Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial

BACKGROUND

We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation.

METHODS

A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2-3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058.

RESULTS

1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period.

CONCLUSION

In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation.

Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid Physicians in the Clinical Management of Patients With Syncope: Systematic Theoretical and User-Centered Design Approach

BACKGROUND

The Canadian Syncope Risk Score (CSRS) was developed to improve syncope management in emergency department settings. Evidence-based tools often fail to have the intended impact because of suboptimal uptake or poor implementation.

OBJECTIVE

In this paper, we aimed to describe the process of developing evidence-based implementation strategies to support the deployment and use of the CSRS in real-world emergency department settings to improve syncope management among physicians.

METHODS

We followed a systematic approach for intervention development, including identifying who needs to do what differently, identifying the barriers and enablers to be addressed, and identifying the intervention components and modes of delivery to overcome the identified barriers. We used the Behaviour Change Wheel to guide the selection of implementation strategies. We engaged CSRS end users (ie, emergency medicine physicians) in a user-centered design approach to generate and refine strategies. This was achieved over a series of 3 qualitative user-centered design workshops lasting 90 minutes each with 3 groups of emergency medicine physicians.

RESULTS

A total of 14 physicians participated in the workshops. The themes were organized according to the following intervention development steps: theme 1-identifying and refining barriers and theme 2-identifying the intervention components and modes of delivery. Theme 2 was subdivided into two subthemes: (1) generating high-level strategies and developing strategies prototypes and (2) refining and testing strategies. The main strategies identified to overcome barriers included education in the format of meetings, videos, journal clubs, and posters (to address uncertainty around when and how to apply the CSRS); the development of a web-based calculator and integration into the electronic medical record (to address uncertainty in how to apply the CSRS); a local champion (to address the lack of team buy-in); and the dissemination of evidence summaries and feedback through email communications (to address a lack of evidence about impact).

CONCLUSIONS

The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure that the CSRS is well positioned for impact, a comprehensive suite of strategies was identified to address known barriers.

Development of practice recommendations based on the Canadian Syncope Risk Score and identification of barriers and facilitators for implementation

BACKGROUND

Wide variations in emergency department (ED) syncope management exist. The Canadian Syncope Risk Score (CSRS) was developed to predict the probability of 30-day serious outcomes after ED disposition. Study objectives were to evaluate the acceptability of proposed CSRS practice recommendations among providers and patients, and identify barriers and facilitators for CSRS use to guide disposition decisions.

METHODS

We conducted semi-structured interviews with 41 physicians involved in ED syncope and 35 ED patients with syncope. We used purposive sampling to ensure a variety of physician specialties and CSRS patient risk levels. Thematic analysis was completed by two independent coders with consensus meetings to resolve conflicts. Analysis proceeded in parallel with interviews until data saturation.

RESULTS

The majority (97.6%; 40/41) of physicians agreed with discharge of low risk (CSRS ≤ 0) but opined that 'no follow up' changed to 'follow-up as needed'. Physicians indicated current practices do not align with the medium-risk recommendation to discharge patients with 15-day monitoring (CSRS = 1-3; due to lack of access to monitors and timely follow-up) and the high-risk recommendation (CSRS ≥ 4) to potentially discharge patients with 15-day monitoring. Physicians recommended brief hospitalization of high-risk patients due to patient safety concerns. Facilitators included the CSRS-based patient education and scores supporting their clinical gestalt. Patients reported receiving varying levels of information regarding syncope and post-ED care, were satisfied with care received and preferred less resource intensive options.

CONCLUSION

Our recommendations based on the study results were: discharge of low-risk patients with physician follow-up as needed; discharge of medium-risk patients with 15-day cardiac monitoring and brief hospitalization of high-risk patients with 15-day cardiac monitoring if discharged. Patients preferred less resource intensive options, in line with CSRS recommended care. Implementation should leverage identified facilitators (e.g., patient education) and address the barriers (e.g., monitor access) to improve ED syncope care.

Performance of single serum progesterone in the evaluation of symptomatic first-trimester pregnant patients: a systematic review and meta-analysis

OBJECTIVES

Pain and bleeding complicate 30% of pregnancies, raising concerns for viability. The objective is to evaluate the diagnostic characteristics of a single serum progesterone level in assessing pregnancy viability among symptomatic patients.

METHODS

We conducted a predefined literature search in MEDLINE, Embase (OVID), CINAHL and Cochrane databases for studies that enrolled patients in first trimester with miscarriage symptoms, measured progesterone and reported pregnancy viability, from inception to July 2020. We extracted data for 2 × 2 tables, progesterone threshold levels and viability. We obtained summary estimates of sensitivity, specificity, Diagnostic Odds Ratio (DOR), and predictive values at given prevalence rates.

RESULTS

We identified 54 publications. There was a total of 15,878 patients enrolled, of whom 7864 patients (49.5%) were confirmed to have a viable pregnancy and 8014 patients (50.5%) were confirmed to have a non-viable pregnancy. The cut-off value of progesterone ranged from 3.2 to 25 ng/mL (20.034-79.5 nmol/L). We evaluated the performance of the following progesterone cut-off categories: < 6.3, 6.3-12.6, 12.7-19.9, and 20-25 ng/mL. To detect non-viable pregnancy, progesterone with cut-off < 6.3 ng/mL had sensitivity 73.1%, specificity 99.2% and DOR 322.0 (PPV 0.91, 0.97 and 0.99 at prevalences 0.1, 0.25, 0.5, respectively, indicating higher likelihood of non-viable pregnancy), and cut-off category 20-25 ng/mL had sensitivity 91.3%, specificity 75% and DOR 31.4 (NPV 0.99, 0.96 and 0.89 at the prevalences above indicating higher likelihood of viable pregnancy).

CONCLUSION

A single progesterone level provides a clinically useful prognostic information on pregnancy viability. More than nine out of ten patients with a level < 6.3 ng/mL (< 20.034 nmol/L) will be diagnosed with a non-viable pregnancy, and more than 90% of patients with a level ≥ 20-25 ng/mL (63.6-79.5 nmol/L) will have a viable pregnancy confirmed.

Outcomes of Immediate Breast Reconstruction in Triple Negative Breast Cancer: A Propensity Score-Matched Analysis

PURPOSE

Triple negative breast cancer (TNBC) patients have a significantly worse prognosis and survival compared to non-TNBC patients. Mastectomy and immediate breast reconstruction (MIBR) is associated with higher rates of complications overall, but whether MIBR significantly increases oncological risk in TNBC patients has not been fully elucidated. Our study aimed to evaluate the oncological safety of MIBR in patients with TNBC compared to non-TNBC.

METHODS

A 6-year prospectively maintained retrospective database at The Ottawa Hospital was reviewed from January 1, 2013 to May 31, 2019. Propensity score-matching was performed using the nearest-neighbour method with a matching ratio of 2:1. Kaplan-Meier and log rank tests were performed to provide statistical comparison of disease-free interval (DFI). DFI was defined as time from MIBR to locoregional recurrence or disease-specific mortality. P-value < 0.05 indicated statistical significance.

RESULTS

Of 277 eligible patients, 153 patients were matched. The cohort consisted of 51(33%) TNBC patients and 102 (67%) non-TNBC patients after 2:1 propensity score-matching. The rates of delays to first radiochemotherapy [17 (33%) vs.14 (14%), p = 0.10], postoperative complications [13 (26%) vs. 34 (33%), p = 0.50], and locoregional recurrence [2 (1.96%) vs. 1 (1.96%), p = 1.0] were statistically similar in TNBC and non-TNBC, respectively. DFI was not significantly different in TNBC compared to non-TNBC patients (log-rank p = 1.0). There was no mortality in this cohort.

CONCLUSIONS

This 6-year retrospective 2:1 propensity score-matched cohort study demonstrated similar oncological safety for MIBR in patients with TNBC and non-TNBC.. Overall, these findings provide additional support for the oncological safety of MIBR in TNBC. . Therefore, MIBR remains a therapeutic option for patients with TNBC.

The effect of immediate breast reconstruction on adjuvant therapy delay, locoregional recurrence, and disease-free survival

BACKGROUND

An important risk inherent to both alloplastic and autologous immediate breast reconstruction (IBR) is the higher incidence of postoperative complications and delays to adjuvant therapy. The main objective of this retrospective cohort study was to identify risk factors for locoregional recurrence after breast cancer mastectomy and IBR.

METHODS

A 6-year retrospective study of breast cancer patients treated with mastectomy only (MO) or mastectomy and IBR (MIBR) was conducted from January 2013 to May 2019. The outcomes of interest included delay in adjuvant chemoradiotherapy, postoperative complications, and locoregional recurrence. Cox regression survival was used to estimate the risk of locoregional recurrence and time to adjuvant therapy.

RESULTS

Of 1832 patients reviewed, 720 (38%) were included. The cohort consisted of 443 (62%) MO and 277 (38%) MIBR [140 (51%) direct-to-implant (MIBRi1), 96(35%) tissue expander to implant (MIBRi2), and 41(15%) autologous flap (MIBRf)]. MIBR had more delays to adjuvant therapy compared to MO [113 (70%) vs. 72 (80%) months, p = 0.022]. Kaplan-Meier analysis showed that MIBRi2 had significantly shorter DFS compared to MO [MIBRi2: 39.2 (15.6) vs MO: 41.7 (19.6) months, log-rank p-value = 0.01]. Cox regression indicated that MIBRi2 was associated with a 3.26-higher risk of locoregional recurrence compared to MO [HR: 3.26; 95% CI: 1.56, 9.24].

CONCLUSIONS

Cox regression showed MIBRi2 was significantly associated with increased risk of locoregional recurrence compared to MO. Neither delays nor postoperative complications were identified as significant risk factors for locoregional recurrence risk.

Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort

BACKGROUND

The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS).

METHODS

We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients.

RESULTS

We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04).

INTERPRETATION

Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.

A comparison of patient-reported outcomes between Alloderm and Dermacell in immediate alloplastic breast reconstruction: A randomized control trial

BACKGROUND

Alloderm and Dermacell are the two leading human acellular dermal matrices (ADM) in immediate breast reconstruction (IBR). Despite differences in sterility, consistency, thickness and cost, there are no comparative trials to date to compare patient-reported outcome measures (PROM) between the two products. The purpose of this study was to determine if there was a difference in patient-reported outcomes (as measured by the BREAST-Q) between patients reconstructed with Alloderm and Dermacell.

METHODS

A single center, open-label, randomized control trial of patients undergoing IBR with an implant for breast cancer or breast cancer prophylaxis was performed. Patients were randomized to either Alloderm or Dermacell. Baseline demographic data were compared, and linear mixed models were used to identify associations with BREAST-Q over time.

RESULTS

Between June 2016 and October 2018, 62 patients were randomized into two groups, 31(50%) Alloderm and 31(50%) Dermacell. Of these, 23(74%) patients in the Alloderm group and 27(87%) patients of the Dermacell group filled out BREAST-Q questionnaires. Baseline BREAST-Q scores with respect to satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being were similar between groups (p>0.05). At 3 months postoperatively, the Alloderm group had a statistically significant improvement with respect to satisfaction with breasts (67 vs 53, p = 0.03), satisfaction with overall results (85 vs 61, p = 0.003), satisfaction with the surgeon (89 vs 67, p = 0.01), and satisfaction with information provided (74 vs 59, p = 0.02). At 12 months postoperatively, there were no statistically significant differences in PROM between groups (p>0.05).

CONCLUSION

We report the first randomized controlled trial to date comparing patient-reported outcomes of the two most commonly used ADMs in IBR in Canada. Although a short-term analysis favors the use of Alloderm, there does not appear to be any difference in outcomes between the two products in the longer term.

A mixed-methods pilot study of 'LIFEView' audiovisual technology: Virtual travel to support well-being and quality of life in palliative and end-of-life care patients

BACKGROUND

There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care.

AIM

To determine (1) the feasibility of integrating 'LIFEView', a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using 'LIFEView' videos.

DESIGN

A mixed-methods pre-post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life.

SETTING/PARTICIPANTS

Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants.

RESULTS

Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System-revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using 'LIFEView', perceptions of the technology, reminiscence, 'LIFEView' as an adaptable technology and ongoing or future use.

CONCLUSION

A future adequately powered study to investigate the impacts of 'LIFEView' on patient well-being and quality of life appears to be feasible.

Complication rates of acellular dermal matrix in immediate breast reconstruction with radiation: A single-institution retrospective comparison study

BACKGROUND

The use of acellular dermal matrix (ADM) in immediate breast reconstruction (IBR) continues to rise despite ongoing concerns with respect to increased complication rates. While the indications for radiation continue to broaden, it is essential to critically evaluate ADM's performance in its context. The purpose of this study was to review complication rates between patients reconstructed with and without ADM, who underwent IBR and radiation.

METHODS

A retrospective review was performed for patients undergoing IBR and radiation from 2010 to 2019. Postoperative outcomes were compared between patients with and without ADM.

RESULTS

Over a 9-year period, 130 patients underwent IBR and radiation (42% preoperatively and 59% postoperatively). For patients with preoperative radiation (36 ADM and 18 non-ADM), the average follow-up was 312 and 296 days, respectively. In this group, there was no difference in minor complications (25% ADM, 22% non-ADM, and p = 1.00) or major complications (31% ADM, 22% Non-ADM, and p = 0.52). For patients with postoperative radiation (53 ADM and 23 non-ADM), the average follow-up was 544 and 748 days, respectively. There was no difference in minor complications (21% ADM, 26% non-ADM, and p = 0.11) or major complications (21% ADM, 26% non-ADM, and p = 0.61). Multivariable logistic regression analyses showed no difference between ADM and non-ADM groups (OR 0.83, 95% CI 0.22-3.08, and p = 0.78).

CONCLUSION

Despite increasing literature supporting the use of ADM in breast reconstruction, postoperative outcomes following radiation remain poorly understood. In the present study, we report no difference in overall complication rates between breasts reconstructed with and without ADM in an irradiated field. Nevertheless, the complication rate remains high, and future studies will be required to determine whether ADM-associated complications in an irradiated field outweigh the purported benefits.

Predicting Falls Using the Stroke Assessment of Fall Risk Tool

BACKGROUND

Falls in the inpatient stroke population are common, resulting in increased morbidity and slow rehabilitation progress. Falls may result from stroke-specific neurologic deficits; however, assessment of these deficits is lacking in many fall screening tools.

OBJECTIVE

To compare the ability to predict falls of the Stroke Assessment of Fall Risk (SAFR) tool, which includes items related to stroke-specific neurologic deficits, and the commonly used Morse Fall Scale, which does not include these items.

DESIGN

Prospective cohort study.

SETTING

Inpatient tertiary stroke rehabilitation unit.

PARTICIPANTS

Patients (N = 220) with acute stroke.

MAIN OUTCOME MEASURES

Falls were captured by the medical records from January 2017 to September 2018. Logistic regression analysis evaluated both screening tools for predicting falls by calculating sensitivity, specificity, area under the receiver operating characteristic (AUC-ROC) curve, and odds ratio (OR). We compared SAFR and Morse mean scores between fallers and non-fallers using t-tests.

RESULTS

Forty-eight (21.8%) patients experienced ≥1 fall. SAFR, but not Morse, scores showed a statistically significant difference between fallers and non-fallers (P = .001 vs P = .24, respectively). Higher SAFR score was associated with higher odds of falls (OR 1.36, 95% CI [1.12, 1.64]), whereas Morse was not (OR 1.04, 95% CI [0.97, 1.12]). SAFR showed a statistically significant difference in hemi-neglect between fallers and non-fallers (P = .03). Sensitivity and specificity of SAFR were 47.9% and 76.7%, vs 45.8% and 68.0% for Morse, respectively. SAFR positive predictive value and negative predictive value were 36.5% and 84.1%, respectively, similar to Morse (28.6% and 81.8%). The AUC-ROC was 0.65 for SAFR and 0.56 for Morse.

CONCLUSIONS

SAFR was significantly associated with fall risk and had better discrimination between fallers and non-fallers than Morse. The neurologic-specific hemi-neglect component of SAFR, a component not present on the Morse, was a fall risk factor. Further research evaluating the predictive value of fall scales that include neurologic deficits is needed.