [PMID: 37715858 DOI: 10.1007/s10877-023-01074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/30/2023] [Indexed: 09/18/2023]
Abstract
The purpose of this study was to evaluate the feasibility and accuracy of remote Video Plethysmography (VPPG) for contactless measurements of blood pressure (BP) and heart rate (HR) in adult surgical patients in a hospital setting. An iPad Pro was used to record a 1.5-minute facial video of the participant's face and VPPG was used to extract vital signs measurements. A standard medical device (Welch Allyn) was used for comparison to measure BP and HR. Trial registration: NCT05165381. Two-hundred-sixteen participants consented and completed the contactless BP and HR monitoring (mean age 54.1 ± 16.8 years, 58% male). The consent rate was 75% and VPPG was 99% successful in capturing BP and HR. VPPG predicted SBP, DBP, and HR with a measurement bias ± SD, -8.18 ± 16.44 mmHg, - 6.65 ± 9.59 mmHg, 0.09 ± 6.47 beats/min respectively. Pearson's correlation for all measurements between VPPG and standard medical device was significant. Correlation for SBP was moderate (0.48), DBP was weak (0.29), and HR was strong (0.85). Most patients were satisfied with the non-contact technology with an average rating of 8.7/10 and would recommend it for clinical use. VPPG was highly accurate in measuring HR, and is currently not accurate in measuring BP in surgical patients. The VPPG BP algorithm showed limitations in capturing individual variations in blood pressure, highlighting the need for further improvements to render it clinically effective across all ranges. Contactless vital signs monitoring was well-received and earned a high satisfaction score.
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Affiliation(s)
- Chi Pham
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Khashayar Poorzargar
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Darshan Panesar
- Ontario Institute for Studies in Education, University of Toronto, Toronto, ON, Canada
| | - Kang Lee
- Ontario Institute for Studies in Education, University of Toronto, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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7
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Tabja Bortesi JP, Ranisau J, Di S, McGillion M, Rosella L, Johnson A, Devereaux PJ, Petch J. Machine Learning Approaches for the Image-Based Identification of Surgical Wound Infections: Scoping Review. J Med Internet Res 2024; 26:e52880. [PMID: 38236623 PMCID: PMC10835585 DOI: 10.2196/52880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/09/2023] [Accepted: 12/12/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Surgical site infections (SSIs) occur frequently and impact patients and health care systems. Remote surveillance of surgical wounds is currently limited by the need for manual assessment by clinicians. Machine learning (ML)-based methods have recently been used to address various aspects of the postoperative wound healing process and may be used to improve the scalability and cost-effectiveness of remote surgical wound assessment. OBJECTIVE The objective of this review was to provide an overview of the ML methods that have been used to identify surgical wound infections from images. METHODS We conducted a scoping review of ML approaches for visual detection of SSIs following the JBI (Joanna Briggs Institute) methodology. Reports of participants in any postoperative context focusing on identification of surgical wound infections were included. Studies that did not address SSI identification, surgical wounds, or did not use image or video data were excluded. We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science Core Collection, IEEE Xplore, Compendex, and arXiv for relevant studies in November 2022. The records retrieved were double screened for eligibility. A data extraction tool was used to chart the relevant data, which was described narratively and presented using tables. Employment of TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guidelines was evaluated and PROBAST (Prediction Model Risk of Bias Assessment Tool) was used to assess risk of bias (RoB). RESULTS In total, 10 of the 715 unique records screened met the eligibility criteria. In these studies, the clinical contexts and surgical procedures were diverse. All papers developed diagnostic models, though none performed external validation. Both traditional ML and deep learning methods were used to identify SSIs from mostly color images, and the volume of images used ranged from under 50 to thousands. Further, 10 TRIPOD items were reported in at least 4 studies, though 15 items were reported in fewer than 4 studies. PROBAST assessment led to 9 studies being identified as having an overall high RoB, with 1 study having overall unclear RoB. CONCLUSIONS Research on the image-based identification of surgical wound infections using ML remains novel, and there is a need for standardized reporting. Limitations related to variability in image capture, model building, and data sources should be addressed in the future.
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Affiliation(s)
| | - Jonathan Ranisau
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shuang Di
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Laura Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada
| | - Jeremy Petch
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, McMaster University, Hamilton, ON, Canada
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Leinum LR, Baandrup AO, Gögenur I, Krogsgaard M, Azawi N. Digitizing fluid balance monitoring may offer a solution for optimizing patient care. Technol Health Care 2024; 32:1111-1122. [PMID: 37781831 DOI: 10.3233/thc-230664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Precise fluid balance monitoring is essential for patient treatment, as incorrect fluid balance can lead to disorders. OBJECTIVE This study aimed to assess the accuracy of the digital technology LICENSE (LIquid balanCE moNitoring SystEm) for fluid balance charting and compare it to the standard method (SM) to determine its usability in clinical practice. METHODS This prospective study included 20 patients. The results from LICENSE were compared to those from SM and a reference measurement (manual weight of fluids, RM). Three LICENSE devices were used for urine output, intravenous fluids, and oral fluid intake. The accuracy of methods was evaluated using Bland Altman plots. RESULTS The mean difference between LICENSE and RM was less than 2 millilitres (p= 0.031 and p= 0.047), whereas the mean difference between SM and RM was 6.6 ml and 10.8 ml (p< 0.0001). The range between the upper and lower limits of agreement was between 16.4 and 27.8 ml for LICENSE measurements and 25.2 and 52 ml for SM. CONCLUSION LICENSE is comparable to or more accurate than the standard method for fluid balance monitoring. The use of LICENSE may improve the accuracy of fluid balance measurements. Further research is needed to evaluate its feasibility in daily clinical practice.
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Affiliation(s)
- Lisbeth R Leinum
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anders O Baandrup
- Department of Radiology, Zealand University Hospital, Roskilde, Denmark
| | - Ismail Gögenur
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | | | - Nessn Azawi
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Hladkowicz E, Auais M, Kidd G, McIsaac DI, Miller J. "I can't imagine having to do it on your own": a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty. BMC Geriatr 2023; 23:848. [PMID: 38093180 PMCID: PMC10716948 DOI: 10.1186/s12877-023-04576-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Adults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care. OBJECTIVE To explore what is important to older adults with frailty during a postoperative transition in care. METHODS This qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis. RESULTS Five themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes. CONCLUSION Future programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.
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Affiliation(s)
- Emily Hladkowicz
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada.
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Canada.
| | - Mohammad Auais
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Gurlavine Kidd
- Patient Engagement in Research Activities, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Canada
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada
| | - Jordan Miller
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
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Aasvang EK, Meyhoff CS. The future of postoperative vital sign monitoring in general wards: improving patient safety through continuous artificial intelligence-enabled alert formation and reduction. Curr Opin Anaesthesiol 2023; 36:683-690. [PMID: 37865847 DOI: 10.1097/aco.0000000000001319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE Monitoring of vital signs at the general ward with continuous assessments aided by artificial intelligence (AI) is increasingly being explored in the clinical setting. This review aims to describe current evidence for continuous vital sign monitoring (CVSM) with AI-based alerts - from sensor technology, through alert reduction, impact on complications, and to user-experience during implementation. RECENT FINDINGS CVSM identifies significantly more vital sign deviations than manual intermittent monitoring. This results in high alert generation without AI-evaluation, both in patients with and without complications. Current AI is at the rule-based level, and this potentially reduces irrelevant alerts and identifies patients at need. AI-aided CVSM identifies complications earlier with reduced staff workload and a potential reduction of severe complications. SUMMARY The current evidence for AI-aided CSVM suggest a significant role for the technology in reducing the constant 10-30% in-hospital risk of severe postoperative complications. However, large, randomized trials documenting the benefit for patient improvements are still sparse. And the clinical uptake of explainable AI to improve implementation needs investigation.
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Affiliation(s)
- Eske K Aasvang
- Department of Anesthesia, Center for Cancer and Organ dysfunction. Copenhagen University Hospital, Rigshospitalet
- Department of Clinical Medicine, University of Copenhagen
| | - Christian S Meyhoff
- Department of Clinical Medicine, University of Copenhagen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Slawaska-Eng D, Gazendam AM, Kendal J, Schneider P, Becker RG, Freitas JP, Bernthal N, Ghert M. Patient and Surgical Risk Factors for Surgical Site Infection in Lower-Extremity Oncological Endoprosthetic Reconstruction: A Secondary Analysis of the PARITY Trial Data. J Bone Joint Surg Am 2023; 105:41-48. [PMID: 37466579 DOI: 10.2106/jbjs.22.01135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The specific risk factors for surgical site infection (SSI) in orthopaedic oncology patients undergoing endoprosthetic reconstruction have not previously been evaluated in a large prospective cohort. In the current study, we aimed to define patient- and procedure-specific risk factors for SSI in patients who underwent surgical excision and endoprosthetic reconstruction for lower-extremity bone or soft-tissue tumors using the prospectively collected data of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. METHODS PARITY was a multicenter, blinded, randomized controlled trial with a parallel 2-arm design that aimed to determine the effect of a long duration (5 days) versus short duration (24 hours) of postoperative prophylactic antibiotics on the rate of SSI in patients undergoing surgical excision and endoprosthetic reconstruction of the femur or tibia. In this secondary analysis of the PARITY data, a multivariate Cox proportional hazards regression model was constructed to explore predictors of SSI within 1 year postoperatively. RESULTS A total of 96 (15.9%) of the 604 patients experienced an SSI. Of the 23 variables analyzed in the univariate analysis, 4 variables achieved significance: preoperative diagnosis, operative time, volume of muscle excised, and hospital length of stay (LOS). However, only hospital LOS was found to be independently predictive of SSI in the multivariate regression analysis (hazard ratio per day = 1.03; 95% confidence interval = 1.01 to 1.05; p < 0.001). An omnibus test of model coefficients demonstrated that the model showed significant improvement over the null model (χ2 = 78.04; p < 0.001). No multicollinearity was found. CONCLUSIONS This secondary analysis of the PARITY study data found that the only independent risk factor for SSI on multivariate analysis was hospital LOS. It may therefore be reasonable for clinicians to consider streamlined discharge plans for orthopaedic oncology patients to potentially reduce the risk of SSI. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Joseph Kendal
- University of California Los Angeles, Los Angeles, California
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12
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Blount E, Davey MG, Joyce WP. Patient reported satisfaction levels with the use of telemedicine for general surgery-A systematic review of randomized control trials. SURGERY IN PRACTICE AND SCIENCE 2023; 12:100152. [PMID: 36570642 PMCID: PMC9769022 DOI: 10.1016/j.sipas.2022.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background As healthcare continues to evolve in the wake of COVID-19 pandemic, surgeons are presented with the opportunity to integrate telemedicine into healthcare in tandem with in-person consultations. We aimed to perform a systematic review of randomized controlled trials to assess patient satisfaction with telemedicine interventions in general surgery. Methods A systematic review was performed in accordance to the PRISMA guidelines. Randomized control trials (RCTs) were included. The risk of bias 2.0 assessment was used to determine potential bias. Results In total, 11 prospective, randomized trials involving 1,598 patients (mean age: 49.1 years) were included. Overall 45.5% (5/11) of the trials compared videoconferencing or telephone follow up to traditional in person follow up. Three studies used smart technologies which include activity tracking devices in combination with a website and mobile application (27.3%). The other 3 interventions involved accelerated discharge on post operative day (POD) 1 with tele videoconferencing on POD 2, Post-operative daily text messages with education videos and video calling capability, and supportive text messages post-operatively. Telemedicine was shown to provide similar levels of patient satisfaction compared to controls in all 11 included RCTs. Conclusion Patient reported satisfaction with the use of telemedicine is similar to standard of care models in general surgery. With several shortcomings confounding the results in support of telemedicine, further experimentation with telemedicine interventions will likely improve patient reported satisfaction with using telemedicine for peroperative surgical care.
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Affiliation(s)
- Eoghan Blount
- Department of Surgery, Galway Clinic, Co. Galway H91 HHT0, Ireland
| | - Matthew G Davey
- Department of Surgery, Galway Clinic, Co. Galway H91 HHT0, Ireland
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
| | - William P Joyce
- Department of Surgery, Galway Clinic, Co. Galway H91 HHT0, Ireland
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
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13
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Keast T, Shelley B. Days alive and at home: refining the definition. Anaesthesia 2023; 78:266-267. [PMID: 36308283 DOI: 10.1111/anae.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 01/11/2023]
Affiliation(s)
- T Keast
- Golden Jubilee National Hospital, Clydebank, UK
| | - B Shelley
- Golden Jubilee National Hospital, Clydebank, UK
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14
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Chang LL, Devereaux PJ, Slobogean G. Choice of Admitting Services for Older Adults with Hip Fracture. N Engl J Med 2022; 387:2466-2468. [PMID: 36577105 DOI: 10.1056/nejmclde2118451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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15
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Ambulatory anesthesia and discharge: an update around guidelines and trends. Curr Opin Anaesthesiol 2022; 35:691-697. [PMID: 36194149 DOI: 10.1097/aco.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia. RECENT FINDINGS Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery. SUMMARY The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.
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16
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Bressman E, Long JA, Honig K, Zee J, McGlaughlin N, Jointer C, Asch DA, Burke RE, Morgan AU. Evaluation of an Automated Text Message-Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge. JAMA Netw Open 2022; 5:e2238293. [PMID: 36287564 PMCID: PMC9606844 DOI: 10.1001/jamanetworkopen.2022.38293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Posthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome. OBJECTIVE To determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had >1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021. EXPOSURE Patients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. MAIN OUTCOMES AND MEASURES The primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat. RESULTS A total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.
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Affiliation(s)
- Eric Bressman
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Judith A. Long
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Katherine Honig
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy McGlaughlin
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia
| | - Carlondra Jointer
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia
| | - David A. Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia
| | - Robert E. Burke
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Anna U. Morgan
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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17
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Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2113-2124. [PMID: 36151483 DOI: 10.1007/s00384-022-04256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals. METHODS Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines. RESULTS Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87). CONCLUSIONS Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions. TRIAL REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.
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Affiliation(s)
- Victoria Archer
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Zacharie Cloutier
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Annie Berg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
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18
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Kamecka K, Foti C, Gawiński Ł, Matejun M, Rybarczyk-Szwajkowska A, Kiljański M, Krochmalski M, Kozłowski R, Marczak M. Telemedicine Technologies Selection for the Posthospital Patient Care Process after Total Hip Arthroplasty. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11521. [PMID: 36141791 PMCID: PMC9517262 DOI: 10.3390/ijerph191811521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
For many years, the importance of using telematic technologies in medicine has been growing, especially in the period of the coronavirus pandemic, when direct contact and supervision of medical personnel over the patient is difficult. The existing possibilities of modern information and communication technologies (ICTs) are not fully used. The aim of the study is to identify the telemedicine technologies that can be used in future implementation projects of the posthospital patient care process after total hip arthroplasty (THA). The literature search is reported according to PRISMA 2020. The search strategy included databases and gray literature. In total, 28 articles (EMBASE, PubMed, PEDro) and 24 records from gray literature (Google Search and Technology presentations) were included in the research. This multi-source study analyzes the possibilities of using different technologies useful in the patient care process. The conducted research resulted in defining visual and wearable types of telemedicine technologies for the original posthospital patient care process after THA. As the needs of stakeholders in the posthospital patient care process after THA differ, the awareness of appropriate technologies selection, information flow, and its management importance are prerequisites for effective posthospital patient care with the use of telemedicine technologies.
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Affiliation(s)
- Karolina Kamecka
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland
| | - Calogero Foti
- Physical and Rehabilitation Medicine, Clinical Sciences and Translational Medicine Department, Tor Vergata University, 00133 Rome, Italy
| | - Łukasz Gawiński
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland
| | - Marek Matejun
- Department of Entrepreneurship and Industrial Policy, Faculty of Management, University of Lodz, 90-237 Lodz, Poland
| | | | - Marek Kiljański
- Polish Association of Physiotherapy Specialists, 95-200 Pabianice, Poland
- Medical Magnus Clinic, 90-552 Lodz, Poland
| | - Marek Krochmalski
- Medical Magnus Clinic, 90-552 Lodz, Poland
- Polish Muscles, Ligaments and Tendons Society, 90-552 Lodz, Poland
| | - Remigiusz Kozłowski
- Center of Security Technologies in Logistics, Faculty of Management, University of Lodz, 90-237 Lodz, Poland
| | - Michał Marczak
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland
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19
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Emery A, Houchens N, Gupta A. Quality and Safety in the Literature: May 2022. BMJ Qual Saf 2022; 31:409-414. [PMID: 35440499 DOI: 10.1136/bmjqs-2022-014848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Albert Emery
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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