Toward Patient Centricity: Why Do Patients With Inflammatory Bowel Disease Participate in Pharmaceutical Clinical Trials? A Mixed-Methods Exploration of Study Participants

Background

A better understanding of motivations to participate as well as recommendations to reduce barriers to enrollment may assist in design of future clinical trials.

Methods

We developed a 32-item electronic questionnaire to explore motivations, experiences, and recommendations of inflammatory bowel disease patients, who had participated in pharmaceutical clinical trials in a tertiary center in Canada over the last decade. We employed a mixed-methods approach that integrates both quantitative and qualitative research methods.

Results

We distributed a total of 69 e-mails with surveys and received 46 responses (66.6% response rate). Study participants were mostly male (27/46, 58.7%), non-Hispanic White (43/46, 93.5%), with a mean age of 45.5 years (SD 10.9). Most decided to participate in a clinical trial to benefit future patients (29/46, 63.0%). Half of the participants (23/46, 50.0%) reported they were worried about the possibility of receiving placebo, although the majority (29/46, 63.0%) understood they could improve on placebo. The most challenging aspect reported was the number and length of questionnaires (15/46, 32.6%), as well as the number of colonoscopies (14/46, 30.4%). Strategies recommended to increase enrollment were reduction of the chance of receiving placebo (20/46, 43.5%), facilitating inclusion of patients who have failed multiple therapies (20/46, 43.5%), allowing virtual visits (18/46, 39.1%), including subtypes of disease traditionally excluded from trials (16/46, 34.8%) and improving outreach to underrepresented populations (13/46, 28.3%). The vast majority (37/46, 80.4%) reported their experience of participation to be better than expected.

Conclusions

These results should help inform the design of future clinical trials with a focus on patient-centricity.

Appropriateness of ICD-coded Diagnostic Inpatient Hospital Discharge Data for Medical Practice Assessment

Objectives: We performed a systematic review to investigate the quality of diagnostic hospital discharge data (DHDD) in order to gain insight in the usefulness of these data for medical practice assessment. We investigated the methods used to evaluate data quality, factors that determine data quality and its consequences for medical practice assessment.

Methods: We selected studies in which both completeness (or sensitivity: SENS) and correctness (or positive predictive value: PPV) were measured. We used the random-effects model to calculate mean SENS and PPV and to explore the effect of a number of covariates.

Results: The 101 included studies were very heterogeneous. We distinguished six typical study designs. We found a mean SENS of 0.67 (95%CI: 0.62– 0.73) and PPV of 0.76 (95%CI: 0.73– 0.79); SENS was significantly lower for comorbidity and complication studies than for some single disease studies. PPV was significantly higher for Scandinavian countries than for other countries. Recoding compared to re-abstracting of the medical record as a gold standard gave a significantly lower PPV. Diagnostic data were considered appropriate by the authors of the studies for quality of care purposes when both SENS and PPV were at least 0.85. Only 13% of the studies fulfilled this criterion.

Conclusions: Variability in quality of care between settings can easily be overshadowed by variability in data quality. However, the use of DHDD by physicians to evaluate their own medical practice may be useful. But only if physicians are willing to critically interpret the meaning of the information for their medical practice assessment.

Long-term Impact of Physician Encoding on Detail and Number of Recorded Diagnoses

Objectives: To improve the recording of diagnostic discharge data, pediatricians encoded diagnostic information as part of discharge letter writing supported by a pediatric list of ICD-9-CM-based codes. We evaluated the effect of this new policy on level of detail and number of recorded diagnoses.

Methods: We compared proportions of specific principal diagnoses and numbers of secondary diagnoses of the four years before with the eight years after introduction.

Results: Immediately after introduction, half of the diagnoses for which both generic and specific codes existed was coded specific. In later years this proportion remained stable at 0.35 (p < 0.05). Diagnoses that fall under the pediatrician’s own subspecialty had more often a specific code than diagnoses that do not. The mean number of secondary diagnoses per admission increased from 0.7 before introduction to 1.4 in the third year after introduction (p < 0.05) but gradually fell back to 0.7. This increase and decrease was mainly due to diagnoses that did not fall under the pediatrician’s own subspecialty. The extra codes in individual discharge summaries had added informational value.

Conclusions: Discharge letter-linked encoding by pediatricians supported by a pediatric list of diseases leads initially to increased detail and number of diagnoses with added informational value. When attention diminishes, especially the level of detail and number of secondary diagnoses that do not fall under one’s own subspecialty decrease. The level of detail of principal diagnoses remains stable because of the advantage for pediatricians of having specific diagnostic codes falling under their own subspecialty.

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer

Background

Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.

Methods/Study design

In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients.

Discussion

The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery.

Trial registration

NCT02371304, registration date: February 2015

Primary retroperitoneal mucinous cystadenoma-A case study and review of the literature

INTRODUCTION

Primary retroperitoneal tumours of mucinous type are extremely rare and can be further sub-divided into benign, borderline or cystadenocarcinoma. Prompt diagnosis of retroperitoneal tumours is important as the majority are malignant.

PRESENTATION OF CASE

Our case describes a 30year old woman, presenting with a 3month history of intermittent right iliac fossa pain. Abdominal examination demonstrated a mass palpable in the right iliac fossa. Ultrasonography of the abdomen demonstrated a cystic mass with a magnetic resonance imaging (MRI) scan of the pelvis further defining the lesion. Laparoscopy was performed to further evaluate and ultimately remove the retroperitoneal mass. Macroscopic and microscopic examination reported mucinous epithelium of endocervical type with no evidence of invasion. Findings were consistent with primary retroperitoneal mucinous cystadenoma.

DISCUSSION

This is the 19th reported case of a benign primary retroperitoneal mucinous cystadenoma in the English literature. The origin of mucinous cystadenomas in the retroperitoneum is widely debated with multiple theories suggested. Diagnosis of retroperitoneal tumours is important but difficult as serological investigations, ultrasonography, computed topography and magnetic resonance imaging, although useful, cannot allow a confident diagnosis.

CONCLUSION

Primary retroperitoneal mucinous cystadenoma is a benign tumour, however because of the malignant nature of the majority of mucinous retroperitoneal tumours they should be considered in the differential of chronic abdominal pain despite their rarity.

Availability and usability of data for medical practice assessment

OBJECTIVE

We analyzed availability and usability of the electronic patient data required for assessment of medical practice for a specific patient group.

DESIGN

Case study in which physicians defined performance indicators and additional exploratory information. Data availability in the hospital information system was determined. Data usability was evaluated based on reason for recording, administrative procedures, and comparison with paper data.

SETTING

A 155 bed pediatric department in a public academic medical center.

STUDY PARTICIPANTS

Pediatricians and children with suspected meningitis.

MAIN OUTCOME MEASURES

Availability and usability of electronic patient data. Usability criteria were standardization, completeness, and accuracy.

RESULTS

A total of 14 performance indicators were defined. Of 39 data items required for indicator quantification, 29 were available, and 19 were usable without manual handling. Completeness and accuracy of the registration of reason for admission and discharge diagnoses were insufficient, leading to problematic patient selection and complication detection. Time-points of patient events were inaccurate or not available. Data regarding outpatient diagnosis, signs and symptoms, indications for test ordering, and medication administration were missing. Test result reports were not adequately standardized. Based on electronic patient data, five out of 14 performance indicators could be quantified reliably, but only after patient selection problems were overcome. For exploratory information, 16 out of 25 required data items were available and 13 were usable.

CONCLUSIONS

Availability and usability of electronic patient data are insufficient for physician-led and detailed assessment of medical practice for specific patient groups. Extended registration of the reason for admission will improve patient selection and assessment of diagnostic process.

Software engineering in medical informatics: the academic hospital as learning environment

In 2001, the revised course Software Engineering has been implemented in the Medical Informatics curriculum at the Academic Medical Center, Amsterdam. This 13 weeks, full-time course consists of three parts: internship, theory and project. All parts are provided in problem-oriented manner with special attention for relevant skills such as project management, documentation and presentation. During the internship, students observe how health care professionals at several hospital wards work and how information supply is organized. In the theory part, students study concepts and methods of software engineering by means of case descriptions and self-directed learning. During the project, they apply their acquired knowledge to an observed, clinical information problem and complete several stages of the software engineering process. Evaluation by inquiry showed that, compared to other courses, students spent more time, and distributed their time more evenly, during the whole period of the course. In conjunction with theory, a combination of internship and project in a hospital seems to provide a surplus value compared to a practical in a computer laboratory. The integration of software theory, clinical practice and problem-based approach, contributed to the enthusiastic, intensive and realistic way students learned in this important topic that might be chosen as a future profession.

Whither mental health legislation? (Locking up the disturbed and the deviant)

The publication of the Government's two-part White Paper - Reforming The Mental Health Act - provides the opportunity to review and comment upon some of its main proposals against a background of current concerns with issues of public protection in mental health and criminal justice.

Did Lady Macbeth have a mind diseas'd'? ( a medico-legal enigma)

The character of Lady Macbeth has often been presented as evil and demonic. In this contribution, an attempt is made to show her in a somewhat different light; in doing so, some implications for forensic-psychiatric practice are suggested. 'Cann'st thou not minister to a mind diseas'd ..?' (Macbeth, to his wife's physician: V:i: 40)1

Availability and accuracy of electronic patient data for medical practice assessment

We analyzed availability and accuracy of electronic patient data needed to assess medical practice. A case study was performed in which pediatricians formulated 14 performance indicators that cover aspects of care for children with suspected meningitis. Data items needed to quantify these indicators were listed. Required patient data were gathered from hospital information system and paper medical records. Accuracy of electronically available data was based on comparison with paper data and, when paper data were not available, on how data were recorded at the source, administrative procedures and original goal for which data were recorded.

CONCLUSION

Registration of reason for admission and diagnoses gives no reliable basis to select patients with 'suspicion on a disease' as selection criterion. Besides, many performance indicators cannot be reliably quantified because data are not recorded electronically (indication, medication, outpatient diagnosis), are not recorded specific enough (intervention time), are not standardized (radiology report), or cannot be obtained from other hospitals.

Effect of discharge letter-linked diagnosis registration on data quality

OBJECTIVE

Diagnostic data are essential for the assessment of medical practice: they are needed for retrieval of clinical cases and describing co-morbidity and complications. In most Western countries, diagnosis registration in hospital information systems is based mainly on completing forms after patient discharge. As this registration plays no role in patient care, data quality is usually unsatisfactory. To improve data quality, we redesigned the process of diagnosis registration at a paediatric department, and now paediatricians provide diagnoses with codes in a separate registration heading of the discharge letter. We compared the quality of this discharge letter-linked diagnosis registration with the quality of the previous form based registration.

DESIGN

Retrospective study with blinded before and after measurement. Re-abstracted diagnosis descriptions of the text of discharge letters were taken as gold standard.

SETTING

A paediatric department in an academic medical centre.

STUDY PARTICIPANTS

From each registration period, 60 admissions were selected randomly. Mean age of the patients was 4.5 (SD +/- 5.5) and 5.2 (SD +/- 5.2) years for the old and new situation respectively. Mean length of stay was 8.8 (SD +/- 11.0) and 7.2 (SD +/- 12.4) days.

INTERVENTION

Discharge letter-linked diagnosis registration.

MAIN OUTCOME MEASURES

Completeness and accuracy, both at three-digit level of ICD-9-CM.

RESULTS

Completeness of form-based diagnosis registration was 51% (95% CI, 44-58%) and of discharge letter-linked diagnosis registration 54% (95% CI, 47-60%). Accuracy was 65% (95% CI, 58-72%) and 67% (95% CI, 60-74%) respectively.

CONCLUSIONS

The discharge letter-linked diagnosis registration does not provide a better basis for assessment of medical practice than the form based diagnosis registration.

Inquiries after homicide in England and Wales

Recent instruction from the Department of Health requires the institution of an independent inquiry into all cases of homicide committed by those who have been in contact with the psychiatric services. The background to this instruction is explored briefly within the context of more general concerns about violence and homicide, and the advantages and disadvantages of such inquiries are discussed.

Can the law serve as the solution to social ills? The case of the Mental Health (Patients in the Community) Act, 1995

The background to the Mental Health (Patients in the Community) Act, 1995 is reviewed briefly. Some problems concerning the Act's provisions for 'supervised discharge' are then discussed. Some more general extrapolations follow concerning the problems of legislating for social and personal 'ills'.

What price the concept of psychopathic disorder?

The current concept of psychopathic disorder is reviewed against a short historical background. Aetiology is commented upon briefly and key characteristics described. Support is provided for the view that the concept has a degree of usefulness in clinical management provided it is viewed in a focused and restricted fashion.

Psychiatry and the concept of evil. Sick in heart or sick in mind?

The Editor's initiative in seeking this Editorial was inspired no doubt by a number of recent cases and events in which the behaviour of those concerned seems to have defied rational explanation, and the power of ‘evil’ has been invoked in order to provide one. Perhaps the most compelling was that of the trial for murder of two ten-year-old boys for the murder of the infant James Bulger.

Is diversion just a diversion?

This paper examines the diversion of the mentally disordered offender against a background of the treatment of the mentally disordered in general. Some myths about incarceration are explored and the proposal is made that diversion is not a new idea. Finally, caution is expressed in the espousal of diversion in an uncritical fashion.

Is psychopathic disorder a treatable condition?

This article extends upon material presented in a previous issue of this journal (Med. Sci. Law, 1990, 30, 39-44). Three groups of respondents were asked to comment upon the degree to which they considered psychopathic disorder to be a treatable condition. The modest findings suggest that although few clear cut views exist as to the best treatment modality there are firmer indications as to those thought to be unhelpful.

Ultrasonographic prenatal diagnosis of conjoined thoracopagus twins: a case report

A case of prenatal diagnosed thoracopagus conjoined twins is presented. In thoracopagus twins the cardiovascular system mainly determines the options for separation and survival. Therefore prenatal investigation of this organ system is indispensable. Ultrasound level-2 examination predicted the impossibility of separation and fully matched the autopsy findings. In conclusion, ultrasound examination appears to be an important tool to enable planning of the optimal delivery approach.

Some observations on the supervision of dangerous offender patients

“All tragedy is the failure of communication”

(Wilson, 1956)

From time to time, general psychiatrists are asked to supervise offender patients who have been conditionally discharged into the community either by direction of the Home Secretary or by a Mental Health Review Tribunal (Mental Health Act 1983, sections 42(2) and 73(2)(4b)). In addition, they may be asked occasionally to provide psychiatric management for offenders released by the Home Secretary on life licence (Criminal Justice Act 1967, section 61). The effect of a conditional discharge following compulsory admission to hospital care by a court under a restriction order (Mental Health Act 1983, sections 37/41) is similar to that of a life licence.

Vampirism--a clinical condition

The phenomenon of the vampire is ancient, ubiquitous, and fascinating; moreover, it can only be understood adequately within the context of more general blood reliefs and rituals. (See Prins, 1984 for a review). References to vampires and associated phenomena may be found in the world's great literature long before Bram Stoker created his notorious and evil Count (Summers, 1960, 1980). Belief in the vampire's actual physical existence was probably encouraged by the prevalent practice of premature burial during times of plague, by the large numbers of itinerants and beggars that abound at such times, and by the fact that many of them took refuge in vaults and graveyards. In addition, the myth was probably given more tangible reality by such physical explanations asErythropoietic Protoporphyriaor its variants. This disorder is said to induce the body to produce an excess of porphyria, which results not only in excess redness of the eyes, skin and teeth, but also a receding of the upper lip and cracking of the skin, which bleeds when exposed to light. It has been suggested that physicians of the day could only treat sufferers by secluding them during the day and by persuading them to drink blood to replace that lost by bleeding (Illis, 1964; Milgrom, 1984; Prins, 1984). In more modern times, there have been accounts of people seeking to protect themselves from vampiric attentions (Farson & Hall, 1978).

Vampirism--legendary or clinical phenomenon?

In this paper I shall consider the extent to which there are any substantial grounds for suggesting that there is a definite condition which some authorities have described as ‘clinical vampirism’. Such a condition, if indeed it can be said to exist, needs to be seen, not only against a background of various vampire myths and beliefs, but within the wider anthropological context of blood beliefs and rituals. Thus, in order to examine this topic we must be prepared to engage the subject matter of anthropology, mythology, folklore and demonology, as well as those disciplines that concern themselves more specifically with seriously pathological behaviour (such as forensic medicine, forensic pathology, forensic psychiatry and psychology).

The care of the psychiatric prisoner--discharge into the community and its implications

Some aspects of the knowledge and skills required for dealing with the psychiatrically disordered offender in the community are identified; for this latter purpose, attention is focused specifically upon those who may have been adjudged to be dangerous in the past or who are thought likely to be dangerous in the future. It is suggested that a knowledge of the world's great literature provides a useful addition to clinical and academic teaching. The importance of team work and good communication is stressed as is the need for socio-forensic workers to identify their blind spots and defences.

Unstable Electrochemical Flows in a Pore System

Starting from the Navier-Stokes and Nernst-Planck equations, an explanation is proposed for the so-called pressure-volume flow limit cycle which can be observed when a polymer filter of weak ion-exchange capacity is subjected to both an electrochemical and pressure gradient. It is indicated that the streaming current cannot be neglected in cases of unstable flow, whereas it may be left out of consideration for stationary regimes. The source of oscillation is shown to arise from non-linearity in the Maxwell pressure tensor. Although not including inertial forces, the present treatment seems satisfactory as a first approach, if boundary conditions are carefully evaluated.