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Aurora M, Keyes ML, Acosta JG, Swartz K, Lombay J, Ciaramitaro J, Rudnick A, Kelleher C, Hally S, Gee M, Madhavan V, Roumiantsev S, Cummings BM, Nelson BD, Lerou PH, Matute JD. Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU. Pediatrics 2022; 150:189570. [PMID: 36164852 PMCID: PMC10026590 DOI: 10.1542/peds.2022-056616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
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Affiliation(s)
- Megan Aurora
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors contributed equally to this work
| | - Madeline L Keyes
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- Harvard Neonatal-Perinatal Medicine Fellowship Program, Boston, Massachusetts
- These authors contributed equally to this work
| | | | | | - Jesiel Lombay
- Divisions of aNewborn Medicine
- Departments of Pediatrics
| | | | | | | | | | - Michael Gee
- Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Paul H Lerou
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
| | - Juan D Matute
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
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Tran QD, Dolgun A, Demirhan H. The impact of grey zones on the accuracy of agreement measures for ordinal tables. BMC Med Res Methodol 2021; 21:70. [PMID: 33853549 PMCID: PMC8048180 DOI: 10.1186/s12874-021-01248-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background In an inter-rater agreement study, if two raters tend to rate considering different aspects of the subject of interest or have different experience levels, a grey zone occurs among the levels of a square contingency table showing the inter-rater agreement. These grey zones distort the degree of agreement between raters and negatively impact the decisions based on the inter-rater agreement tables. In this sense, it is important to know how the existence of a grey zone impacts the inter-rater agreement coefficients to choose the most reliable agreement coefficient against the grey zones to reach out with more reliable decisions. Methods In this article, we propose two approaches to create grey zones in simulations setting and conduct an extensive Monte Carlo simulation study to figure out the impact of having grey zones on the weighted inter-rater agreement measures for ordinal tables over a comprehensive simulation space. Results The weighted inter-rater agreement coefficients are not reliable against the existence of grey zones. Increasing sample size and the number of categories in the agreement table decreases the accuracy of weighted inter-rater agreement measures when there is a grey zone. When the degree of agreement between the raters is high, the agreement measures are not significantly impacted by the existence of grey zones. However, if there is a medium to low degree of inter-rater agreement, all the weighted coefficients are more or less impacted. Conclusions It is observed in this study that the existence of grey zones has a significant negative impact on the accuracy of agreement measures especially for a low degree of true agreement and high sample and tables sizes. In general, Gwet’s AC2 and Brennan-Prediger’s κ with quadratic or ordinal weights are reliable against the grey zones. Supplementary Information The online version contains supplementary material available at (10.1186/s12874-021-01248-3).
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Affiliation(s)
- Quoc Duyet Tran
- An Giang University, VNU-HCM, Long Xuyen City, An Giang Province, 076, Vietnam.,Mathematical Sciences, School of Science, RMIT University, Melbourne, Victoria, 3000, Australia
| | - Anil Dolgun
- Mathematical Sciences, School of Science, RMIT University, Melbourne, Victoria, 3000, Australia
| | - Haydar Demirhan
- Mathematical Sciences, School of Science, RMIT University, Melbourne, Victoria, 3000, Australia.
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Guideline Adherence and Registry Recruitment of Congenital Primary Hypothyroidism: Data from the German Registry for Congenital Hypothyroidism (HypoDok). Int J Neonatal Screen 2021; 7:ijns7010010. [PMID: 33673307 PMCID: PMC8006240 DOI: 10.3390/ijns7010010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 12/19/2022] Open
Abstract
Neonatal screening for congenital primary hypothyroidism (CH) is mandatory in Germany but medical care thereafter remains inconsistent. Therefore, the registry HypoDok of the German Society of Pediatric Endocrinology and Diabetology (DGKED) was analyzed to evaluate the implementation of evidence-based guidelines and to assess the number of included patients. Inclusion criteria were (i) date of birth between 10/2001 and 05/2020 and (ii) increased thyroid-stimulating hormone (TSH) at screening and/or confirmation. The cohort was divided into before (A) and after (B) guideline publication in 02/2011, to assess the guideline's influence on medical care. A total of 659 patients were analyzed as group A (n = 327) and group B (n = 332) representing 17.5% and 10.3% of CH patients identified in the German and Austrian neonatal screening program during the respective time period. Treatment start and thyroxine doses were similar in both groups and consistent with recommendations. Regular follow-ups were documented. In the first three years of life, less than half of the patients underwent audiometry; developmental assessment was performed in 49.3% (A) and 24.8% (B) (p < 0.01). Documentation of CH patient care by pediatric endocrinologists seemed to be established, however, it reflected only a minority of the affected patients. Therefore, comprehensive documentation as an important instrument of quality assurance and evidence-based medicine should be legally enforced and officially funded in order to record, comprehend, and optimize care and outcome in patients with rare diseases such as CH.
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Vogel AM, Zhang J, Mauldin PD, Williams RF, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman JS, Streck CJ. Variability in the evalution of pediatric blunt abdominal trauma. Pediatr Surg Int 2019; 35:479-485. [PMID: 30426222 DOI: 10.1007/s00383-018-4417-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA.
| | - Jingwen Zhang
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Regan F Williams
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | - Eunice Y Huang
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | | | - Kuojen Tsao
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | | | - Robert T Russell
- University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA
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Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline. J Med Syst 2018; 42:257. [PMID: 30406316 DOI: 10.1007/s10916-018-1117-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
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Eckhauser A, Pasquali SK, Ravishankar C, Lambert LM, Newburger JW, Atz AM, Ghanayem N, Schwartz SM, Zhang C, Jacobs JP, Minich LL. Variation in care for infants undergoing the Stage II palliation for hypoplastic left heart syndrome. Cardiol Young 2018; 28:1109-1115. [PMID: 30039776 PMCID: PMC6156925 DOI: 10.1017/s1047951118000999] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Single Ventricle Reconstruction trial randomised neonates with hypoplastic left heart syndrome to a systemic-to-pulmonary-artery shunt strategy. Patients received care according to usual institutional practice. We analysed practice variation at the Stage II surgery to attempt to identify areas for decreased variation and process control improvement. METHODS Prospectively collected data were available in the Single Ventricle Reconstruction public-use database. Practice variation across 14 centres was described for 397 patients who underwent Stage II surgery. Data are centre-level specific and reported as interquartile ranges across all centres, unless otherwise specified. RESULTS Preoperative Stage II median age and weight across centres were 5.4 months (interquartile range 4.9-5.7) and 5.7 kg (5.5-6.1), with 70% performed electively. Most patients had pre-Stage-II cardiac catheterisation (98.5-100%). Digoxin was used by 11/14 centres in 25% of patients (23-31%), and 81% had some oral feeds (68-84%). The majority of the centres (86%) performed a bidirectional Glenn versus hemi-Fontan. Median cardiopulmonary bypass time was 96 minutes (75-113). In aggregate, 26% of patients had deep hypothermic circulatory arrest >10 minutes. In 13/14 centres using deep hypothermic circulatory arrest, 12.5% of patients exceeded 10 minutes (8-32%). Seven centres extubated 5% of patients (2-40) in the operating room. Postoperatively, ICU length of stay was 4.8 days (4.0-5.3) and total length of stay was 7.5 days (6-10). CONCLUSIONS In the Single Ventricle Reconstruction Trial, practice varied widely among centres for nearly all perioperative factors surrounding Stage II. Further analysis may facilitate establishing best practices by identifying the impact of practice variation.
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Affiliation(s)
- Aaron Eckhauser
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
| | - Sara K Pasquali
- 2Department of Pediatrics,Division of Pediatric Cardiology,University of Michigan,C.S. Mott Children's Hospital,Ann Arbor,MI,USA
| | - Chitra Ravishankar
- 3Department of Pediatrics,Division of Pediatric Cardiology,Children's Hospital of Philadelphia,Philadelphia,PA,USA
| | - Linda M Lambert
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
| | - Jane W Newburger
- 4Department of Cardiology,Boston Children's Hospital,Boston,MA,USA
| | - Andrew M Atz
- 6Department of Pediatrics,Division of Cardiology,Medical University of South Carolina,Charleston,SC,USA
| | - Nancy Ghanayem
- 7Department of Pediatrics,Division of Pediatric Critical Care,Baylor College of Medicine,Texas Children's Hospital,Houston,TX,USA
| | - Steven M Schwartz
- 8Departments of Critical Care Medicine and Paediatrics,Divisions of Cardiac Critical Care Medicine and Cardiology,University of Toronto,The Hospital for Sick Children,Toronto,CA,USA
| | - Chong Zhang
- 9Division of Epidemiology,University of Utah,Salt Lake City,UT,USA
| | - Jeffery P Jacobs
- 10Department of Surgery,Division of Cardiovascular Surgery,John's Hopkins University,Johns Hopkins All Children's Hospital,St. Petersburg,FL,USA
| | - L LuAnn Minich
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
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7
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Djulbegovic B, Hozo I, Dale W. Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies. J Eval Clin Pract 2018; 24:1247-1254. [PMID: 29484787 DOI: 10.1111/jep.12895] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/25/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Contemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a "black-box" operation-a process with defined inputs and outputs but without sufficient knowledge of its internal workings. METHODS Increased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs. RESULTS To realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies. CONCLUSIONS Fast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care.
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Affiliation(s)
| | - Iztok Hozo
- Department of Mathematics, Indiana University NW, Gary, Indiana, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, Duarte, California, USA
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8
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Sandberg EM, Hehenkamp WJK, Geomini PM, Janssen PF, Jansen FW, Twijnstra ARH. Laparoscopic hysterectomy for benign indications: clinical practice guideline. Arch Gynecol Obstet 2017; 296:597-606. [PMID: 28748339 PMCID: PMC5548857 DOI: 10.1007/s00404-017-4467-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/18/2017] [Indexed: 11/07/2022]
Abstract
Purpose Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced laparoscopic procedures has greatly increased worldwide. It seems therefore, timely to standardize laparoscopic gynecologic care according to the principles of evidence-based medicine. With this goal in mind—the Dutch Society of Gynecological Endoscopic Surgery initiated in The Netherlands the development of a national guideline for laparoscopic hysterectomy (LH). This present article provides a summary of the main recommendations of the guideline. Methods This guideline was developed following the Dutch guideline of medical specialists and in accordance with the AGREE II tool. Clinically important issues were firstly defined and translated into research questions. A literature search per topic was then conducted to identify relevant articles. The quality of the evidence of these articles was rated following the GRADE systematic. An expert panel consisting of 18 selected gynecologists was consulted to formulate best practice recommendations for each topic. Results Ten topics were considered in this guideline, including amongst others, the different approaches for hysterectomy, advice regarding tissue extraction, pre-operative medical treatment and prevention of ureter injury. This work resulted in the development of a clinical practical guideline of LH with evidence- and expert-based recommendations. The guideline is currently being implemented in The Netherlands. Conclusion A guideline for LH was developed. It gives an overview of best clinical practice recommendations. It serves to standardize care, provides guidance for daily practice and aims to guarantee the quality of LH at an (inter)national level.
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Affiliation(s)
- Evelien M Sandberg
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - Peggy M Geomini
- Department of Gynecology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Petra F Janssen
- Department of Gynecology, Elisabeth-Twee Steden Hospital, Tilburg, The Netherlands
| | - Frank Willem Jansen
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Andries R H Twijnstra
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Ren CL, Schechter MS. Reducing practice variation through clinical pathways-Is it enough? Pediatr Pulmonol 2017; 52:577-579. [PMID: 28135046 DOI: 10.1002/ppul.23653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 11/20/2016] [Accepted: 11/23/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Clement L Ren
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
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11
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Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals. J Pediatr Surg 2015; 50:1885-92. [PMID: 26190133 DOI: 10.1016/j.jpedsurg.2015.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/21/2015] [Accepted: 06/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. METHODS Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. RESULTS NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. CONCLUSIONS Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
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Tumino R, Minicozzi P, Frasca G, Allemani C, Crocetti E, Ferretti S, Giacomin A, Natali M, Mangone L, Falcini F, Capocaccia R, Sant M. Population-based method for investigating adherence to international recommendations for pathology reporting of primary cutaneous melanoma: Results of a EUROCARE-5 high resolution study. Cancer Epidemiol 2015; 39:424-9. [PMID: 25735220 DOI: 10.1016/j.canep.2015.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/05/2015] [Indexed: 10/23/2022]
Abstract
AIM Our study aim was to investigate the degree of adherence to international recommendations for cutaneous melanoma pathology reports at the population level by a EUROCARE high resolution study. METHODS The availability of nine characteristics - predominant cell type, tumour-infiltrating lymphocytes, mitotic index, histological subtype, growth phase, Clark level, Breslow thickness, ulceration, and sentinel-node biopsy - was examined on pathology reports of a random sample of 636 cases diagnosed in 2003-2005 in seven Italian cancer registries: Biella, Ferrara, Firenze, Latina, Ragusa, Reggio Emilia, Romagna. The odds of having (versus not having) information for all four core characteristics (last four listed above) were estimated. RESULTS Sentinel node biopsy was available most often, followed by Clark level, Breslow thickness, histological subtype and ulceration. Information on all nine characteristics was more often available in Biella and Ferrara (northern Italy) than elsewhere. Information on all four core items was available for 78% of cases. Odds of four-core-item availability were higher (than mean) in Biella and lower in Latina (centre) and Ragusa (south). CONCLUSIONS The availability of information important for staging and management was good overall on pathology reports, but varied with geography. It is likely to be improved by wider dissemination of reporting guidelines and adoption of a standardised synoptic reporting system.
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Affiliation(s)
- Rosario Tumino
- Ragusa Cancer Registry, Department of Medical Prevention, Provincial Health Unit, Ragusa, Italy; Histopathology Unit, "MP Arezzo" Civic Hospital, Ragusa, Italy.
| | - Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy.
| | - Graziella Frasca
- Ragusa Cancer Registry, Department of Medical Prevention, Provincial Health Unit, Ragusa, Italy.
| | - Claudia Allemani
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy.
| | | | - Stefano Ferretti
- Ferrara Cancer Registry, Department of Experimental and Diagnostic Medicine, Ferrara, Italy.
| | - Adriano Giacomin
- Piedmont Cancer Registry, Province of Biella (CPO), Epidemiology Unit, Biella, Italy.
| | | | - Lucia Mangone
- Statistical, Quality and Clinical Studies Unit, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.
| | - Fabio Falcini
- Romagna Cancer Registry, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Forlì, Italy.
| | - Riccardo Capocaccia
- National Centre for Epidemiology, Surveillance and Health Promotion, Department of Cancer Epidemiology, Istituto Superiore di Sanità, Roma, Italy.
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy.
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Melderis S, Gutowski JP, Harendza S. Overspecialized and undertrained? Patient diversity encountered by medical students during their internal medicine clerkship at a university hospital. BMC MEDICAL EDUCATION 2015; 15:62. [PMID: 25880036 PMCID: PMC4384319 DOI: 10.1186/s12909-015-0353-y] [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: 11/23/2014] [Accepted: 03/26/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND During the four-month internal medicine clerkship in their final year, undergraduate medical students are closely involved in patient care. Little is known about what constitutes their typical learning experiences with respect to patient diversity within the different subspecialties of internal medicine and during on call hours. METHODS 25 final year medical students (16 female, 9 male) on their internal medicine clerkship participated in this observational single-center study. To detail the patient diversity encountered by medical students at a university hospital during their 16-week internal medicine clerkship, all participants self-reported their patient contacts in the different subspecialties and during on call hours on patient encounter cards. Patients' chief complaint, suspected main diagnosis, planned diagnostic investigations, and therapy in seven different internal medicine subspecialties and the on call medicine service were documented. RESULTS 496 PECs were analysed in total. The greatest diversity of chief complaints (CC) and suspected main diagnoses (SMD) was observed in patients encountered on call, with the combined frequencies of the three most common CCs or SMDs accounting for only 23% and 25%, respectively. Combined, the three most commonly encountered CC/SMD accounted for high percentages (82%/63%), i.e. less diversity, in oncology and low percentages (37%/32%), i.e. high diversity, in nephrology. The percentage of all diagnostic investigations and therapies that were classified as "basic" differed between the subspecialties from 82%/94% (on call) to 37%/50% (pulmonology/oncology). The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations. With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call. CONCLUSIONS Internal medicine clerkships at a university hospital provide students with a very limited patient diversity in most internal medicine subspecialties. Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.
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Affiliation(s)
- Simon Melderis
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Jan-Philipp Gutowski
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Sigrid Harendza
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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McFadyen C, Lankshear S, Divaris D, Berry M, Hunter A, Srigley J, Irish J. Physician level reporting of surgical and pathology performance indicators: a regional study to assess feasibility and impact on quality. Can J Surg 2015; 58:31-40. [PMID: 25427336 DOI: 10.1503/cjs.004314] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels. METHODS Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact. RESULTS Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained. CONCLUSION We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology.
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Affiliation(s)
- Craig McFadyen
- Cancer Care Ontario, Toronto, Ont. and Trillium Health Partners, Mississauga, Ont
| | | | - Dimitrios Divaris
- Cancer Care Ontario, Toronto, Ont. and Grand River Hospital, Kitchener, Ont
| | | | | | | | - Jonathan Irish
- Cancer Care Ontario, and Princess Margaret Cancer Centre, Toronto, Ont
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Hurwitz BA, Hurwitz KB, Ashwal S. Child neurology practice guidelines: past, present, and future. Pediatr Neurol 2015; 52:290-301. [PMID: 25576177 DOI: 10.1016/j.pediatrneurol.2014.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/16/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Practice guidelines have been developed in child neurology during the last fifteen years to address important clinical questions and provide evidence-based recommendations for patient care. METHODS This review describes the guideline development process and how it has evolved to meet the needs of child neurologists. RESULTS Several current child neurology guidelines are reviewed and the advantages and disadvantages of guidelines, as well as the legal consequences of using them to determine a standard of care are discussed. The future of guidelines and of their influence on integrated support systems also is considered. CONCLUSIONS Child neurology practice guidelines are a helpful resource for clinicians, families and institutions as they provide evidence-based recommendations concerning the diagnosis and management of common neurological conditions affecting children. Incorporating consensus processes has allowed expansion of clinically relevant recommendations that has increased the utility of guidelines.
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Affiliation(s)
| | | | - Stephen Ashwal
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California.
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17
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Schwartz DG. Research Commentary—The Disciplines of Information: Lessons from the History of the Discipline of Medicine. INFORMATION SYSTEMS RESEARCH 2014. [DOI: 10.1287/isre.2014.0516] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Goyal SS, Shah R, Roberson DW, Schwartz ML. Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals. Laryngoscope 2013; 123:2560-6. [PMID: 23907959 DOI: 10.1002/lary.24172] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 03/08/2013] [Accepted: 04/01/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals. STUDY DESIGN Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database. METHODS There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions. RESULTS Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA. CONCLUSIONS Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Samita S Goyal
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Morris AH, Ioannidis JPA. Limitations of medical research and evidence at the patient-clinician encounter scale. Chest 2013; 143:1127-1135. [PMID: 23546485 DOI: 10.1378/chest.12-1908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We explore some philosophical and scientific underpinnings of clinical research and evidence at the patient-clinician encounter scale. Insufficient evidence and a common failure to use replicable and sound research methods limit us. Both patients and health care may be, in part, complex nonlinear chaotic systems, and predicting their outcomes is a challenge. When trustworthy (credible) evidence is lacking, making correct clinical choices is often a low-probability exercise. Thus, human (clinician) error and consequent injury to patients appear inevitable. Individual clinician decision-makers operate under the philosophical influence of Adam Smith's "invisible hand" with resulting optimism that they will eventually make the right choices and cause health benefits. The presumption of an effective "invisible hand" operating in health-care delivery has supported a model in which individual clinicians struggle to practice medicine, as they see fit based on their own intuitions and preferences (and biases) despite the obvious complexity, errors, noise, and lack of evidence pervading the system. Not surprisingly, the "invisible hand" does not appear to produce the desired community health benefits. Obtaining a benefit at the patient-clinician encounter scale requires human (clinician) behavior modification. We believe that serious rethinking and restructuring of the clinical research and care delivery systems is necessary to assure the profession and the public that we continue to do more good than harm. We need to evaluate whether, and how, detailed decision-support tools may enable reproducible clinician behavior and beneficial use of evidence.
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Affiliation(s)
- Alan H Morris
- Pulmonary and Critical Care Divisions, Departments of Medicine, Intermountain Medical Center, Intermountain Healthcare and The University of Utah School of Medicine, Salt Lake City, UT.
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
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Leviton A, Loddenkemper T, Pomeroy SL. Clinical practice guidelines and practice parameters for the child neurologist. J Child Neurol 2013; 28:917-25. [PMID: 23576411 DOI: 10.1177/0883073813483362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Guidance about how to practice child neurology has been around for decades. Recently, however, clinical practice guidelines, practice parameters, and standardized clinical assessment and management plans are gaining increasing attention. This overview, written for child neurologists, addresses such issues as the following: what are clinical practice guidelines, why are they needed, how are they created, how should they be created, how well are they accepted and adhered to, what influences acceptance and adherence, do guidelines improve care, do they reduce costs, will they be viewed by courts as the standard of care, how can they be updated and improved, and are there better alternatives?
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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21
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Witkin LR, Farrar JT, Ashburn MA. Can assessing chronic pain outcomes data improve outcomes? PAIN MEDICINE 2013; 14:779-91. [PMID: 23574493 DOI: 10.1111/pme.12075] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes. DESIGN Review Manuscript. SETTING The clinical management of chronic, non-cancer pain. SUBJECTS Adult patients receiving treatment for chronic, non-cancer pain. RESULTS While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes. CONCLUSIONS Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.
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Affiliation(s)
- Lisa R Witkin
- Penn Pain Medicine Center, Department of Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, Pennsylvania 19146, USA
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Ozel D, Bilge U, Zayim N, Cengiz M. A web-based intensive care clinical decision support system: from design to evaluation. Inform Health Soc Care 2012; 38:79-92. [PMID: 22958108 DOI: 10.3109/17538157.2012.710687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The aim of this study is to develop and evaluate a web-based clinical decision support system (CDSS) containing clinical guidelines and protocols that will support intensive care unit (ICU) providers in making decisions more effectively and quickly. First, a survey was carried out with 38 physicians in order to determine their preferences, needs and concerns regarding decision support tools. After the survey, guidelines were prepared by a group of specialists in ICU, and a medical informatician converted the guidelines into algorithm forms. Ten CDSS were developed using the algorithms, and placed onto the Intensive Care Decision Support Website (ICDSW). In order to evaluation of the website, 15 physicians were asked to answer 10 questions in 10 different scenarios first using a paper-based approach, then with ICDSW. When the answers were analyzed, it was found that the answers given by using ICDSW were significantly better than the paper-based approach (p < 0.001). However, there was no significant difference in terms of the time needed to answer the questions (p = 0.138). The usability score of the website was 85.6 ± 8.89. The study demonstrated the successful implementation of an ICDSW within intensive care units.
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Affiliation(s)
- Deniz Ozel
- Department of Biostatistics and Medical Informatics, Akdeniz University, Antalya, Turkey.
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McLeod L, French B, Dai D, Localio R, Keren R. Patient volume and quality of care for young children hospitalized with acute gastroenteritis. ACTA ACUST UNITED AC 2011; 165:857-63. [PMID: 21893651 DOI: 10.1001/archpediatrics.2011.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To explore the relationship between the volume of children admitted to the hospital with acute gastroenteritis and adherence to recommended quality indicators. DESIGN Retrospective cohort study. SETTING Premier Perspective clinical and financial information systems database (Premier Inc, Charlotte, North Carolina). PARTICIPANTS A total of 12,604 otherwise healthy children aged 3 months to 10 years hospitalized between January 1, 2007, and December 31, 2009, at 280 US hospitals with International Classification of Diseases, Ninth Revision diagnosis codes indicating acute gastroenteritis. MAIN EXPOSURE Volume of hospital admissions per year of children with acute gastroenteritis. MAIN OUTCOME MEASURES Quality indicators for overuse and misuse of care in the management of acute gastroenteritis based on nationally published guidelines. These include blood testing, stool studies, use of antibiotics, and use of nonrecommended antiemetic or antidiarrheal medications (hereafter referred to as nonrecommended medications). RESULTS Selected blood, stool, and rotavirus tests (overuse indicators) were performed in 85%, 46%, and 56% of children, respectively. Six percent of children received nonrecommended medications, and 26% received antibiotics (misuse indicators). Higher volumes of hospital admission for acute gastroenteritis were associated with less use of blood tests (odds ratio [OR], 0.67 [95% confidence interval {CI}, 0.50-0.89]), nonrecommended medications (OR, 0.84 [95% CI, 0.76-0.93]), and antibiotics (OR, 0.93 [95% CI, 0.86-0.99]). Children admitted to hospitals in the 25th vs 75th percentile of patient volume had a 10%, 30%, and 10% increased chance of having blood tests, nonrecommended medications, and antibiotics ordered, respectively. CONCLUSIONS In a nationally representative sample of hospitals that care for children with acute gastroenteritis, higher patient volumes were associated with greater adherence to established quality indicators. Further investigation is needed to identify the hospital characteristics driving the volume-quality relationship for this common pediatric condition.
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Affiliation(s)
- Lisa McLeod
- Department of Pediatrics, Children's Hospital of Philadelphia, PA 19104, USA.
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Pugdahl K, Fuglsang-Frederiksen A, Tankisi H, Johnsen B, Carvalho MD, Fawcett PRW, Labarre-Vila A, Liguori R, Nix W, Schofield IS. Impact of medical audit on electrodiagnostic medicine in polyneuropathy. Clin Neurophysiol 2011; 122:2523-9. [PMID: 21703925 DOI: 10.1016/j.clinph.2011.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/01/2011] [Accepted: 05/22/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of the study was to investigate whether experienced physicians' electrodiagnostic practice and criteria can be influenced by international collaboration involving peer review medical audit. METHODS Data was obtained from the ESTEEM project, an ongoing collaboration since 1991 among European neurophysiologists concerned with quality improvement in electrodiagnostic medicine. Three sets of the physicians' polyneuropathy examinations performed with intervals of 2-4 years were analysed. RESULTS Changes towards increased homogeneity among the physicians were found in (1) the average number of studies performed per patient and the number of abnormal studies required for accepting the diagnosis of polyneuropathy, with the most pronounced changes seen for abnormal motor nerve segments, abnormal F-wave studies, and electromyographic studies, and (2) the agreement on pathophysiological interpretation of nerve conduction studies and classification of polyneuropathy. CONCLUSIONS Changes towards increased homogeneity contributed to years of participation in peer review medical audit, were seen among a group of experienced physicians. Peer review medical audit as carried out here is however difficult to scale up. Therefore guidelines or minimal criteria should ideally supplement a medical audit process to disseminate the results obtained to a larger audience. SIGNIFICANCE These results support the role of international peer review medical audit in quality improvement of electrodiagnostic medicine.
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Affiliation(s)
- Kirsten Pugdahl
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
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Thorn J, Maun A, Bornhöft L, Kornbakk M, Wedham S, Zaffar M, Thanner C. Increased access rate to a primary health-care centre by introducing a structured patient sorting system developed to make the most efficient use of the personnel: a pilot study. Health Serv Manage Res 2011; 23:166-71. [PMID: 21097727 DOI: 10.1258/hsmr.2010.010005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The primary health-care centre (PHCC) participating in the study has had financial problems for several years and it has been particularly difficult to recruit general practitioners (GPs). As a result, the access rate to the PHCC was low. The purpose of this study was to increase the access rate to the PHCC and to make the most efficient use of the staff by introducing a structured patient sorting system. All personnel were involved in the implementation process and participated regularly in interdisciplinary work-groups. A variety of Drop-in receptions were created and a manual for sorting patients by condition was introduced. The main finding was that the total access rate to the PHCC increased by 27% and that each staff member increased their personal access rate by an average of 13%. Eighty-three percent of the patients who were initially treated by the rehabilitation team were treated solely by the team and did not need to see a GP. No medical backlashes were reported. These findings indicate a more efficient use of the personnel. Furthermore, both personnel and patients indicated an improvement in the possibility to book patient appointments after the introduction of the structured patient sorting system.
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Affiliation(s)
- Jörgen Thorn
- Primary Health Care, Västra Götaland Region, Sweden.
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Fuglsang-Frederiksen A, Pugdahl K. Current status on electrodiagnostic standards and guidelines in neuromuscular disorders. Clin Neurophysiol 2011; 122:440-455. [DOI: 10.1016/j.clinph.2010.06.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 05/25/2010] [Accepted: 06/04/2010] [Indexed: 11/27/2022]
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Abstract
Relief from pain is itself a marker of high-quality medical care. Quality assurance in the case of pain management could simply mean successful elimination of pain. Because the means of controlling pain are imperfect, it is essential to consider whether pain interventions actually achieve the primary goal of pain relief and also whether they are safe, cost-effective, and even capable of producing secondary benefits such as early recovery from surgery. Quality assurance and assessment in pain management therefore becomes a complex undertaking that must incorporate into its processes the often-conflicting goals of comfort versus safety versus patients' rights.
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Sumner W. Health and life insurance as an alternative to malpractice tort law. BMC Health Serv Res 2010; 10:150. [PMID: 20525190 PMCID: PMC2902464 DOI: 10.1186/1472-6963-10-150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 06/02/2010] [Indexed: 11/17/2022] Open
Abstract
Background Tort law has legitimate social purposes of deterrence, punishment and compensation, but medical tort law does none of these well. Tort law could be counterproductive in medicine, encouraging costly defensive practices that harm some patients, restricting access to care in some settings and discouraging innovation. Discussion Patients might be better served by purchasing combined health and life insurance policies and waiving their right to pursue malpractice claims. The combined policy should encourage the insurer to profit by inexpensively delaying policyholders' deaths. A health and life insurer would attempt to minimize mortal risks to policyholders from any cause, including medical mistakes and could therefore pursue systematic quality improvement efforts. If policyholders trust the insurer to seek, develop and reward genuinely effective care; identify, deter and remediate poor care; and compensate survivors through the no-fault process of paying life insurance benefits, then tort law is largely redundant and the right to sue may be waived. If expensive defensive medicine can be avoided, that savings alone could pay for fairly large life insurance policies. Summary Insurers are maligned largely because of their logical response to incentives that are misaligned with the interests of patients and physicians in the United States. Patient, provider and insurer incentives could be realigned by combining health and life insurance, allowing the insurer to use its considerable information access and analytic power to improve patient care. This arrangement would address the social goals of malpractice torts, so that policyholders could rationally waive their right to sue.
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Affiliation(s)
- Walton Sumner
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA.
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Morris AH, Hirshberg E, Sward KA. Computer protocols: how to implement. Best Pract Res Clin Anaesthesiol 2009; 23:51-67. [PMID: 19449616 DOI: 10.1016/j.bpa.2008.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Variation in clinical practice impedes control, is associated with unwanted and widespread error, and may preclude replicability. Methodologic replicability enhances our ability to detect signals of interest by both increasing the signal through consistent application of the intervention, and by reducing the obscuring effects of noise. Decision-support tools are intended to standardize some aspect of clinical care and thereby help lead to uniform implementation of clinical interventions. This is realized by explicit replicable computer protocols that can produce appropriate patient-specific decisions and introduce control of process into clinical care. Development of such protocols has required around-the-clock implementation for patient management because of the influence of patient history and previous patient states on the output of the computer protocol. Three successful computer protocols for management of blood glucose provide compelling examples. This clinician driven "bottom-up" approach complements the common information technology service driven "top-down" approach to clinical problems.
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Affiliation(s)
- A H Morris
- Pulmonary and Critical Care Divisions, Departments of Medicine, LDS Hospital, Intermountain Medical Center, University of Utah School of Medicine, Salt Lake City, UT USA.
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Fraser KD, Estabrooks C. What factors influence case managers' resource allocation decisions? A systematic review of the literature. Med Decis Making 2008; 28:394-410. [PMID: 18480042 DOI: 10.1177/0272989x07312709] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Case managers' decisions directly affect the amount and type of services individual clients receive, as well as overall home care program available resources. We know little about the resource allocation decision-making processes of case managers. The question guiding this review was, "What factors influence case managers' resource allocation decisions in home care?'' METHODS The authors did a systematic literature review to answer the above question. After assessing the articles for inclusion, they assessed the quality (internal validity) of each included study. They described the characteristics of the studies and provided a synthesis of the findings of the primary studies. RESULTS Five qualitative and 6 quantitative articles met the inclusion criteria for this review. The findings of these studies are equivocal. Despite this, the authors were able to create a preliminary taxonomy of the factors that influence case manager resource allocation decisions. Despite evidence-based decision making receiving so much attention in contemporary health care literature, the authors found a near absence of reference to research use in the context of case manager decision making. CONCLUSIONS Currently, there are relatively few studies in the literature on the factors that influence, and how they are used in, case manager resource allocation decisions. Studies are often lacking in terms of conceptual clarity and theoretical framing. They are often not guided by theoretical frameworks and are not situated within the larger field of decision making or even within the clinical decision-making literature. These issues are impeding progress in this area.
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Affiliation(s)
- Kimberly D Fraser
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
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Hozo I, Djulbegovic B. When Is Diagnostic Testing Inappropriate or Irrational? Acceptable Regret Approach. Med Decis Making 2008; 28:540-53. [DOI: 10.1177/0272989x08315249] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors provide a new model within the framework of theories of bounded rationality for the observed physicians' behavior that their ordering of diagnostic tests may not be rational. Contrary to the prevailing thinking, the authors find that physicians do not act irrationally or inappropriately when they order diagnostic tests in usual clinical practice. When acceptable regret (i.e., regret that a decision maker finds tolerable upon making a wrong decision) is taken into account, the authors show that physicians tend to order diagnostic tests at a higher level of pretest probability of disease than predicted by expected utility theory. They also show why physicians tend to overtest when regret about erroneous decisions is extremely small. Finally, they explain variations in the practice of medicine. They demonstrate that in the same clinical situation, different decision makers might have different acceptable regret thresholds for withholding treatment, for ordering a diagnostic test, or for administering treatment. This in turn means that for some decision makers, the most rational strategy is to do nothing, whereas for others, it may be to order a diagnostic test, and still for others, choosing treatment may be the most rational course of action.
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Affiliation(s)
- Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary
| | - Benjamin Djulbegovic
- Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida, Tampa,
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Runtime application of Hybrid-Asbru clinical guidelines. J Biomed Inform 2006; 40:507-26. [PMID: 17276145 DOI: 10.1016/j.jbi.2006.12.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2006] [Revised: 12/07/2006] [Accepted: 12/16/2006] [Indexed: 11/29/2022]
Abstract
Clinical guidelines are a major tool in improving the quality of medical care. However, to support the automation of guideline-based care, several requirements must be filled, such as specification of the guidelines in a machine-interpretable format and a connection to an Electronic Patient Record (EPR). For several different reasons, it is beneficial to convert free-text guidelines gradually, through several intermediate representations, to a machine-interpretable format. It is also realistic to consider the case when an EPR is unavailable. We propose an innovative approach to the runtime application of intermediate-represented Hybrid-Asbru guidelines, with or without an available EPR. The new approach capitalizes on our extensive work on developing the Digital electronic Guideline Library (DeGeL) framework. The new approach was implemented as the Spock system. For evaluation, three guidelines were specified in an intermediate format and were applied to a set of simulated patient records designed to cover prototypical cases. In all cases, the Spock system produced the expected output, and did not produce an unexpected one. Thus, we have demonstrated the capability of the Spock system to apply guidelines encoded in the Hybrid-Asbru intermediate representation, when an EPR is not available.
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Patkar V, Hurt C, Steele R, Love S, Purushotham A, Williams M, Thomson R, Fox J. Evidence-based guidelines and decision support services: A discussion and evaluation in triple assessment of suspected breast cancer. Br J Cancer 2006; 95:1490-6. [PMID: 17117181 PMCID: PMC2360742 DOI: 10.1038/sj.bjc.6603470] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Widespread health service goals to improve consistency and safety in patient care have prompted considerable investment in the development of evidence-based clinical guidelines. Computerised decision support (CDS) systems have been proposed as a means to implement guidelines in practice. This paper discusses the general concept in oncology and presents an evaluation of a CDS system to support triple assessment (TA) in breast cancer care. Balanced-block crossover experiment and questionnaire study. One stop clinic for symptomatic breast patients. Twenty-four practising breast clinicians from United Kingdom National Health Service hospitals. A web-based CDS system. Clinicians made significantly more deviations from guideline recommendations without decision support (60 out of 120 errors without CDS; 16 out of 120 errors with CDS, P<0.001). Ignoring minor deviations, 16 potentially critical errors arose in the no-decision-support arm of the trial compared with just one (P=0.001) when decision support was available. Opinions of participating clinicians towards the CDS tool became more positive after they had used it (P<0.025). The use of decision support capabilities in TA may yield significant measurable benefits for quality and safety of patient care. This is an important option for improving compliance with evidence-based practice guidelines.
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Affiliation(s)
- V Patkar
- Advanced Computation Laboratory, Cancer Research UK, London WC2A 3PX, UK.
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Del Fiol G, Rocha RA, Bradshaw RL, Hulse NC, Roemer LK. An XML Model That Enables the Development of Complex Order Sets by Clinical Experts. ACTA ACUST UNITED AC 2005; 9:216-28. [PMID: 16138538 DOI: 10.1109/titb.2005.847200] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Medication errors are significant and well-known problems in health care. Despite the evidence supporting the use of computerized physician order entering (CPOE) to help reduce medication errors, only a small number of hospitals in the U.S. have successfully implemented a CPOE system. Different authors have indicated that the utilization of order sets derived from best-practice standards can reduce medication errors and improve physicians' acceptance of CPOE systems. However, a variety of issues related to the development and continuous maintenance of best-practice order sets still need to be understood. This paper presents a model that supports an order set development process driven by clinical experts. Model requirements and details are presented and discussed.
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Nannings B, Abu-Hanna A, Bosman RJ. Data-Driven Analysis of Blood Glucose Management Effectiveness. Artif Intell Med 2005. [DOI: 10.1007/11527770_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The delivery of health care is in the process of "industrialization" in that it is undergoing changes in the organization of work which mirror those that began in other industries a century ago. This process is characterized by an increasing division of labor, standardization of roles and tasks, the rise of a managerial superstructure, and the degradation (or de-skilling) of work. The consolidation of the health care industry, the fragmentation of physician roles, and the increasing numbers of nonphysician clinicians will likely accelerate this process. Although these changes hold the promise of more efficient and effective health care, physicians should be concerned about the resultant loss of autonomy, disruption of continuity of care, and the potential erosion of professional values.
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Affiliation(s)
- Darius A Rastegar
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.
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Tierney WM, Overhage JM, Murray MD, Harris LE, Zhou XH, Eckert GJ, Smith FE, Nienaber N, McDonald CJ, Wolinsky FD. Effects of computerized guidelines for managing heart disease in primary care. J Gen Intern Med 2003; 18:967-76. [PMID: 14687254 PMCID: PMC1494965 DOI: 10.1111/j.1525-1497.2003.30635.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care). OBJECTIVE To assess the effects of computer-based cardiac care suggestions. DESIGN A randomized, controlled trial targeting primary care physicians and pharmacists. SUBJECTS A total of 706 outpatients with heart failure and/or ischemic heart disease. INTERVENTIONS Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. MEASUREMENTS Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines. RESULTS Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients. CONCLUSIONS Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.
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Affiliation(s)
- William M Tierney
- Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Dhillon B. Methods for performing human reliability and error analysis in health care. Int J Health Care Qual Assur 2003. [DOI: 10.1108/09526860310495697] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sintchenko V, Coiera E, Iredell JR, Gilbert GL. Comparative impact of guidelines, clinical data, and decision support on prescribing decisions: an interactive web experiment with simulated cases. J Am Med Inform Assoc 2003; 11:71-7. [PMID: 14527970 PMCID: PMC305460 DOI: 10.1197/jamia.m1166] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the clinical impact of computerized decision support with and without electronic access to clinical guidelines and laboratory data on antibiotic prescribing decisions. DESIGN A crossover trial was conducted of four levels of computerized decision support-no support, antibiotic guidelines, laboratory reports, and laboratory reports plus a decision support system (DSS), randomly allocated to eight simulated clinical cases accessed by the Web. MEASUREMENTS Rate of intervention adoption was measured by frequency of accessing information support, cost of use was measured by time taken to complete each case, and effectiveness of decision was measured by correctness of and self-reported confidence in individual prescribing decisions. Clinical impact score was measured by adoption rate and decision effectiveness. RESULTS Thirty-one intensive care and infectious disease specialist physicians (ICPs and IDPs) participated in the study. Ventilator-associated pneumonia treatment guidelines were used in 24 (39%) of the 62 case scenarios for which they were available, microbiology reports in 36 (58%), and the DSS in 37 (60%). The use of all forms of information support did not affect clinicians' confidence in their decisions. Their use of the DSS plus microbiology report improved the agreement of decisions with those of an expert panel from 65% to 97% (p=0.0002), or to 67% (p=0.002) when antibiotic guidelines only were accessed. Significantly fewer IDPs than ICPs accessed information support in making treatment decisions. On average, it took 245 seconds to make a decision using the DSS compared with 113 seconds for unaided prescribing (p<0.001). The DSS plus microbiology reports had the highest clinical impact score (0.58), greater than that of electronic guidelines (0.26) and electronic laboratory reports (0.45). CONCLUSION When used, computer-based decision support significantly improved decision quality. In measuring the impact of decision support systems, both their effectiveness in improving decisions and their likely rate of adoption in the clinical environment need to be considered. Clinicians chose to use antibiotic guidelines for one third and microbiology reports or the DSS for about two thirds of cases when they were available to assist their prescribing decisions.
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Affiliation(s)
- Vitali Sintchenko
- Centre for Health Informatics, University of New South Wales, Sydney 2052, Australia.
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Meurer SJ, Rubio DM, Counte MA, Burroughs T. Development of a healthcare quality improvement measurement tool: results of a content validity study. Hosp Top 2002; 80:7-13. [PMID: 12238232 DOI: 10.1080/00185860209597989] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Current methods of measuring continuous quality improvement (CQI) implementation are too long and not comprehensive. A new survey for CQI implementation was developed and tested for content validity using a panel of 8 experts--7 from the United States and 1 from England. The survey was reduced from 70 items to 22. The resultant survey had a clarity interrater agreement (IR) of .91, a representativeness IR of .93, a clarity content validity index (CVI) of .73, and a representativeness CVI of .91. Content validity served as an excellent data reduction method in building a valid, concise, and comprehensive measure of CQI implementation.
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Affiliation(s)
- Alberto Yagüe
- Laboratorio de Microbiología, Hospital Vega Baja, Orihuela, Alicante, Spain.
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Akalin HE. Surgical prophylaxis: the evolution of guidelines in an era of cost containment. J Hosp Infect 2002; 50 Suppl A:S3-7. [PMID: 11993641 DOI: 10.1053/jhin.2001.1121] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Postoperative infections account for a large proportion of hospital-acquired infections, are associated with a high morbidity and mortality, and place a large burden upon the inpatient healthcare budget. Prophylaxis is desirable and is based on a combination of preoperative preparation, surgical techniques, perioperative antibiotic prophylaxis and postoperative wound care. There is considerable evidence that antibiotics are used excessively and inappropriately in the prevention and treatment of hospital-acquired infections, including surgical-site infections. In the case of the latter, timing of prophylaxis is crucial to success yet antibiotics are often administered at the wrong time or for too long a period, with implications for the cost of patient care. Several studies have shown that the local implementation of practice guidelines can yield significant improvements in antibiotic use and the cost of surgical prophylaxis. More rational use of antibiotics is likely to benefit the treatment of future surgical patients by reducing the pressure to select for antibiotic-resistant bacterial pathogens.
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Affiliation(s)
- H Erdal Akalin
- Pfizer Pharmaceuticals Group, Pfizer Ilaçlari A.S., Istanbul, Turkey.
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DeChristopher PJ, Anderson RR. Practice Parameters for Transfusion Medicine. Lab Med 2001. [DOI: 10.1309/mp8w-b2bn-ln8c-qx3h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Phillip J. DeChristopher
- University of Illinois at Chicago Medical Center, Department of Pathology, Blood Bank/Transfusion Medicine, Chicago, IL
| | - Richard R. Anderson
- Associated Pathology Consultants, Department of Pathology, S.C. Edward Hospital, Naperville, IL
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Bernhardt B. Doc, shouldn't we be getting some tests?". J Clin Oncol 2000; 18:3739-41. [PMID: 11054451 DOI: 10.1200/jco.2000.18.21.3739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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