Implementation of a performance improvement initiative in colorectal cancer care

Effect of wrist-ankle acupuncture therapy combined with auricular acupuncture on cancer pain: A four-parallel arm randomized controlled trial

BACKGROUND

Cancer pain affects the quality of life of cancer patients; therefore, various methods exist for alleviating the adverse effects caused by cancer pain. Nonpharmacological intervention is regarded as an important means of auxiliary therapy for drug treatment, with acupuncture receiving the most attention; However, there are numerous types of acupuncture therapies, including acupuncture, wrist-ankle acupuncture (WAA) and auricular acupuncture (AA). Previous studies have demonstrated that all types of acupuncture therapy can alleviate cancer pain. However, the effects and pathways of different acupuncture treatments are not similar, and it is unknown whether single therapy or combination therapy has better analgesic effects. This study aimed to examine the effect of WAA therapy combined with AA on cancer pain.

DESIGN

A randomized controlled trial.

METHOD

A total of 160 patients were selected and randomly divided into groups A, B, C and D, with 40 patients in each group. Group A received conventional analgesia alone, with opioids administered based on the World Health Organization (WHO) 3-tiered "cancer pain ladder". Group B received WAA, in addition to the treatment received by group A. Group C received AA, in addition to the treatment received by group A. Group D received WAA combined with AA, in addition to the treatment received by group A. Analgesic effects and analgesic drug use before and 3, 5 and 7 days after treatment were observed in each group.

RESULT

A total of 159 patients were included in the analysis. The verbal rating scale (VRS) and numeric rating scale (NRS) scores for patients who received mono-acupuncture therapy and combination therapy for 1 week were significantly different from those of the control group. Combination therapy had a stronger effect on the VRS score and a faster onset time, based on the NRS score, and the patients who received combination therapy had reduced analgesic drug use.

CONCLUSION

WAA combined with AA can more quickly reduce pain symptoms with more lasting analgesic effects and can effectively reduce analgesic drug use.

Compounded topical preparations in plaque psoriasis: Still a place for it in 2018?

Compounded topical preparations (CTP) were used to treat psoriasis until the last century and have disappeared from guidelines. The present authors report two severe psoriasis patients who were treated with CTP. A man had psoriasis with a PASI of 23 and a body surface area (BSA) of 43%. He had been using daily for several weeks a CTP including minoxidil, clobetasol propionate and hydroxyprogesterone formulated in an alcohol based vehicle. A woman suffered from psoriasis with an annular inflammatory pattern and a central healing. The PASI was 20 and the BSA was 30%. She had been using a CTP daily for 4 months including resorcinol, salicylic acid, 0.05% tretinoin cream, bethamethasone dipropionate cream. Until the 1970s, the dermatological textbooks recommended to treat severe psoriasis with CTP. Nowadays, CTP are considered outdated because of the large therapeutic armamentarium. The stability and benefit risks of the CTP used here were not documented. The use of CTP in psoriasis should be regulated and must be evidence based. Strict protocol and stability evaluation for preparations must be confirmed prior to compounding.

Identifying critical steps towards improved access to innovation in cancer care: a European CanCer Organisation position paper

In recent decades cancer care has seen improvements in the speed and accuracy of diagnostic procedures; the effectiveness of surgery, radiation therapy and medical treatments; the power of information technology; and the development of multidisciplinary, specialist-led approaches to care. Such innovations are essential if we are to continue improving the lives of cancer patients across Europe despite financial pressures on our healthcare systems. Investment in innovation must be balanced with the need to ensure the sustainability of healthcare budgets, and all health professionals have a responsibility to help achieve this balance. It requires scrutiny of the way care is delivered; we must be ready to discontinue practices or interventions that are inefficient, and prioritise innovations that may deliver the best outcomes possible for patients within the limits of available resources. Decisions on innovations should take into account their long-term impact on patient outcomes and costs, not just their immediate costs. Adopting a culture of innovation requires a multidisciplinary team approach, with the patient at the centre and an integral part of the team. It must take a whole-system and whole-patient perspective on cancer care and be guided by high-quality real-world data, including outcomes relevant to the patient and actual costs of care; this accurately reflects the impact of any innovation in clinical practice. The European CanCer Organisation is committed to working with its member societies, patient organisations and the cancer community at large to find sustainable ways to identify and integrate the most meaningful innovations into all aspects of cancer care.

Cancer pain: a review of epidemiology, clinical quality and value impact

Cancer-related pain, reported by more than 70% of patients, is one of the most common and troublesome symptoms affecting patients with cancer. Despite the availability of effective treatments, cancer-related pain may be inadequately controlled in up to 50% of patients. With the growing focus on ‘value’ (healthcare outcomes achieved per dollar spent) in healthcare, the management of cancer-related pain has assumed novel significance in recent years. Data from initiatives that assess the quality of pain management in clinical practice have shown that effective management of cancer-related pain improves patient-perceived value of cancer treatment. As a result, assessment and effective management of cancer-related pain are now recognized as important measures of value in cancer care.

Impact of a Performance Improvement CME activity on the care and treatment of patients with psoriasis

BACKGROUND

The Performance Improvement (PI) CME format improves physician performance in other specialties but data are lacking in dermatology.

OBJECTIVE

We sought to assess the impact of a PI CME activity on physician practice patterns for patients with psoriasis, which was developed, implemented, and evaluated by the American Academy of Dermatology (AAD), in part to assist dermatologists in fulfilling Part IV of their Maintenance of Certification requirements.

METHODS

In this PI CME activity, participants: (1) self-audited patient charts, which met inclusion criteria in stage A, and reflected on their results, benchmarked against peers; (2) reviewed educational materials in stage B and developed an improvement plan; and (3) self-audited a different set of patient charts following the plan's implementation. Aggregate stage A and C data were analyzed using χ(2) tests.

RESULTS

We found a statistically significant improvement in the advisement of patients with psoriasis regarding their increased risk for cardiovascular disease, to contact their primary care provider for cardiovascular risk assessment, and in shared decision making regarding the treatment plan. We also found an overall statistically significant improvement in history taking per the guidelines.

LIMITATIONS

Learner chart selection bias, self-reporting of chart data, and lack of a control group are limitations.

CONCLUSIONS

The AAD psoriasis PI CME activity demonstrated significantly improved dermatologists' documentation of patient's history, counseling of patients for lifestyle behaviors, and shared decision making.

Quality Improvement: An Assessment of Participation and Attitudes of Medical Oncologists

Canadian medical oncologists face limitations to participating in QI initiatives as a result of lack of time, publication resources, and knowledge about ongoing initiatives. Improving networking opportunities and prioritizing QI at the institutional level can address this need.

Estimating health care cost savings from an educational intervention to prevent bleeding-related complications: the outcomes impact analysis model

INTRODUCTION

Investments in continuing medical education (CME) exceed $2 billion annually, but few studies report the economic impact of CME activities. Analysis of patient-level economic outcomes data is often not feasible. Accordingly, we developed a model to illustrate estimation of the potential economic impact associated with CME activity outcomes.

METHODS

Outcomes impact analysis demonstrated how costs averted from a CME symposium that promoted prevention of bleeding-related complications (BRC) and reoperation for bleeding (RFB) in cardiac and thoracic operations could be estimated. Model parameter estimates were from published studies of costs associated with BRC and RFB. Operative volume estimates came from the Society of Thoracic Surgeons workforce data. The base case predicted 3 in 10 participants preventing one BRC or RFB in 2% or 1.5% of annual operations, respectively. Probabilistic sensitivity analysis (PSA) evaluated the effect of parameter uncertainty.

RESULTS

92% of participants (n = 133) self-reported commitment to change, a validated measure of behavior change. For BRC, estimates for costs averted were $1,502,769 (95% confidence interval [CI], $869,860-$2,359,068) for cardiac operations and $2,715,246 (95% CI, $1,590,308-$4,217,092) for thoracic operations. For RFB, the savings estimates were $2,233,988 (95% CI, $1,223,901-$3,648,719).

DISCUSSION

Our economic model demonstrates that application of CME-related learning to prevent bleeding complications may yield substantial cost savings. Model prediction of averted costs associated with CME allows estimation of the economic impact on outcomes in the absence of patient-level outcomes data related to CME activities.

Improving clinician performance of inpatient venous thromboembolism risk assessment and prophylaxis

Clinicians are aware of the importance of thromboprophylaxis, and that the application of measures to prevent venous thromboembolism (VTE) occurrence in hospitalized patients must be improved. To enhance clinician execution of appropriate steps to reduce the risk of inpatient VTE, a performance improvement (PI) continuing medical education (CME) initiative consisting of 3 independent tracks for hospitalized patients-patients who are medically ill, patients receiving oncology treatment, and patients undergoing major orthopedic surgery-was designed and implemented. After a baseline chart review of select evidenced-based performance measures for VTE risk stratification and prevention, participants identified ≥ 1 area of personal improvement. Participants then engaged in a period of self-improvement and reassessed their performance with a second chart review. After participating in the PI CME activity, clinician participants in the medically ill track increased their documentation of VTE risk assessments upon patient admission from baseline (56% vs 93%, n = 250; P < 0.001) and their prescription of low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux (72% vs 88%, n = 250; P < 0.001). Orthopedic-track participants were significantly more likely to prescribe 15 to 35 days of VTE prophylaxis after total hip arthroplasty or hip fracture surgery upon patient discharge compared with baseline (51%, n = 123 vs 61%, n = 107; P < 0.001). Oncology-track participants demonstrated a nonsignificant trend for assessing and documenting bleeding risk after participation in the PI CME activity (56% vs 68%, n = 80; P = 0.143). Improvements in evidence-based strategies to reduce the risk of inpatient VTE were associated with PI CME participation. Although areas for improvement remain, increased participant identification and use of prophylactic measures can reduce the risk of VTE in hospitalized patients.