Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty

INTRODUCTION

Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up.

METHODS

Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing.

RESULTS

From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28 years postsurgery (median 5 years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC.

DISCUSSION

This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC.

CONCLUSIONS

A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.

The prevalence of potential drug-drug interactions in adults with intellectual disability

BACKGROUND

There is a high use of medications in adults with intellectual disability (ID). One implication of taking multiple medications is the potential for drug-drug interactions (DDIs). However, despite this being well highlighted in the mainstream literature, little is known about the incidence or associations of DDIs in the ID population.

METHODS

This study describes the prevalence, patterns and associations of potential DDIs in a total administrative sample of adults with ID known to services in Jersey. Demographic, health-related and medication data were collected from 217 adults known to ID services. Data were collected using a face-to-face survey. The Anatomical Therapeutic Chemical classification system was used to categorise medications, and Stockley's Drug Interaction Checker was used to classify potential DDIs. Drug-drug pairings were considered to be of clinical significance if they were to be 'avoided, adjusted, monitored or required further information'.

RESULTS

Potential DDIs of clinical significance were common. Exposure to potential DDIs of clinical significance was associated with being female, taking more than five medications (polypharmacy), living in residential care and having more health conditions. A simple regression was used to understand the effect of number of prescribed medications on potential DDIs of clinical significance. Every prescribed drug led to a 0.87 (95% confidence interval: 0.72-1.00) increase in having a potential DDI of clinical significance.

CONCLUSION

Adults with ID who live in residential care, who are female, exposed to polypharmacy and have more health conditions may be more likely to have potential DDIs of clinical significance. Urgent consideration needs to be given to the potential of DDIs in this population given their exposure to high levels of medication.

A group intervention which assists patients with dual diagnosis reduce their drug use: a randomized controlled trial

BACKGROUND

There is a well-recognized association between substance use and psychotic disorders, sometimes described as 'dual diagnosis'. The use of substances by people with psychosis has a negative impact in terms of symptoms, longitudinal course of illness and psychosocial adjustment. There are few validated treatments for such individuals, and those that do exist are usually impracticable in routine clinical settings. The present study employs a randomized controlled experimental design to examine the effectiveness of a manualized group-based intervention in helping patients with dual diagnosis reduce their substance use.

METHOD

The active intervention consisted of weekly 90-min sessions over 6 weeks. The manualized intervention was tailored to participants' stage of change and motivations for drug use. The control condition was a single educational session.

RESULTS

Sixty-three subjects participated, of whom 58 (92%) completed a 3-month follow-up assessment of psychopathology, medication and substance use. Significant reductions in favour of the treatment condition were observed for psychopathology, chlorpromazine equivalent dose of antipsychotics, alcohol and illicit substance use, severity of dependence and hospitalization.

CONCLUSIONS

It is possible to reduce substance use in individuals with psychotic disorders, using a targeted group-based approach. This has important implications for clinicians who wish to improve the long-term outcome of their patients.

The Health of the Nation Outcome Scales: validating factorial structure and invariance across two health services

OBJECTIVE

The Health of the Nation Outcome Scale (HoNOS) was developed in the mid-1990s as an inclusive and comprehensive instrument to measure patient outcomes in four main factors: behaviour, impairment, symptoms and social problems. This paper attempts to investigate whether similar health services rate the HoNOS with equivalent psychometric calibration.

METHOD

The purpose of this study was to test for invariant construct interpretation of the instrument across two equivalent health services, using simultaneous confirmatory factor analysis.

RESULTS

Although the four-factor model of the HoNOS was confirmed, structural non-invariance occurred, casting doubt on the equivalent interpretability and generalisability of the instrument across similar heath services.

CONCLUSIONS

Over-inclusiveness, lack of specificity and questionable independence of observations may have contributed to the non-invariant factor structure between the two health services. Such results shed some doubt on the ability of the HoNOS and like observational instruments to provide equivalent comparisons between health services.

Predicting community survival in early psychosis and schizophrenia populations after receiving intensive case management

OBJECTIVE

The study was undertaken to assess whether social and living skills functioning predicted community survival between subjects with chronic schizophrenia and early episode psychosis after receiving assertive community-based case management.

METHOD

Forty-two chronic schizophrenia patients and 49 early psychosis subjects were measured on hospitalisation for up to 3 years after receiving equivalent community-based assertive case management. A Kaplan-Meier survival analysis was performed to compare community survival between the two groups. A Cox-regression analysis was used to investigate whether sex, age, social and occupational functioning measured by the social and occupational functional assessment score (SOFAS), living skills measured by the life skills profile score (LSP), and overall role functioning measured by the role functioning scale (RFS) predicted community survival. Subscales of the LSP were also analysed in a subsequent Cox-regression using the forward selection method.

RESULTS

Differences in rate of community survival were not statistically significant (using the log-rank Chi-squared test) between subjects with early psychosis and chronic schizophrenia; however, half of the early psychosis subjects survived past the 12-month period while only a third of the chronic schizophrenia subjects did so within the same time period. The life skill profile was a significant predictor of community survival with low scores on the subscale of non-turbulence (i.e. antisocial behaviour) contributing to poorer community survival.

CONCLUSION

The amount of antisocial behaviour displayed while receiving assertive community-based case management may be an important predictor of community survival among subjects with early psychosis and chronic schizophrenia. Treatment of such behaviour may improve community survival among these populations.

Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study

OBJECTIVE

The study attempted to identify whether chronic mentally ill persons after receiving intensive case management (ICM) could demonstrate improved inpatient service utilisation compared with a matched control group cohort. Costings were measured to observe whether the increase in providing intensive outpatient contacts would be offset by savings in reduced inpatient service utilisation.

METHOD

Eighty ICM patients were matched on ICD-9 diagnosis, age, gender, length of illness, age at first inpatient and outpatient contact, marital status, educational level, employment status, country of birth, year of arrival to Australia and religion. Inpatient bed-days and outpatient contacts were recorded and compared 12 months prior to ICM treatment, 12 and 24 months after ICM using within/between group repeated measures analysis of variance.

RESULTS

The ICM group demonstrate significant reductions in inpatient service utilisation both within the 12- and 24-month period after receiving ICM treatment. The cost differential by 24 months of treatment was $801,475 in favour of the ICM model. The increase in costs of outpatient contacts were offset by a significant reduction in inpatient service utilisation.

CONCLUSION

When outpatient contacts averaged one contact a week for the duration of the study period no significant reductions in inpatient service utilisation was recorded, as demonstrated by comparison with the matched control group. By increasing outpatient contacts by 3-4 contacts a week, inpatient contacts reduced by 36.8%. ICM is an efficacious and cost effective way to implement community-based services to the chronically long-term mentally ill.

Paclitaxel (Taxol)--a guide to administration

The introduction of a new chemotherapeutic agent has implications for nursing care. Paclitaxel (Taxol) chemotherapy is now being used throughout Europe for treatment of patients with ovarian cancer who have previously failed a platinum-containing chemotherapy regimen, and in many countries to treat metastatic breast cancer. Nurses need to be equipped to care for these patients receiving Paclitaxel. This paper introduces nurses to Paclitaxel, the history of its development, its mechanism of action, potential side-effects and administration. Paclitaxel's side-effects include hypersensitivity reactions, neutropaenia, peripheral neuropathy, asymptomatic bradycardia, alopecia, malaise, myalgias and arthralgias. Administration guidelines will be discussed because Paclitaxel leaches plasticizer from polyvinyl chloride (PVC) intravenous-giving sets normally used to administer chemotherapy, hence an alternative delivery system is required.

High performance for expert systems: II. A system for leukaemia diagnosis

A system for diagnosing leukaemia subtypes from monoclonal antibody test results has been programmed directly from the expertise of one immunologist. It gives an acceptable conclusion for 400 past cases, with summaries of its reasoning and suggestions for further tests. Its development included three major components: elicitation of the basic items of knowledge, formulation of a coordinated overall scheme, and representation in a computer language. All three were interdependent and required many cycles of trial and error, involving further discussions with the expert at all stages. By far the most difficult component was the formulation of a comprehensive specification for the problems of the domain, and this was only achieved when the knowledge engineer had gained a fair understanding of the application. The system is a tree-structured logic program written in PROLOG. This format facilitated experimentation with different knowledge representations, control of the interrelationships between rules and the elimination of errors. The problems of quality control and maintenance are of paramount importance for high-performance systems.