Designing person-centred technologies to support patients undergoing cancer surgery: a pharmacist-led, qualitative study

Introduction

Lifestyle changes made during the pre-operative period can positively influence post-operative outcomes and the overall success of cancer surgeries.1 Digital technologies (including smartphone apps and fitness trackers) which support patients with physical activity and rehabilitation advice present an opportunity to support surgical patients remotely.2 However, little is known about the best way to design or provide these digital technologies in a person-centred manner. In order to develop effective digital strategies for this unique patient cohort, it is important to first understand in what way(s) do cardiothoracic cancer surgery patients want to be supported with technology.3

Aim

To understand how digital technologies could be designed and delivered to better support patients undergoing cancer surgery, specifically: 1) what support do patients want from technologies, 2) how do they want to use them, and 3) when should they be implemented pre- and/or post-operatively?

Methods

The EQUATOR guidelines and COREQ checklist were followed. Pre- and post-operative patients attending cardiothoracic cancer surgery clinics within one large teaching hospital in the North of England were invited to take part. Purposive sampling was employed to recruit a representative sample of patients. Semi-structured interviews took place between September 2020-February 2021, during the coronavirus pandemic; interviews were conducted over the telephone or via video call-based software, and were audio-recorded and transcribed verbatim. Interviews included questions on participant surgical experience, behaviour change and perspectives on digital technologies. Reflexive thematic analysis enabled the development of themes from the data. QSR NVivo software (Version 12) facilitated data analysis. The Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualisation. Ethical approval was obtained from the NHS Health Research Authority (HRA) and Care Research Wales (reference: 19/NE/0318).

Results

Sixteen participants were recruited; these included 9 females, with 6 interviews being ran via Zoom®, and an average age for all participants of 65-years (SD 8.29). Four themes were developed from the data that related to the design and delivery of person-centred technologies in order to best meet the needs of patients undergoing cardiothoracic cancer surgery; these centred on: (i) “getting the technology to tell me, guide me and encourage me”; (ii) “tracking me and supporting me to reach my goals”; (iii) “feeling comfort in knowing I’m not alone”; and (iv) “getting the timing right for me”.

Discussion/Conclusion

This study is one of the first in this patient cohort to involve pre- and post-operative participants. It provides key insights to address knowledge gaps relating to the design and optimisation of person-centred digital technologies for patients undergoing surgery for cardiothoracic cancer. We acknowledge some limitations with our work; whilst we did not sample participants by socioeconomic status, it is possible that different socioeconomic classes may have varied experiences with technologies. Our focus was solely cardiothoracic cancer surgery and thus findings may not be generalisable to other surgical procedures. These findings have the potential to shape and influence future work on the co-design and optimisation of person-centred digital health technologies in modern healthcare settings.

References

1. Silver JK, et al. Cancer rehabilitation may improve function in survivors and decrease the economic burden of cancer to individuals and society. Work, 2013, 46(4):455-472.

2. Robinson A, et al. The effectiveness of digital technologies to support surgical patients in changing their health behaviours: a systematic review. BJS Open, 2021. DOI: 10.1093/bjsopen/zraa009.

3. Robinson A, et al. Digital and mobile technologies to promote physical health behaviour change and provide psychological support for elective surgical patients: a meta-ethnography and systematic review. JMIR mHealth and uHealth, 2020. 8(12): e19237. DOI: 10.2196/19237.

Predicting infection and sepsis; what predictors have been used to train machine learning algorithms? A systematic review

Introduction

Sepsis is a life-threatening condition that is associated with increased mortality. Artificial intelligence tools can inform clinical decision making by flagging patients who may be at risk of developing infection and subsequent sepsis and assist clinicians with their care management.

Aim

To identify the optimal set of predictors used to train machine learning algorithms to predict the likelihood of an infection and subsequent sepsis and inform clinical decision making.

Methods

This systematic review was registered in PROSPERO database (CRD42020158685). We searched 3 large databases: Medline, Cumulative Index of Nursing and Allied Health Literature, and Embase, using appropriate search terms. We included quantitative primary research studies that focused on sepsis prediction associated with bacterial infection in adult population (>18 years) in all care settings, which included data on predictors to develop machine learning algorithms. The timeframe of the search was 1st January 2000 till the 25th November 2019. Data extraction was performed using a data extraction sheet, and a narrative synthesis of eligible studies was undertaken. Narrative analysis was used to arrange the data into key areas, and compare and contrast between the content of included studies. Quality assessment was performed using Newcastle-Ottawa Quality Assessment scale, which was used to evaluate the quality of non-randomized studies. Bias was not assessed due to the non-randomised nature of the included studies.

Results

Fifteen articles met our inclusion criteria (Figure 1). We identified 194 predictors that were used to train machine learning algorithms to predict infection and subsequent sepsis, with 13 predictors used on average across all included studies. The most significant predictors included age, gender, smoking, alcohol intake, heart rate, blood pressure, lactate level, cardiovascular disease, endocrine disease, cancer, chronic kidney disease (eGFR<60ml/min), white blood cell count, liver dysfunction, surgical approach (open or minimally invasive), and pre-operative haematocrit < 30%. These predictors were used for the development of all the algorithms in the fifteen articles. All included studies used artificial intelligence techniques to predict the likelihood of sepsis, with average sensitivity 77.5±19.27, and average specificity 69.45±21.25.

Conclusion

The type of predictors used were found to influence the predictive power and predictive timeframe of the developed machine learning algorithm. Two strengths of our review were that we included studies published since the first definition of sepsis was published in 2001, and identified factors that can improve the predictive ability of algorithms. However, we note that the included studies had some limitations, with three studies not validating the models that they developed, and many tools limited by either their reduced specificity or sensitivity or both. This work has important implications for practice, as predicting the likelihood of sepsis can help inform the management of patients and concentrate finite resources to those patients who are most at risk. Producing a set of predictors can also guide future studies in developing more sensitive and specific algorithms with increased predictive time window to allow for preventive clinical measures.

A survey of the knowledge and attitudes of Egyptian healthcare professionals towards the application of Health Information Technology to optimize antibiotic therapy

Introduction

Antimicrobial resistance is a global health problem, especially in developing countries. Antimicrobial Stewardship Programmes (AMS) have been shown to be effective at reducing antimicrobial resistance and hospital patient stays. Health information technology (HIT) can support Outpatient Parenteral Antimicrobial Therapy (OPAT) through more accurate diagnosis and management of infectious diseases.

Aim

To evaluate the knowledge and attitude of Egyptian healthcare professionals towards the application of HIT to optimize OPAT.

Methods

Healthcare professionals who worked in either private or public sectors of Egyptian healthcare system were emailed and asked if they would be willing to complete an electronic questionnaire (using google forms). One reminder was sent by email each week for two weeks (two in total) from the first invitation. The survey was laid out in four sections. The first section included specific details about the healthcare professional’s current employment and role, the second related to HIT services available in their organisations, the third covered their training in HIT and antimicrobial stewardship programmes, and the fourth included their use of HIT to optimize OPAT. Ethical approval was obtained from National Heart Institute, Egypt. Descriptive analysis was carried out for all the variables. One-way ANOVA testing at level of significance P-value <0.05, was used to compare numerical variables. SPSS version 26 was used for statistical analysis.

Results

Three hundred and eighty-five healthcare professionals were invited to respond to the questionnaire. (The response rate was 75.34% (290)). Of these, 152 (52.6%) were pharmacists, 134 (46.4%) physicians, and 3 (1%) nurses, and many participants (30.8%) had between 6 to 10 years of experience working in either outpatient or in-patient units. Only 15.2% of respondents mentioned that they have access to OPAT in their organizations, 51.2% did not have the service, while 33.6% responded that they did not know if the service was available. However, 27.3% had a training on ASP and 18.3% had a training on HIT. Mean scores for both knowledge (14.31±5.49) and attitude (14.67±2.53) were significantly higher in professionals who had received training in HIT (p = 0.003 & 0.006 respectively). However, scores for attitude were better than scores for knowledge.

Conclusions

In developing countries, HIT applications in OPAT are still in their infancy with only a few organisations adopting them. Egyptian healthcare professionals showed positive attitudes towards HIT use, especially when their knowledge was improved through training. Two strengths of this study include our high response rate and the wide breadth of different healthcare professionals who responded from both private and public healthcare settings. However, being a questionnaire, some questions were left unanswered and some respondents may not have been aware of their reasons for a particular answer. That said, this study has important implications for practice, with more awareness amongst healthcare professionals required on the availability of HIT services in their hospitals and how further training may be needed on the applications of HIT in optimizing OPAT.

Association of severity of primary open-angle glaucoma with serum vitamin D levels in patients of African descent

Purpose

To study the relationship between primary open-angle glaucoma (POAG) in a cohort of patients of African descent (AD) and serum vitamin D levels.

Methods

A subset of the AD and glaucoma evaluation study III (ADAGES III) cohort, consisting of 357 patients with a diagnosis of POAG and 178 normal controls of self-reported AD, were included in this analysis. Demographic information, family history, and blood samples were collected from all the participants. All the subjects underwent clinical evaluation, including visual field (VF) mean deviation (MD), central cornea thickness (CCT), intraocular pressure (IOP), and height and weight measurements. POAG patients were classified into early and advanced phenotypes based on the severity of their visual field damage, and they were matched for age, gender, and history of hypertension and diabetes. Serum 25-Hydroxy (25-OH) vitamin D levels were measured by enzyme-linked immunosorbent assay (ELISA). The association of serum vitamin D levels with the development and severity of POAG was tested by analysis of variance (ANOVA) and the paired t-test.

Results

The 178 early POAG subjects had a visual field MD of better than -4.0 dB, and the 179 advanced glaucoma subjects had a visual field MD of worse than -10 dB. The mean (95% confidence interval [CI]) levels of vitamin D of the subjects in the control (8.02 ± 6.19 pg/ml) and early phenotype (7.56 ± 5.74 pg/ml) groups were significantly or marginally significantly different from the levels observed in subjects with the advanced phenotype (6.35 ± 4.76 pg/ml; p = 0.0117 and 0.0543, respectively). In contrast, the mean serum vitamin D level in controls was not significantly different from that of the subjects with the early glaucoma phenotype (p = 0.8508).

Conclusions

In this AD cohort, patients with advanced glaucoma had lower serum levels of vitamin D compared with early glaucoma and normal subjects.

The African Descent and Glaucoma Evaluation Study (ADAGES) III: Contribution of Genotype to Glaucoma Phenotype in African Americans: Study Design and Baseline Data

PURPOSE

To describe the study protocol and baseline characteristics of the African Descent and Glaucoma Evaluation Study (ADAGES) III.

DESIGN

Cross-sectional, case-control study.

PARTICIPANTS

Three thousand two hundred sixty-six glaucoma patients and control participants without glaucoma of African or European descent were recruited from 5 study centers in different regions of the United States.

METHODS

Individuals of African descent (AD) and European descent (ED) with primary open-angle glaucoma (POAG) and control participants completed a detailed demographic and medical history interview. Standardized height, weight, and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA, and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California, San Diego, Data Coordinating Center for standardized processing and quality review.

MAIN OUTCOME MEASURES

Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and control participants were described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use, or past glaucoma surgery. Ocular conditions, including diabetic retinopathy, age-related macular degeneration, and past cataract surgery, were recorded.

RESULTS

The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD control participants, and 227 ED control participants. The AD POAG patients and control participants were significantly younger (both, 67.4 years) than ED POAG patients and control participants (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared with ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all P < 0.001). Family history of glaucoma did not differ between AD and ED POAG patients.

CONCLUSIONS

With its large sample size, extensive specimen collection, and deep phenotyping of AD and ED glaucoma patients and control participants from different regions in the United States, the ADAGES III genomics study will address gaps in our knowledge of the genetics of POAG in this high-risk population.