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Ashmore DL, Wilson T, Halliday V, Lee M. Malnutrition in emergency general surgery: a survey of National Emergency Laparotomy Audit Leads. J Hum Nutr Diet 2024; 37:663-672. [PMID: 38436051 DOI: 10.1111/jhn.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients who are malnourished and have emergency general surgery, such as a laparotomy, have worse outcomes than those who are not malnourished. It is paramount to identify these patients and minimise this risk. This study aimed to describe current practices in identifying malnutrition in patients undergoing a laparotomy, specifically focusing on screening, assessment, nutrition pathways and barriers encountered by clinicians. METHODS Following piloting and validity assessment, anaesthetic and surgical National Emergency Laparotomy Audit (NELA) Leads at hospitals across England and Wales were emailed an invitation to a survey. Responses were gathered using Qualtrics. Descriptive analysis and correlation with laparotomy volume and professional role were performed in SPSSv26. University of Sheffield ethical approval was obtained (UREC 046205). The results from the survey are reported according to the CHERRIES guidelines. RESULTS The survey was completed by 166/289 NELA Leads from 117/167 hospitals (57.4% and 70.1% response rates, respectively). Participants reported low rates of nutritional screening (42/166; 25.3%) and assessment (26/166; 15.7%) for malnutrition preoperatively. More than one third of respondents (40.1%) had no awareness of local screening tools; indeed, the Malnutrition Universal Screening Tool (MUST) was used by approximately half of respondents (56.6%). Contrary to guidelines, NELA Leads report albumin levels continue to be used to determine malnutrition risk (73.5%; 122/166). Postoperative nutrition pathways were common (71.7%; 119/166). Reported barriers to nutritional screening and assessment included a lack of time, training and education, organisational support and ownership. Participants indicated nutrition risk is inadequately identified and is an important missing data item from NELA. There was no significant correlation with hospital laparotomy volume in relation to screening or assessment for malnutrition, the use of nutritional support pathways or organisational barriers. There was interprofessional agreement across a number of domains, although some differences did exist. CONCLUSIONS Wide variation exists in the current practice of identifying malnutrition risk in NELA patients. Barriers include a lack of time, knowledge and ownership. Nutrition pathways that encompass the preoperative phase and incorporation of nutrition data in NELA may support improvements in care.
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Affiliation(s)
- Daniel L Ashmore
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Timothy Wilson
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Vanessa Halliday
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
| | - Matthew Lee
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
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Stone L, Frank O, Tam CWM. Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests. JAMA 2023; 329:175. [PMID: 36625817 DOI: 10.1001/jama.2022.20739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Louise Stone
- Australian National University, Canberra, Australia
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O’Connor DA, Glasziou P, Maher CG, McCaffery KJ, Schram D, Maguire B, Ma R, Billot L, Gorelik A, Traeger AC, Albarqouni L, Checketts J, Vyas P, Clark B, Buchbinder R. Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial. JAMA 2022; 328:850-860. [PMID: 36066518 PMCID: PMC9449798 DOI: 10.1001/jama.2022.14587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. OBJECTIVE To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). DESIGN, SETTING, AND PARTICIPANTS This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. INTERVENTIONS Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. MAIN OUTCOMES AND MEASURES The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. RESULTS A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). CONCLUSIONS AND RELEVANCE Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12619001503112.
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Affiliation(s)
- Denise A. O’Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten J. McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Dina Schram
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brigit Maguire
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Robert Ma
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Adrian C. Traeger
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Juliet Checketts
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Parima Vyas
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brett Clark
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
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Hysong SJ, SoRelle R, Hughes AM. Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration. Hum Factors 2022; 64:99-108. [PMID: 33830786 DOI: 10.1177/00187208211005620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.
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Affiliation(s)
- Sylvia J Hysong
- Michael E. DeBakey VA Medical Center, Texas, USA
- 3989 Baylor College of Medicine, Texas, USA
| | | | - Ashley M Hughes
- 5228 University of Illinois at Chicago, Champaign, USA
- 20116 Edward Hines JR VA Medical Center, Illinois, USA
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Holmstrom AL, Ott KC, Weiss HK, Ellis RJ, Hungness ES, Shapiro MB, Yang AD. Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative. J Trauma Acute Care Surg 2021; 90:1048-1053. [PMID: 34016928 DOI: 10.1097/ta.0000000000003152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS. METHODS Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests. RESULTS Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009). CONCLUSION Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals. LEVEL OF EVIDENCE Care management, Level IV.
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Affiliation(s)
- Amy L Holmstrom
- From the Department of Surgery (A.L.H., K.C.O., H.K.W., R.J.E., E.S.H., M.B.S., A.D.Y.), Feinberg School of Medicine, and Surgical Outcomes and Quality Improvement Center (R.J.E., A.D.Y.), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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6
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Zhu Y, Simon GJ, Wick EC, Abe-Jones Y, Najafi N, Sheka A, Tourani R, Skube SJ, Hu Z, Melton GB. Applying Machine Learning Across Sites: External Validation of a Surgical Site Infection Detection Algorithm. J Am Coll Surg 2021; 232:963-971.e1. [PMID: 33831539 DOI: 10.1016/j.jamcollsurg.2021.03.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/13/2021] [Accepted: 03/03/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical complications have tremendous consequences and costs. Complication detection is important for quality improvement, but traditional manual chart review is burdensome. Automated mechanisms are needed to make this more efficient. To understand the generalizability of a machine learning algorithm between sites, automated surgical site infection (SSI) detection algorithms developed at one center were tested at another distinct center. STUDY DESIGN NSQIP patients had electronic health record (EHR) data extracted at one center (University of Minnesota Medical Center, Site A) over a 4-year period for model development and internal validation, and at a second center (University of California San Francisco, Site B) over a subsequent 2-year period for external validation. Models for automated NSQIP SSI detection of superficial, organ space, and total SSI within 30 days postoperatively were validated using area under the curve (AUC) scores and corresponding 95% confidence intervals. RESULTS For the 8,883 patients (Site A) and 1,473 patients (Site B), AUC scores were not statistically different for any outcome including superficial (external 0.804, internal [0.784, 0.874] AUC); organ/space (external 0.905, internal [0.867, 0.941] AUC); and total (external 0.855, internal [0.854, 0.908] AUC) SSI. False negative rates decreased with increasing case review volume and would be amenable to a strategy in which cases with low predicted probabilities of SSI could be excluded from chart review. CONCLUSIONS Our findings demonstrated that SSI detection machine learning algorithms developed at 1 site were generalizable to another institution. SSI detection models are practically applicable to accelerate and focus chart review.
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Affiliation(s)
- Ying Zhu
- Institute for Health Informatics, University of Minnesota, Twin Cities, Minneapolis, MN
| | - Gyorgy J Simon
- Institute for Health Informatics, University of Minnesota, Twin Cities, Minneapolis, MN; Departments of Medicine, University of Minnesota, Twin Cities, Minneapolis, MN
| | | | - Yumiko Abe-Jones
- Departments of Surgery, University of California San Francisco, San Francisco, CA
| | - Nader Najafi
- Departments of Surgery, University of California San Francisco, San Francisco, CA
| | - Adam Sheka
- Medicine, University of California San Francisco, San Francisco, CA
| | - Roshan Tourani
- Institute for Health Informatics, University of Minnesota, Twin Cities, Minneapolis, MN
| | - Steven J Skube
- Medicine, University of California San Francisco, San Francisco, CA
| | - Zhen Hu
- Institute for Health Informatics, University of Minnesota, Twin Cities, Minneapolis, MN
| | - Genevieve B Melton
- Institute for Health Informatics, University of Minnesota, Twin Cities, Minneapolis, MN; Medicine, University of California San Francisco, San Francisco, CA.
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Dolly SO, Jones G, Allchorne P, Wheeler D, Ali S, Mukadam Y, Zheng S, Rahman L, Sindhar J, Moss CL, Harari D, Van Hemelrijck M, Cunliffe A, De Michele LV. The effectiveness of the Guy's Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients. Br J Cancer 2021; 124:1079-1087. [PMID: 33402736 PMCID: PMC7783491 DOI: 10.1038/s41416-020-01207-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. METHODS We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service. RESULTS There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)-with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%). CONCLUSIONS RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%-justifying the RDC approach in vague symptom patients.
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Affiliation(s)
| | - Geraint Jones
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- South East London Cancer Alliance, London, UK
| | - Paula Allchorne
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
| | - Daniel Wheeler
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sunnyath Ali
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Yaseen Mukadam
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Sifan Zheng
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Loay Rahman
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Jan Sindhar
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - Charlotte Louise Moss
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Danielle Harari
- Guy's and St Thomas' NHS Foundation Trust (GSTT), Medical Oncology, London, UK
- King's College London, Geriatric and Acute Medicine, Department of Ageing and Health, London, UK
| | - Mieke Van Hemelrijck
- King's College London, School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), London, UK
| | - Anthony Cunliffe
- Joint National Lead Macmillan GP Adviser and Joint Clinical Chair, South East London Cancer alliance, London, UK
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Jones PG, Gardener M. Referral for investigation: a redundant SNOMED-CT chief presenting complaint. N Z Med J 2021; 134:39-44. [PMID: 33582706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The Ministry of Health has mandated that all emergency department (ED) presentations are coded using the Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) from 2021. The current ED reference set contains the non-specific term 'Referral for investigation' in the list of available chief presenting complaints (CPCs). The aim of this study was to determine the rate of use of this term and how often a more specific (and therefore more clinically useful) term was used. METHOD This was a cross-sectional audit of routinely collected presenting complaint data, supplemented by a retrospective case note review. RESULTS 'Referral for investigation' was used for 497/9,067 (5.5%, 95%CI 5-6%) presentations, with increased use for urgent cases. An alternative CPC was available in 467/497 (94.0%, 95%CI 92-96%) of cases from the existing reference set. Of 98 different CPCs, the common alternatives were: 'Chest pain' (6.4%), 'Shortness of breath' (4.2%) 'Abdominal pain' (3.6%), 'Altered mental status' (3.4%) and 'Postoperative complication' (3.2%). Six of 13 cardiac arrests and eight of 63 of multiple trauma cases were coded as 'Referral for investigation'. With the addition of two new terms to the New Zealand reference set ('Abnormal blood test' and 'Radiology request'), each of the remaining 30 presentations would have an alternative and more accurate CPC. CONCLUSION 'Referral for investigation' should be removed from the New Zealand emergency department reference set for chief presenting complaints to improve data quality.
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Affiliation(s)
- Peter G Jones
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board; Department of Surgery, School of Medicine, University of Auckland
| | - Mark Gardener
- Adult Emergency Department, Auckland City Hospital, Auckland District Health Board
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9
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Jones PG, Dance A, Shah N. Accuracy of SNOMED-CT Chief Presenting Complaint Codes: an audit of 1,000 cases. N Z Med J 2020; 133:67-75. [PMID: 33332341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) coding system has been introduced to emergency departments in New Zealand, starting with the patient's chief presenting complaint (CPC). However, it is not known how accurate CPC coding at triage is, or whether coding accuracy varies by patient characteristics. The aim of this study was to determine the accuracy of CPC coding. METHOD We compared the real-time triage recorded CPC with the presenting complaints recorded in medical notes by the treating clinician. Agreement was determined by exact CPC matches and the kappa statistic. RESULTS From 1,000 consecutive presentations 852 were eligible (89 CPCs). Real-time CPC agreed with clinical notes in 514/852 (60.3%) cases. When real-time free text comments were included, agreement was 732/852 (85.9%). There were no differences by age, sex or ethnicity. Agreement for the common CPCs: 'trauma' (21%); 'abdominal pain' (11%), 'chest pain' 87 (10%) and 'shortness of breath' (8%) was substantial, k=0.66 (95% CI: 0.61, 0.70). Use of non-specific CPC such as 'referral for investigation' (5%) and 'general weakness/fatigue/unwell' (2%) was uncommon but associated with poor agreement. CONCLUSION The accuracy of real-time coding for CPC using SNOMED-CT was reasonable, except for non-specific CPCs, which should be avoided where possible.
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Affiliation(s)
- Peter G Jones
- Associate Professor, Department of Surgery, School of Medicine, University of Auckland, Auckland; Emergency Physician, Adult Emergency Department, Auckland City Hospital, Auckland
| | - Annette Dance
- Charge Nurse, Adult Emergency Department, Auckland City Hospital, Auckland
| | - Nikhar Shah
- House Officer, Auckland City Hospital, Auckland
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10
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Callaway M, Harden S, Ramsden W, Beavon M, Drinkwater K, Vanburen T, Rubin C, Beale A. A national UK audit for diagnostic accuracy of preoperative CT chest in emergency and elective surgery during COVID-19 pandemic. Clin Radiol 2020; 75:705-708. [PMID: 32600651 PMCID: PMC7311900 DOI: 10.1016/j.crad.2020.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/19/2020] [Indexed: 01/07/2023]
Abstract
AIM To report on a snap audit of all departments in the UK as to the value of preoperative thoracic imaging, preferably computed tomography (CT), of patients undergoing any surgery to assess for changes consistent with COVID-19 preoperatively. MATERIALS AND METHODS All Imaging departments in the UK were contacted and asked to record the number of preoperative CT examinations performed in patients being considered for both emergency and elective surgical intervention over a 5-day period in May 2020. RESULTS Forty-seven percent of departments replied with data provided on >820 patients. Nineteen percent of additional preoperative CT was in patients undergoing elective intervention and 81% in patients presenting with surgical abdominal pain. There was a high rate of false positives in patients who tested negative for COVID-19, producing a sensitivity for thoracic CT of 68.4%. CONCLUSION This UK-wide audit demonstrates that a large number of additional thoracic imaging examinations over a 5-day period were performed with a low sensitivity for the identification of COVID-19 in this preoperative group of patients. Given these findings, it is difficult to justify this additional examination in this group of patients.
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Affiliation(s)
- M Callaway
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK.
| | - S Harden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - W Ramsden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - M Beavon
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - K Drinkwater
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - T Vanburen
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - C Rubin
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - A Beale
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
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Abdullah I, Jafta AD, Chapanduka ZC. The impact of physician education regarding the importance of providing complete clinical information on the request forms of thrombophilia-screen tests at Tygerberg hospital in South Africa. PLoS One 2020; 15:e0235826. [PMID: 32760142 PMCID: PMC7410402 DOI: 10.1371/journal.pone.0235826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/23/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Thrombophilia-screen tests are specialised haemostasis tests that are affected by numerous unique patient variables including the presence of acute thrombosis, the concomitant use of medication and patient demographics. Complete information on the request form is therefore crucial for the haematological pathologist to make patient-specific interpretation of patients' results. OBJECTIVES To assess the completeness of thrombophilia-screen test request forms and determine the impact of provision of incomplete information, on the interpretive comments generated by reporting haematological pathologists. To assess the impact of an educational session given to clinicians on the importance of providing all the relevant information on the request forms. METHOD Two retrospective audits, each covering 3 months, were performed to evaluate the completeness of demographic and clinical information on thrombophilia-screen request forms and its impact on the quality of the interpretive comments before and after an educational intervention. RESULTS One hundred and seventy-one request forms were included in the first audit and 146 in the second audit. The first audit revealed that all 171 thrombophilia-screen request forms had complete patient demographic information but none had clinical information. Haematological pathologists only made generic comments which could not be applied to a specific patient. The second audit, conducted after a physician educational session, did not reveal any improvement in the clinical information provision by the test-ordering physicians. This was reportedly due to the lack of space on the request form. The interpretive comments therefore remained generic and not patient-specific. CONCLUSION Physicians' failure to provide relevant clinical information made it impossible for pathologists to make patient-specific interpretation of the results. A single physician education session did not change the practice, reportedly due to the inappropriate design of the test request form. Further studies are required to investigate the impact of an improved request form and the planned electronic test requesting.
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Affiliation(s)
- Ibtisam Abdullah
- National Health Laboratory Service Tygerberg Hospital and Division of Haematological Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrea D. Jafta
- AMPATH Laboratories and Division of Haematological Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Zivanai C. Chapanduka
- National Health Laboratory Service Tygerberg Hospital and Division of Haematological Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
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Lipton G, Stewart M, McDermid R, Docking R, Urquhart C, Morrison M, Montgomery J. Multispecialty tracheostomy experience. Ann R Coll Surg Engl 2020; 102:343-347. [PMID: 32233651 PMCID: PMC7374792 DOI: 10.1308/rcsann.2019.0184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. METHODS A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. RESULTS A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. CONCLUSIONS This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.
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Cegolon L, Mastrangelo G, Heymann WC, Dal Pozzo G, Ronfani L, Barbone F. A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015. Sci Rep 2019; 9:19442. [PMID: 31857615 PMCID: PMC6923393 DOI: 10.1038/s41598-019-55389-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 11/18/2019] [Indexed: 12/31/2022] Open
Abstract
Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.
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Affiliation(s)
- L Cegolon
- Local Health Unit N.2 "Marca Trevigiana", Public Health Department, Treviso, Italy.
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.
| | - G Mastrangelo
- Padua University, Department of Cardio-Thoracic & Vascular Sciences, Padua, Italy
| | - W C Heymann
- Florida State University, College of Medicine, Department of Clinical Sciences, Sarasota, Florida, USA
- Florida Department of Health, Sarasota County Health Department, Sarasota, Florida, USA
| | - G Dal Pozzo
- Obstetrics & Gynecology Unit, Hospital "Villa Salus", Venice, Italy
| | - L Ronfani
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - F Barbone
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
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Doris G, Devaraj NK, Shakirin SR, Sahimi M, Noraini M. A national audit on the utilisation and documentation of dabigatran checklist for patients initiated on dabigatran. Med J Malaysia 2019; 74:425-430. [PMID: 31649220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) especially dabigatran, have gain popularity for their efficacy, fixed dosing and favourable safety profile. A dabigatran prescribing checklist has been prepared by the Ministry of Health, Malaysia (MOH) to ensure rational and safe prescribing of dabigatran. This study therefore aimed to audit the utilization and documentation of this checklist and use of dabigatran in the government healthcare facilities. METHODS This is a nationwide retrospective audit on the documentation of Dabigatran Prescribing and Dispensing Checklist for a period of two years from January 2013 till December 2014. Data from these Dabigatran Checklists (indication, dose, duration, renal function and adverse drug reactions encountered) were extracted by the pharmacist at MOH healthcare facilities. RESULTS A total of 52 out of 56 (92.9%) of MOH facilities complied to usage of checklist at their centres involving a total of 582 patients of which 569 (97.7%) patients were initiated on dabigatran for the approved indications. The recommended dose of dabigatran was used correctly in 501 (99.6%) of patients. Reason for switching to DOACs use was only documented in 76.7% (131/171) of patients. The most common reason for switching from warfarin was poor INR control (n=39), history of bleeding/overwarfarinisation (n=22) and unable to attend regular INR clinic (n=21). There were 75 cases of adverse events reported. The most common adverse event reported were abdominal discomfort (n=10) followed by gum bleeding (n=9) and dizziness (n=5). CONCLUSIONS Compliance to the dabigatran check list was high with 70% of patients prescribed the appropriate dosing.
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Affiliation(s)
- G Doris
- Hospital Raja Permaisuri Bainun, Department of Pharmacy, Ipoh, Perak, Malaysia.
| | - N K Devaraj
- Universiti Putra Malaysia, Faculty of Medicine and Health Sciences, Department of Family Medicine, Serdang, Selangor, Malaysia
| | - S R Shakirin
- Ministry of Health, Pharmacy Practice & Development Division, Petaling Jaya, Selangor, Malaysia
| | - M Sahimi
- Hospital Tengku Ampuan Afzan, Pharmacy Department, Kuantan, Pahang, Malaysia
| | - M Noraini
- National Cancer Institute, Pharmacy Department, Putrajaya, Wilayah Persekutuan Putrajaya, Malaysia
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Brown C, Neep MJ, Pozzias E, McPhail SM. Reducing risk in the emergency department: a 12-month prospective longitudinal study of radiographer preliminary image evaluations. J Med Radiat Sci 2019; 66:154-162. [PMID: 31449740 PMCID: PMC6745362 DOI: 10.1002/jmrs.341] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/22/2019] [Accepted: 05/02/2019] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Innovations are necessary to accommodate the increasing demands on emergency departments whilst maintaining a high level of patient care and safety. Radiographer Preliminary Image Evaluation (PIE) is one such innovation. The purpose of this study was to determine the accuracy of radiographer PIE in clinical practice within an emergency department over 12 months. METHODS A total of 6290 radiographic examinations were reviewed from 15 January 2016 to 15 January 2017. The range of adult and paediatric examinations incorporated in the review included the appendicular and axial skeleton including the chest and abdomen. Each examination was compared to the radiologist's report this allowed calculated mean sensitivity and specificity values to indicate if the radiographer's PIE was of a true negative/positive or false negative/positive value. Cases of no PIE participation or series' marked as unsure for pathology by the radiographer were also recorded. This allowed mean sensitivity, specificity and diagnostic accuracy to be calculated. RESULTS The study reported a mean ± 95% confidence level (standard deviation) for sensitivity, specificity, accuracy, no participation and unsure of 71.1% ± 2.4% (6.1), 98.4% ± 0.04% (0.9), 92.0% ± 0.68% (1.9), 5.1% (1.6) and 3.6% (0.14) respectively. CONCLUSIONS This study has demonstrated that the participating radiographers provided a consistent PIE service while maintaining a reasonably high diagnostic accuracy. This form of image interpretation can complement an emergency referrer's diagnosis when a radiologist's report is unavailable at the time of patient treatment. PIE promotes a reliable enhancement of the radiographer's role with the multi-disciplinary team.
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Affiliation(s)
- Cameron Brown
- Department of Medical ImagingLogan HospitalCorner of Armstrong Road and Loganlea RoadMeadowbrookQueenslandAustralia
| | - Michael J. Neep
- Department of Medical ImagingLogan HospitalCorner of Armstrong Road and Loganlea RoadMeadowbrookQueenslandAustralia
- School of Public Health and Social WorkQueensland University of TechnologyKelvin GroveBrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin GroveBrisbaneAustralia
- Centre for Functioning and Health ResearchMetro South HealthBuranda Plaza, Corner Ipswich Road and Cornwall Street BurandaBrisbaneAustralia
| | - Efrosini Pozzias
- Department of Medical ImagingLogan HospitalCorner of Armstrong Road and Loganlea RoadMeadowbrookQueenslandAustralia
| | - Steven M. McPhail
- School of Public Health and Social WorkQueensland University of TechnologyKelvin GroveBrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin GroveBrisbaneAustralia
- Centre for Functioning and Health ResearchMetro South HealthBuranda Plaza, Corner Ipswich Road and Cornwall Street BurandaBrisbaneAustralia
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Chopra S, George K, Engineer R, Rajamanickam K, Nojin S, Joshi K, Swamidas J, Shetty N, Patkar S, Patil P, Ostwal V, Mehta S, Goel M. Stereotactic body radio therapy for inoperable large hepatocellular cancers: results from a clinical audit. Br J Radiol 2019; 92:20181053. [PMID: 31219706 PMCID: PMC6732911 DOI: 10.1259/bjr.20181053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/01/2019] [Accepted: 06/14/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To evaluate the outcomes of stereotactic radiotherapy (SBRT) in the treatment of inoperable hepatocellular carcinomas (HCC) that are unsuitable for, or refractory to other liver-directed therapies. METHODS Between March 2015 and June 2018, patients with primary HCCs refractory to or unsuitable for treatment with other liver-directed therapies were treated with SBRT. Patients of Child status A5-B7 and with normal liver reserve ≥ 700 cc were preferred. Local control (LC), overall survival (OS), progression free survival (PFS) and effect of prognostic factors were analysed. RESULTS 21 patients with inoperable HCCs were treated. The median tumour diameter was 9.6 cm (5-21) and median tumour volume was 350 cc (32.9 - 2541). The median SBRT dose prescription was 42 Gy/6 fractions (25 - 54 Gy/6#). The 1- and 2-year LC rate was 88 and 43 % respectively. Overall rate of > grade III toxicity was 14 %. Patients with Child A5 liver function had a better median OS than A6 and B7 patients [21 vs 11 vs 8 months]. Also, tumours with GTV < 350 cc volumes had a better OS compared to GTV of greater than 350 cc [24 months vs 8 months, p value = 0.004]. CONCLUSIONS This study showed that SBRT can be used safely and effectively to treat inoperable HCCs with or without prior loco-regional therapies, resulting in good local control and survival with acceptable toxicity. ADVANCES IN KNOWLEDGE Use of SBRT in inoperable HCC is safe and effective.
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Affiliation(s)
- Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Karishma George
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Karthick Rajamanickam
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Siji Nojin
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Kishore Joshi
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Jamema Swamidas
- Department of Radiation Oncology, Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Nitin Shetty
- Department of Interventional Radiology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prachi Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shaesta Mehta
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Abstract
INTRODUCTION Acute pancreatitis is a common surgical emergency. Identifying variations in presentation, incidence and management may assist standardisation and optimisation of care. The objective of the study was to document the current incidence management and outcomes of acute pancreatitis against international guidelines, and to assess temporal trends over the past 20 years. METHODS A prospective four-month audit of patients with acute pancreatitis was performed across the Wessex region. The Atlanta 2012 classifications were used to define cases, severity and complications. Outcomes were recorded using validated systems and correlated against guideline standards. Case ascertainment was validated with clinical coding and hospital episode statistics data. RESULTS A total of 283 patient admissions with acute pancreatitis were identified. Aetiology included 153 gallstones (54%), 65 idiopathic (23%), 29 alcohol (10%), 9 endoscopic retrograde cholangiopancreatography (3%), 6 drug related (2%), 5 tumour (2%) and 16 other (6%). Compliance with guidelines had improved compared with our previous regional audit. Results were 6.5% mortality, 74% severity stratification, 23% idiopathic cases, 65% definitive treatment of gallstones within 2 weeks, 39% computed tomography within 6-10 days of severe pancreatitis presentation and 82% severe pancreatitis critical care admission. The Atlanta 2012 severity criteria significantly correlated with critical care stay, length of stay, development of complications and mortality (2% vs 6% vs 36%, P < 0.0001). CONCLUSIONS The incidence of acute pancreatitis in southern England has risen substantially. The Atlanta 2012 classification identifies patients with severe pancreatitis who have a high risk of fatal outcome. Acute pancreatitis management is seen to have evolved in keeping with new evidence and updated clinical guidelines.
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Affiliation(s)
- PanWessex Study Group
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Nwose EU, Ekotogbo B, Ogbolu CN, Mogbusiaghan M, Agofure O, Igumbor EO. Evaluation of ADL and BMI in the management of diabetes mellitus at secondary and tertiary health facilities. Diabetes Metab Syndr 2019; 13:2266-2271. [PMID: 31235167 DOI: 10.1016/j.dsx.2019.05.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/24/2019] [Indexed: 12/18/2022]
Abstract
AIMS Physical activities of daily living (ADL) constitutes one of diabetes management options. This study aimed to assess the extent that ADL and BMI are evaluated among diabetes patients in hospital practice. METHOD This was a clinical observational baseline study in two hospitals. Audit of medical files was performed to assess if BMI and occupations were recorded (N = 112). Afterwards, 'N = 38' who consented to participate in prospective study were conveniently sampled to assess ADL in relation to accessible metabolic syndrome tests. A validated questionnaire was used to collect data, which were analysed using SPSS version 20. RESULTS Audit shows 55/112 of clients' occupation were taken, of which 31% has BMI record. Those with lipid profile results are without blood pressure and vice versa. In the cross-sectional assessment, 74% are in physically demanding ADL occupations, but affirmed inactivity is 98% on leisure exercise. Further, 47% have BMI >25 kg/m2 and were consistently less active on all leisure ADL relative to those with BMI <25 kg/m2 (p < 0.02). CONCLUSION This report highlights oversight in clinical practice, whereby accessible metabolic syndrome parameters and occupation of clients living with diabetes are being assessed inconsistently. This implies an unmet need in the integration BMI and occupational information to improve diabetes self-management.
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Affiliation(s)
- Ezekiel U Nwose
- Department of Public & Community Health, Novena University, Ogume, Nigeria; School of Community Health, Charles Sturt University, Orange, Australia.
| | - Benjamin Ekotogbo
- Department of Public & Community Health, Novena University, Ogume, Nigeria
| | | | | | - Otovwe Agofure
- Department of Public & Community Health, Novena University, Ogume, Nigeria
| | - Eunice O Igumbor
- Department of Public & Community Health, Novena University, Ogume, Nigeria
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Desalu OO, Oyedepo OO, Ojuawo OB, Ibraheem M, Aladesanmi AO, Suleiman ZA, Opeyemi CM, Adesina KT, Sanya EO, Salami AK. Acute Oxygen Therapy on Hospital Wards in Low Middle-Income Country: Experience from a Referral Centre in Ilorin, Nigeria. West Afr J Med 2019; 36:122-128. [PMID: 31385597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Oxygen is like any other medication that can cause severe consequences if administered inappropriately. OBJECTIVE To audit the pattern of acute oxygen therapy on regular hospital wards of a referral centre in Ilorin, Nigeria. METHODS We reviewed 150 patients that received or had a prescription for acute oxygen therapy in three months and extracted relevant information using a proforma. RESULTS About one-third of the patients (30%) were >65 years of age and the male to female ratio was 1:1. The commonest indication and medical condition for acute oxygen administration were hypoxemia (70.7%) and pneumonia (26.0%), respectively. Pneumonia accounted for most (41.2 %) of the oxygen therapy in childhood. The majority of patients (88.0%) had written order for oxygen prescription, 40.7% had a prescription to target oxygen saturation and only 31.3% achieved their target saturation. Oxygen prescription was adequate (documentation of delivery device, flow rate of oxygen, and target oxygen saturations) in 40.7% of patients. The assessment, monitoring and titration of oxygen therapy were adequate in 92.7%, 65.3% and 28 % of patients respectively. Overall mortality was 27.3% in patients receiving acute oxygen supplementation. Eleven patients had unstable COPD, and 63.6 %, 54.5 % and 45.6 % of them had adequate oxygen prescription, monitoring and titration respectively. The challenges to oxygen use were faulty delivery devices, emptied oxygen cylinders, inability to routinely do arterial blood gas analysis and lack of hospital oxygen protocol. CONCLUSION The current practice of acute oxygen therapy is not satisfactory and interventions are advocated to improve the healthcare providers' administration of oxygen.
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Affiliation(s)
- O O Desalu
- Department of Medicine, University of Ilorin Teaching Hospital, PMB 1459, Ilorin,Nigeria
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Lee JL. An audit of the practice of electroconvulsive therapy (ECT) in a Victorian Health Service before and after the Mental Health Act 2014. Australas Psychiatry 2019; 27:197. [PMID: 30994031 DOI: 10.1177/1039856218810163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Patel S, Thompson D, Innocent S, Narbad V, Selway R, Barkas K. Risk factors for surgical site infections in neurosurgery. Ann R Coll Surg Engl 2019; 101:220-225. [PMID: 30698457 PMCID: PMC6400918 DOI: 10.1308/rcsann.2019.0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) are of profound significance in neurosurgical departments, resulting in high morbidity and mortality. There are limited public data regarding the incidence of SSIs in neurosurgery. The aim of this study was to determine the rate of SSIs (particularly those requiring reoperation) over a seven-year period and identify factors leading to an increased risk. METHODS An age matched retrospective analysis was undertaken of a series of 16,513 patients at a single centre. All patients who required reoperation for suspected SSIs within a 7-year period were identified. Exclusion criteria comprised absence of infective material intraoperatively and patients presenting with primary infections. Clinical notes were reviewed to confirm presence or absence of suspected risk factors. RESULTS Of the 16,513 patients in the study, 1.20% required at least one further operation to treat a SSI. Wound leak (odds ratio [OR]: 27.41), dexamethasone use (OR: 3.55), instrumentation (OR: 2.74) and operative duration >180 minutes (OR: 1.85) were statistically significant risk factors for reoperation. CONCLUSIONS This is the first UK study of such a duration that has documented a SSI reoperation rate in a cohort of this size. Various risk factors are associated with the development of SSIs, making it essential to have robust auditing and monitoring of high risk patients to ensure excellent standards of healthcare. Departmental and public registers to record all SSIs may be beneficial, particularly for those treated solely by general practitioners, allowing units to address potential risk factors prior to surgical intervention.
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Affiliation(s)
- S Patel
- King’s College NHS Foundation Trust, UK
| | | | | | - V Narbad
- King’s College NHS Foundation Trust, UK
| | - R Selway
- King’s College NHS Foundation Trust, UK
| | - K Barkas
- King’s College NHS Foundation Trust, UK
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Watterson LM, Hyde S, Bajenov S, Kennedy SE. The training environment of junior anaesthetic registrars learning epidural labour analgesia in Australian teaching hospitals. Anaesth Intensive Care 2019; 35:38-45. [PMID: 17323664 DOI: 10.1177/0310057x0703500133] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Junior anaesthetic registrars perform epidural labour analgesia in many Australian hospitals, however data evaluating training and outcomes are scarce. We aimed to describe and evaluate training practices and environments provided for registrars who learn epidural labour analgesia in their first year of training. Twenty-nine registrars audited their epidurals, participated in semi-structured interviews and completed surveys for six months. The median (interquartile range) number of epidurals performed by each registrar was 17 (15–25). Fifty percent performed less than 20. Among 216 audited cases, complications were reported in 19% (dural puncture in 1.4%) and technical difficulties in 16%. Direct supervision was provided for a median (range) of 2.5 (6) epidurals per registrar and for a significantly higher proportion of epidurals performed in tertiary hospitals compared with district metropolitan and rural hospitals (35%, 6% and 22% respectively; P=0.001). Registrars felt senior staff had supportive attitudes, however the onus for initiating supervision appeared to be with the registrars and responses to survey items addressing role clarity and access to supervision showed wide variation. Only 33% of registrars agreed that they received adequate training before their first epidural and 67% reported workplace stress. None received formal assessments designed to ensure adequate supervision and competency. These results suggest that current training practices for these trainees are inadequate and could be improved by audit and structured workplace learning and assessment activities. We have demonstrated the potential value of measuring a range of training outcomes and environmental factors and have provided baseline data for future research.
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Affiliation(s)
- L M Watterson
- Sydney Medical Simulation Centre, Department of Anaesthesia and Pain and Management, Royal North Shore Hospital, Office of Teaching and Learning in Medicine, University of Sydney, Australia
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Abstract
Robot-assisted anatomic prostatectomy is an emerging technique for management of prostate cancer. It requires a coordinated approach by anaesthetist and surgeon as the surgery is performed using a modified laparoscopic technique and is potentially of long duration in a Trendelenberg position. We describe some aspects of the surgical technique and our anaesthetic approach with the first 40 cases at our institution. The mean hospital stay was 4.2 days and none of the patients required blood transfusion. A retrospective audit indicated that the use of epidural analgesia in the early postoperative period reduced opioid analgesic requirements.
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Affiliation(s)
- T G Costello
- Department of Anaesthesia, Epworth Hospital, Melbourne, Victoria, Australia
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Abstract
Objective: To pilot study an audit looking at whether CT scan request forms are completed to an appropriate level. This was based on the adequacy of the detail provided and the use of abbreviations based on local trust guidance. Methods: 60 CT scan requests were retrospectively analysed at University Hospital South Manchester. The following factors were considered: clinical information provided, the offering of a differential diagnosis and use of abbreviations in requests. Results: Of the scan requests analysed, 44 (73%) were adequately completed according to the criteria set. The adequacy of requests and use of appropriate abbreviations varied between the types of scan being requested. There were 59 different abbreviations used in 34 of the requests (57%). Of these, only two (3%) were considered inappropriate. Conclusion: There is still room for improvement in the completion of CT scan requests at University Hospital South Manchester. The poor completion of the forms and use of poor abbreviations can have a detrimental effect on the reporting and therefore, care of the patient. It is important that this problem is tackled appropriately. Advances in Knowledge: There is scope for improvement in the completion of CT request forms. This audit highlights this issue and provides the basis for implementing larger studies looking at completion of radiological request forms.
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Affiliation(s)
- Rechard Rawoo
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Abstract
Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.
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Affiliation(s)
- S Hallam
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
| | - BS Mothe
- Royal Liverpool Hospital, Liverpool, UK
| | - RMR Tirumulaju
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
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Bekker W, Kong VY, Laing GL, Bruce JL, Manchev V, Clarke DL. The spectrum and outcome of blunt trauma related enteric hollow visceral injury. Ann R Coll Surg Engl 2018; 100:290-294. [PMID: 29484938 PMCID: PMC5958856 DOI: 10.1308/rcsann.2018.0013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction This audit focused on patients who sustained enteric injury following blunt abdominal trauma. Methods Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. Results Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty-five of these were peritonitic on presentation. All patients with a SBI had a chest x-ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x-ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8-25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3-13 hours). Conclusions Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.
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Affiliation(s)
- W Bekker
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - VY Kong
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - GL Laing
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - JL Bruce
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - V Manchev
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - DL Clarke
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
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Hall M, Dondo TB, Yan AT, Mamas MA, Timmis AD, Deanfield JE, Jernberg T, Hemingway H, Fox KAA, Gale CP. Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort. PLoS Med 2018; 15:e1002501. [PMID: 29509764 PMCID: PMC5839532 DOI: 10.1371/journal.pmed.1002501] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI. METHODS AND FINDINGS This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population. CONCLUSIONS Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT03037255.
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Affiliation(s)
- Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Tatendashe B. Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Adam D. Timmis
- NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London, United Kingdom
| | - John E. Deanfield
- National Institute for Cardiovascular Outcomes Research, University College London, London, United Kingdom
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, London, United Kingdom
| | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
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Rhee SJ, Han BK, Ko ES, Choi JS, Ko EY. An audit of the results of ultrasound-guided core needle biopsy of mammography versus ultrasound screen-detected breast lesions. J Clin Ultrasound 2017; 45:261-266. [PMID: 28182285 DOI: 10.1002/jcu.22454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 11/17/2016] [Accepted: 12/28/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE To analyze the malignancy rate of ultrasound-guided core needle biopsy (US-CNB) for screen-detected breast lesions and to evaluate the results according to the mode of detection of the target lesions. METHODS This is a retrospective review of 703 consecutive women who underwent US-CNB for screen-detected breast lesions at a single tertiary hospital. Breast Imaging Reporting and Data System (BI-RADS) categories and histopathological results of the target lesions were assessed. The cases were divided into two groups: the mammography-based detected lesions (M-group) and the US-based detected lesions (U-group). The biopsy performances of the two groups were compared using the χ2 test. RESULTS The malignancy rate in the entire population was 22.0%: 0.8%, 12.3%, 65.2%, 89.3%, and 94.6% in BI-RADS categories 3, 4A, 4B, 4C, and 5, respectively. The malignancy rate was significantly higher in the M-group (54.1% [79/146]) than in the U-group (13.6% [76/557]) (p < 0.001). BI-RADS category 3 was the most common assessment overall that led to a US-CNB (362/703, 51.5%) and the rate of BI-RADS category 3 diagnoses that led to US-CNB was significantly higher in the U-group (p < 0.001). CONCLUSIONS The malignancy rate associated with US-CNB for screen-detected breast lesions was 22.0%. The breast lesions detected by mammography have a higher malignancy rate than those detected by US. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:261-266, 2017.
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Affiliation(s)
- Sun Jung Rhee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
- Department of Radiology, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Republic of Korea
| | - Boo-Kyung Han
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Eun Sook Ko
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Ji Soo Choi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Eun Young Ko
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
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Strigel RM, Rollenhagen J, Burnside ES, Elezaby M, Fowler AM, Kelcz F, Salkowski L, DeMartini WB. Screening Breast MRI Outcomes in Routine Clinical Practice: Comparison to BI-RADS Benchmarks. Acad Radiol 2017; 24:411-417. [PMID: 27986508 DOI: 10.1016/j.acra.2016.10.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/21/2016] [Accepted: 10/24/2016] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES The BI-RADS Atlas 5th Edition includes screening breast magnetic resonance imaging (MRI) outcome benchmarks. However, the metrics are from expert practices and clinical trials of women with hereditary breast cancer predispositions, and it is unknown if they are appropriate for routine practice. We evaluated screening breast MRI audit outcomes in routine practice across a spectrum of elevated risk patients. MATERIALS AND METHODS This Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all consecutive screening breast MRI examinations from July 1, 2010 to June 30, 2013. Examination indications were categorized as gene mutation carrier (GMC), personal history (PH) breast cancer, family history (FH) breast cancer, chest radiation, and atypia/lobular carcinoma in situ (LCIS). Outcomes were determined by pathology and/or ≥12 months clinical and/or imaging follow-up. We calculated abnormal interpretation rate (AIR), cancer detection rate (CDR), positive predictive value of recommendation for tissue diagnosis (PPV2) and biopsy performed (PPV3), and median size and percentage of node-negative invasive cancers. RESULTS Eight hundred and sixty examinations were performed in 566 patients with a mean age of 47 years. Indications were 367 of 860 (42.7%) FH, 365 of 860 (42.4%) PH, 106 of 860 (12.3%) GMC, 14 of 860 (1.6%) chest radiation, and 8 of 22 (0.9%) atypia/LCIS. The AIR was 134 of 860 (15.6%). Nineteen cancers were identified (13 invasive, 4 DCIS, two lymph nodes), resulting in CDR of 19 of 860 (22.1 per 1000), PPV2 of 19 of 88 (21.6%), and PPV3 of 19 of 80 (23.8%). Of 13 invasive breast cancers, median size was 10 mm, and 8 of 13 were node negative (61.5%). CONCLUSIONS Performance outcomes of screening breast MRI in routine clinical practice across a spectrum of elevated risk patients met the American College of Radiology Breast Imaging Reporting and Data System benchmarks, supporting broad application of these metrics. The indication of a personal history of treated breast cancer accounted for a large proportion (42%) of our screening examinations, with breast MRI performance in this population at least comparable to that of other screening indications.
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Affiliation(s)
- Roberta M Strigel
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792; Department of Medical Physics, University of Wisconsin, Madison, Wisconsin; Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin.
| | - Jennifer Rollenhagen
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792
| | - Elizabeth S Burnside
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792; Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin
| | - Mai Elezaby
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792
| | - Amy M Fowler
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792; Department of Medical Physics, University of Wisconsin, Madison, Wisconsin; Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin
| | - Frederick Kelcz
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792
| | - Lonie Salkowski
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792
| | - Wendy B DeMartini
- Department of Radiology, University of Wisconsin, 600 Highland Ave, Madison, WI 53792
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Abstract
Background: An audit of tumour marker requests was carried out in Northern Ireland. The aims were to establish the extent of inappropriate requesting, to effect change in request practice if required, and to standardize laboratory reports for tumour markers. Methods: A baseline audit was conducted to investigate the appropriateness of tumour marker requesting patterns in Northern Ireland. Information booklets containing guidelines for tumour markers were then distributed to all clinicians and a post-intervention audit was carried out. Results: At baseline, 80% of requests for tumour markers were appropriate for the source of the tumour; however, 54% of clinicians used tumour markers to screen for malignancy and there was a low index of suspicion in 35% of these. Requests for more than two tumour markers were received for 5% of request forms. The postintervention survey showed no change in requesting practice. Comments were returned by requestors for 55% of questionnaires. They appeared to be appropriate in 72% of cases. Conclusions: There is a low level of inappropriate requesting of tumour markers in Northern Ireland. Audit and feedback combined with circulation of guidelines were unsuccessful interventions in improving the appropriateness of request practice for these tests.
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Affiliation(s)
- Margaret McDonnell
- Department of Clinical Biochemistry, Belfast City Hospital, Lisburn Road, Belfast BT9 7AD, Northern Ireland.
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Hardwick C, White D, Osman H. An audit of the results of the Roche Amplicor gonorrhoea test on female genital samples – a cheaper and more sensitive method than culture in an urban English population. Int J STD AIDS 2016; 18:347-8. [PMID: 17524199 DOI: 10.1258/095646207780749682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report an audit of the use of the Roche Amplicor gonorrhoea test in an urban English genitourinary (GU) medicine clinic. A number of studies have shown polymerase chain reaction (PCR) to be more sensitive than culture in detecting Neisseria gonorrhoea (NG) in genital samples. PCR also offers benefits over culture in terms of samples transport and storage requirements but cannot produce antibiotic sensitivities. In this audit, the use of both methods within an algorithm has reduced the overall cost of NG detection by approximately 30%. In all, 4.2% (99 out of 2336) of the endocervical samples were positive, but only 69% (68 out of 99) of these were also positive by culture. Urine samples showed twice as many inhibitory results as positive results: 19 (3%) inhibitory and 10 (1.5%) positive out of 662 samples. The use of the GC PCR in this protocol has been cost-saving and has increased the sensitivity of GC detection, but some results have been difficult to interpret. We hope to remedy this by the introduction of confirmatory testing for discrepant PCR results.
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Affiliation(s)
- Christine Hardwick
- Department of Sexual Medicine, Birmingham Heartlands Hospital and Health Protection Agency, Birmingham, UK.
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Abstract
The aim of this study was to investigate the compliance of management of gonorrhoea with the national recommendations. The method used was a retrospective audit on consecutive cases of culturally proven gonorrhoea. In total, 131 men and 100 women were included. Four men and nine women were not treated with the appropriate antibiotic. Seven women had not received any treatment. Only 0.33 partners for each case of gonorrhoea were contacted. Uptake of HIV testing was 64%. Treatment failure was recorded among three of 33 patients with test of cure. Oro-pharyngeal swabs were obtained in 34% of the patients with a history of oral sex. In only three of the nine auditable standards targets were met. In conclusion, staff re-training, updated local protocols, routine offer of test of cure and methods to improve partner notification were implemented to improve the management of gonorrhoea.
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Affiliation(s)
- R Sawyer
- Department of Genitourinary Medicine, Whittall Street Clinic, Whittall Street, Birmingham, UK
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Saokaew S, Sugimoto T, Kamae I, Pratoomsoot C, Chaiyakunapruk N. Healthcare Databases in Thailand and Japan: Potential Sources for Health Technology Assessment Research. PLoS One 2015; 10:e0141993. [PMID: 26560127 PMCID: PMC4641604 DOI: 10.1371/journal.pone.0141993] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022] Open
Abstract
Background Health technology assessment (HTA) has been continuously used for value-based healthcare decisions over the last decade. Healthcare databases represent an important source of information for HTA, which has seen a surge in use in Western countries. Although HTA agencies have been established in Asia-Pacific region, application and understanding of healthcare databases for HTA is rather limited. Thus, we reviewed existing databases to assess their potential for HTA in Thailand where HTA has been used officially and Japan where HTA is going to be officially introduced. Method Existing healthcare databases in Thailand and Japan were compiled and reviewed. Databases’ characteristics e.g. name of database, host, scope/objective, time/sample size, design, data collection method, population/sample, and variables were described. Databases were assessed for its potential HTA use in terms of safety/efficacy/effectiveness, social/ethical, organization/professional, economic, and epidemiological domains. Request route for each database was also provided. Results Forty databases– 20 from Thailand and 20 from Japan—were included. These comprised of national censuses, surveys, registries, administrative data, and claimed databases. All databases were potentially used for epidemiological studies. In addition, data on mortality, morbidity, disability, adverse events, quality of life, service/technology utilization, length of stay, and economics were also found in some databases. However, access to patient-level data was limited since information about the databases was not available on public sources. Conclusion Our findings have shown that existing databases provided valuable information for HTA research with limitation on accessibility. Mutual dialogue on healthcare database development and usage for HTA among Asia-Pacific region is needed.
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Affiliation(s)
- Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- The Canon Institute for Global Studies, Tokyo, Japan
- Graduate School of Public Policy, University of Tokyo, Tokyo, Japan
- Meiji Institute for Global Affairs, Meiji University, Tokyo, Japan
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Takashi Sugimoto
- Graduate School of Public Policy, University of Tokyo, Tokyo, Japan
| | - Isao Kamae
- The Canon Institute for Global Studies, Tokyo, Japan
- Graduate School of Public Policy, University of Tokyo, Tokyo, Japan
- Meiji Institute for Global Affairs, Meiji University, Tokyo, Japan
| | | | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- School of Pharmacy, Monash University Sunway Campus, Selangor, Malaysia
- School of Population Health, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Wisconsin, Madison, United States of America
- * E-mail:
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Ng I, Segal R, Lee KL, Ilyas S, Story D. A prospective audit of difficult airway equipment at University of Melbourne-affiliated hospitals. Anaesth Intensive Care 2015; 43:528. [PMID: 26099768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Bazzo S, Battistella G, Riscica P, Moino G, Dal Pozzo G, Bottarel M, Geromel M, Czerwinsky L. Reliability of a self-report Italian version of the AUDIT-C questionnaire, used to estimate alcohol consumption by pregnant women in an obstetric setting. Riv Psichiatr 2015; 50:89-94. [PMID: 25994619 DOI: 10.1708/1872.20456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
AIM Alcohol consumption during pregnancy can result in a range of harmful effects on the developing foetus and newborn, called Fetal Alcohol Spectrum Disorders (FASD). The identification of pregnant women who use alcohol enables to provide information, support and treatment for women and the surveillance of their children. The AUDIT-C (the shortened consumption version of the Alcohol Use Disorders Identification Test) is used for investigating risky drinking with different populations, and has been applied to estimate alcohol use and risky drinking also in antenatal clinics. The aim of the study was to investigate the reliability of a self-report Italian version of the AUDIT-C questionnaire to detect alcohol consumption during pregnancy, regardless of its use as a screening tool. METHODS The questionnaire was filled in by two independent consecutive series of pregnant women at the 38th gestation week visit in the two birth locations of the Local Health Authority of Treviso (Italy), during the years 2010 and 2011 (n=220 and n=239). Reliability analysis was performed using internal consistency, item-total score correlations, and inter-item correlations. The "discriminatory power" of the test was also evaluated. Results. Overall, about one third of women recalled alcohol consumption at least once during the current pregnancy. The questionnaire had an internal consistency of 0.565 for the group of the year 2010, of 0.516 for the year 2011, and of 0.542 for the overall group. The highest item total correlations' coefficient was 0.687 and the highest inter-item correlations' coefficient was 0.675. As for the discriminatory power of the questionnaire, the highest Ferguson's delta coefficient was 0.623. CONCLUSIONS These findings suggest that the Italian self-report version of the AUDIT-C possesses unsatisfactory reliability to estimate alcohol consumption during pregnancy when used as self-report questionnaire in an obstetric setting.
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Coleman N, Young R, Greally M, O'Riordan L, Breathnach O, Grogan L. Introducing a specialist drug kardex can significantly change prescribing practices for VTE in cancer patients. Ir Med J 2014; 107:188. [PMID: 24988843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Harvey HB, Chow D, Boston M, Zhao J, Lucey L, Monticciolo DL. Initial outcomes from federally mandated accreditation site surveys of advanced diagnostic imaging facilities performed by the ACR. J Am Coll Radiol 2014; 11:686-91. [PMID: 24837354 DOI: 10.1016/j.jacr.2014.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/06/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate the findings of the first year of validation site surveys performed by the ACR pursuant to new federal accreditation requirements for nonhospital advanced diagnostic imaging (ADI) facilities. METHODS In the first year of validation site surveys (November 2012 to November 2013), the ACR surveyed 943 ADI facilities across 21 states. Data were extracted from these site survey reports and analyzed on the basis of the survey outcomes and the frequency and type of deficiencies and recommendations. Follow-up data were obtained from the ACR for facilities deemed noncompliant on the site survey to determine if these facilities adequately took the corrective actions necessary to maintain accreditation. RESULTS Of the 943 ADI facilities surveyed, 45% (n = 421) were deemed compliant with the ACR accreditation standards, and 55% (n = 522) had one or more deficiencies. Failure to produce the required personnel documentation and absence of mandatory written policies were the two most common causes of deficiencies. Facilities accredited in more modalities tended to fare better in the site surveys, with the number of accredited modalities at a facility negatively associated with the likelihood of a deficiency (P = .007). Of the facilities with deficiencies, 73% (n = 382) took the necessary corrective actions to maintain accreditation, 27% (n = 140) were in the process of taking corrective actions, and no facility has lost accreditation because of an inability to adequately address the deficiencies. Nonbinding recommendations were made to 37% (n = 346) of facilities, and facilities with deficiencies were statistically more likely to receive recommendations (P < .001). CONCLUSIONS Initial site surveys of ADI facilities demonstrated a high proportion of deficient facilities, but no facility has lost accreditation because of an inability to correct these deficiencies. Knowledge of the most common sources of deficiencies and recommendations can assist ACR-accredited ADI facilities in better preparing for validation site surveys, reducing the likelihood of facility noncompliance.
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Affiliation(s)
- H Benjamin Harvey
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - David Chow
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Marion Boston
- Department of Quality and Safety, American College of Radiology, Reston, Virginia
| | - Jing Zhao
- Harvard School of Public Health, Cambridge, Massachusetts
| | - Leonard Lucey
- Department of Quality and Safety, American College of Radiology, Reston, Virginia
| | - Debra L Monticciolo
- Scott and White Department of Radiology, Texas A&M College of Medicine, Temple, Texas
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Cohn CS, Welbig J, Bowman R, Kammann S, Frey K, Zantek N. A data-driven approach to patient blood management. Transfusion 2014; 54:316-22. [PMID: 23772663 DOI: 10.1111/trf.12276] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/10/2013] [Accepted: 04/17/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient blood management (PBM) has become a topic of intense interest; however, implementing a robust PBM system in a large academic hospital can be a challenge. In a joint effort between transfusion medicine and information technology, we have developed three overlapping databases that allow for a comprehensive, semiautomated approach to monitoring up-to-date red blood cell (RBC) usage in our hospital. Data derived from this work have allowed us to target our PBM efforts. STUDY DESIGN AND METHODS Information on transfusions is collected using three databases: daily report, discharge database, and denominator database. The daily report collects data on all transfusions in the past 24 hours. The discharge database integrates transfusion data and diagnostic billing codes. The denominator database allows for rate calculations by tracking all patients with a hemoglobin test ordered. A set of algorithms is applied to automatically audit RBC transfusions. The transfusions that do not fit the algorithms' rules are manually reviewed. Data from audits are compiled into reports and distributed to medical directors. Data are also used to target education efforts. RESULTS Since our PBM program began, the percentage of appropriate RBC orders increased from an initial 70%-80% to 90%-95%, and the overall RBC transfusions/1000 patient-days has decreased by 67% in targeted areas of the hospital. Our PBM program has shaved approximately 3% from our hospital's blood budget. CONCLUSION Our semiautomated auditing system allows us to quickly and comprehensively analyze and track blood usage throughout our hospital. Using this technology, we have seen improvements in our hospital's PBM.
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Affiliation(s)
- Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School; Fairview Health Services, University of Minnesota Medical Center, Minneapolis, Minnesota; Fairview Health Services, Southdale Hospital, Edina, Minnesota
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Clemans L, Cooksley T, Holland M. Palliative and end of life care on the Acute Medical Unit. Acute Med 2014; 13:12-15. [PMID: 24616898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Early and appropriate recognition of patients requiring palliative care is essential to delivering high quality management and Acute Medical Units have a pivotal role to play in ensuring its implementation. AIM To identify the prevalence of patients admitted to Acute Medical Unit (AMU) who met palliative criteria, the overall prevalence of terminal diagnoses and the frequency of appropriate referrals to the units Palliative Care in reach team. METHODS An audit was performed at a University Hospital AMU to examine these issues. The NHS Supportive and Palliative Care Tool (SPCIT) was used to identify palliative patients. 409 patients were admitted to the AMU during the study period. RESULTS 66 (16.1%) of patients were identified as palliative. Two-thirds of these patients had a non-malignant diagnosis. 30% of palliative patients were referred to the palliative care team of which 85.4% had a diagnosis of cancer. 88% of patients that received ongoing palliative care review had a diagnosis of cancer. CONCLUSION There is a high prevalence of patients with a terminal diagnosis presenting to the AMU reflecting an aging population and increasingly complex co-morbidities. Palliative patients with a non-cancer diagnosis are less likely to be referred to the palliative care team, which has the potential to disadvantage their care.
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Affiliation(s)
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester
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Affiliation(s)
- George Chapman
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Pakpoor J, Butler S, Agius M, Zaman R. Audit of the prevalence of anxiety in bipolar disorder--a comorbidity that requires attention and action. Psychiatr Danub 2013; 25 Suppl 2:S354-S357. [PMID: 23995208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Bipolar affective disorder (BPD) frequently occurs with co-morbid mental health problems. This study shows that that the prevalence of co-morbid BPD and anxiety symptoms is especially high. This is important because for a person affected by both BPD and anxiety there is a negative impact on the symptoms, treatment response and recovery. A clinician faces particular treatment challenges when managing these co-morbid conditions due to a limited evidence base for effective interventions. The frequent occurrence of anxiety symptoms and BPD together has informed theories of the shared aetiology of these conditions.
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Affiliation(s)
- Jina Pakpoor
- Selwyn College Cambridge, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Bongards EN, Zaman R, Agius M. Audit to identify the number of patients with multiple diagnoses in a community mental health team in Bedford, England. Psychiatr Danub 2013; 25 Suppl 2:S247-S249. [PMID: 23995186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Patients with 'simple' mental health problems should be able to be managed exclusively in primary care. It is therefore anticipated that only the more complex cases would be referred to secondary care. In order to test this hypothesis, the number of patients registered with a community mental health team (CMHT) in Bedford, United Kingdom, who had received multiple psychiatric diagnoses in 2010, 2011 and 2013, was determined and analysed. METHOD Using a secure and anonymised Microsoft Excel® database that contains all patient data, the proportions of patients with more than one diagnosis were audited and thus determined for the months of August 2010, June 2011 and February 2013. The total number of patients registered was also determined for comprehensiveness. We had established the basic audit standard that every patient should have only one mental health diagnosis if this was possible. RESULTS Many patients were indeed found to have received multiple diagnoses. Furthermore, an increase in the proportion of patients with multiple diagnoses was observed; from 23.2% in 2010 to 25.2% in 2011 to 34.3% in 2013. DISCUSSION Several psychiatric conditions have been shown to be associated with particular psychiatric co-morbidities, which may be one reason why many of the Bedford CMHT's patients receive multiple diagnoses. Furthermore, the trend observed may reflect improving mental healthcare in primary care and therefore fewer referrals of patients with 'simple' mental health conditions to secondary care, thus causing the CMHT's caseload to become increasingly complex. It may also reflect improving communication between primary and secondary care, which may also lead to fewer referrals. Finally, the trend may merely reflect better use of the available database. CONCLUSION We have found that numerous patients received multiple diagnoses. We have also observed an increase in the proportion of such patients over three years, which may reflect improved management of mental health problems in primary care. Our results may therefore provide an incentive to establish formal shared care of psychiatric patients between primary and secondary care to improve patient management even further. Furthermore, our results reflect the complexity of the cases referred to secondary care, which are far more difficult to treat than those exclusively managed in primary care.
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Affiliation(s)
- Eva Nora Bongards
- School of Clinical Medicine, Christ's College, University of Cambridge, United Kingdom
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Chalouhi GE, Salomon LJ, Fontanges M, Althuser M, Haddad G, Scemama O, Chabot JM, Duyme M, Fries N. Formative assessment based on an audit and feedback improves nuchal translucency ultrasound image quality. J Ultrasound Med 2013; 32:1601-1605. [PMID: 23980221 DOI: 10.7863/ultra.32.9.1601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The purpose of this work was to study the impact of an audit and feedback on the quality of routine first-trimester nuchal transparency ultrasound images. METHODS Eighty-eight sonographers were each sent 2 different series of 30 consecutive nuchal translucency images at a mean interval of 3 months to a dedicated, protected server for remote double-blind independent analysis based on the new Collège Français d'Echographie Foetale/Centre National de la Recherche Scientifique image-scoring method (https://www.cfef.org/evaluation/ISMCFEFCNRS.pdf). The sonographers were classified as low (score below the median) or high (score above the median) scorers for each series. Before their second evaluation, 73 of the 88 sonographers received a feedback report on their first series of images, whereas the other 15 participants received no feedback. The baseline characteristics of the participants who did and did not receive feedback were comparable. RESULTS Participants who received feedback increased their average score significantly, from a mean ± SD of 11.1 ± 1.3 to 13.4 ± 1.4 among low scorers (P < .00001) and from 15.1 ± 1.2 to 16.0 ± 1.4 among high scorers (P < .001), whereas no significant change was seen among participants who received no feedback (low scorers, 10.9 ± 1.5 to 12.1 ± 2.0; P = .11; high scorers, 14.7 ± 1.3 to 14.6 ± 1.3; P = .99). The proportion of satisfactory images increased by 48% among low scorers who received feedback. CONCLUSIONS Formative assessment based on a moderately intensive audit and feedback is feasible and effective for improving the quality of routine first-trimester nuchal transparency ultrasound images.
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Affiliation(s)
- Gihad E Chalouhi
- Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants-Malades, Paris, France
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Bongards EN, Zaman R, Agius M. Can we prevent under-diagnosis and misdiagnosis of bipolar affective disorder? Repeat audits to assess the epidemiological change in the caseload of a community mental health team when bipolar disorder is accurately assessed and diagnosed. Psychiatr Danub 2013; 25 Suppl 2:S129-S134. [PMID: 23995161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Bipolar Affective Disorder is frequently under-diagnosed and misdiagnosed, particularly as unipolar depression. This has serious implications on treatment and outcome of the condition. A community mental health team (CMHT) in Bedford, United Kingdom, has therefore reassessed patients to examine whether it is possible to increase the sensitivity of diagnosis of bipolar affective disorder; to identify more cases and to identify them earlier, in order to be able to offer adequate treatment as early as possible. METHOD Standards were decided within the team for the diagnosis of bipolar disorder based on the DSM4 criteria for the diagnosis of Bipolar I and Bipolar II illness. Patients were reassessed and patient data from 2006, 2007, 2010 and 2011, as well as from 2013, with respect to psychiatric diagnoses. The results were audited and analysed in every year in question. The proportions of total bipolar, bipolar I affective disorder and bipolar II affective disorder diagnoses, as well as the proportions of recurrent depressive disorder and other unipolar depression diagnoses were determined. RESULTS There was a steady increase in the proportions of both bipolar I and bipolar II diagnoses -from 10.5% in 2006 to 11.0% in 2013 for bipolar I affective disorder, and from 0% in 2006 (4.9% in 2007) to 9.7% in 2013 for bipolar II affective disorder-, and a steady decrease in the proportions of both recurrent depressive disorder and other unipolar depression diagnoses - from 16.1% and 18.7%, respectively, in 2006, to 4.8% and 8.0%, respectively, in 2013. DISCUSSION The results confirm that it is possible to increase the sensitivity of bipolar affective disorder diagnosis and that this results in an increased number of diagnoses of the disorder, and a decreased number of diagnoses of unipolar depression. Unexpectedly, the data also showed that increasingly more patients are receiving multiple psychiatric diagnoses. CONCLUSIONS This paper shows that it is possible to increase the sensitivity of diagnosis of bipolar affective disorder. This may be particularly useful in the light of increasingly more mental health problems being treated exclusively in primary care, since bipolar diagnoses will be less likely to be missed. Better identification, and therefore treatment, of bipolar affective disorder is likely to lead to better social and professional functioning of affected individuals.
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Affiliation(s)
- Eva Nora Bongards
- School of Clinical Medicine, Christ's College, University of Cambridge, United Kingdom
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Vaja R, Agius M, Zaman R. Audit to assess the prevalence of autoimmune disorders among patients suffering from psychiatric illnesses. Psychiatr Danub 2013; 25 Suppl 2:S305-S314. [PMID: 23995199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
While knowledge of the aetiology of psychiatric disorders is complex and has not been fully elucidated, recently it has been noted that a sizeable proportion of psychiatric patients have coexisting immunological health conditions. It is debatable whether inflammatory factors plays a role in the aetiology of the psychiatric conditions, or if psychiatric conditions predispose to immune dysfunction. However, previous work has given weight to the theory that the immune system has important neuromodulatory roles in the brain, and disturbances in this system can lead to psychiatric manifestations. Epidemiological evidence is needed to explore the strength of the correlation between immune conditions and psychiatric disorders, and this audit attempts to investigate this potential association using the psychiatric patient databaseof Bedford East Community Mental Health Team (Bedfordshire, UK). In this audit, the patient information was analysed to obtain prevalence data for an array of autoimmune conditions. This was then compared to the expected prevalence of the same autoimmune conditions. The results showed that patients with each psychiatric condition had a higher than expected prevalence of autoimmune conditions overall. The most striking discrepancy was that the percentage of patients with coexisting hypothyroidism was higher than expected in almost every psychiatric condition recorded. Other patterns in prevalence of autoimmune conditions were also noted. A causative link between psychiatric and autoimmune diseases is still questionable, and this issue needs to be researched further in terms of prevalence data and aetiological evidence. There are significant implications for clinical practice if a greater incidence of autoimmune conditions among psychiatric patients is proven. This includes screening opportunities and risk assessments, as well as potential for new pharmacological therapies based around immune regulation.
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Affiliation(s)
- Rakhee Vaja
- Department of Psychiatry University of Cambridge, Cambridge, UK
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Vadiveloo T, Donnan PT, Murphy MJ, Leese GP. Age- and gender-specific TSH reference intervals in people with no obvious thyroid disease in Tayside, Scotland: the Thyroid Epidemiology, Audit, and Research Study (TEARS). J Clin Endocrinol Metab 2013; 98:1147-53. [PMID: 23345094 DOI: 10.1210/jc.2012-3191] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to examine the association of tested TSH with age, gender, and diabetes in a large population-based cohort without evidence of thyroid disease. DESIGN Record-linkage technology was used retrospectively to identify people without evidence of thyroid disease in the general population of Tayside, Scotland, from July 1, 2003, to December 31, 2009. COHORT All Tayside residents who had thyroid function tests performed were identified. Using a unique patient identifier, data linkage enabled a cohort without thyroid disease to be identified by excluding anyone with thyroid or antithyroid prescription, thyroid-related admission or surgery, treatment with radioactive iodine and/or positive thyroid antibodies. Cases below 18 years of age were also excluded. OUTCOME MEASURES We measured TSH distribution among different age groups and by gender. RESULTS We identified the latest TSH measurements in 153127 people from the reference population after applying the exclusion criteria. There was a significant increase in median TSH (1.58 mU/L at 31-40 y to 1.86 mU/L at >90 y; P < .001) and 97.5th centile TSH (3.98 to 5.94 mU/L, respectively) with increasing age. The 2.5th centile decreased with age (0.51 to 0.31 mU/L). Patients with diabetes had marginally higher TSH concentration (1.80 vs 1.70 mU/L; P < .001). CONCLUSION The use of these age-specific reference intervals for TSH, especially in those over 70 years old, would result in the reclassification of many TSH results from "abnormal" to "normal" (within the 95th centile reference interval) and avoid unnecessary treatment.
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Affiliation(s)
- Thenmalar Vadiveloo
- Dundee Epidemiology and Biostatistics Unit, Division of Population Health Sciences, Medical Research Institute, MacKenzie Building, Kirsty Semple Way, University of Dundee, Dundee DD2 4BF, Scotland, United Kingdom.
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Le Jeune I, Masterton-Smith C, Subbe CP, Ward D. "State of the Nation"--the Society for Acute Medicine's Benchmarking Audit 2013 (SAMBA '13). Acute Med 2013; 12:214-219. [PMID: 24364052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Benchmarking is important to improve quality of care. AIM To audit the performance of Acute Medical Units (AMUs) against the clinical quality indicators published by the Society for Acute Medicine (SAM). METHODS 24-hour data collection on the 20th of June 2013 with follow-up data at 72 hours. RESULTS 43 units submitted data on 1425 patients. 76% of patients had early warning scores recorded within 30 minutes of admission, 95% of patients had been seen by a competent decision maker within four hours. 79% of patients were seen by a consultant physicians within the appropriate period of time. CONCLUSION The difference in compliance with quality standards between UK units opens opportunities for learning. The reasons why some units perform better than others require further investigation.
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Affiliation(s)
| | | | - C P Subbe
- Senior Clinical Lecturer, Bangor University, School of Medical Sciences, Ysbyty Gwynedd, Penrhosgarnedd, LL57 2PW, Bangor
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Subbe CP, Ward D, Latip L, Le Jeune I, Bell D. A day in the life of the AMU--the Society for Acute Medicine's benchmarking audit 2012 (SAMBA '12). Acute Med 2013; 12:69-73. [PMID: 23732129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The absence of published data for benchmarking serves as a disincentive for Acute Medical Units to improve care. AIM To test feasibility of a national audit in Acute Medicine for compliance with common standards. METHODS On line questionnaire with summary data for patients admitted to participating Acute Medicine Units over a 24-hour-period. RESULTS 30 units submitted summary data. The mean number of admission was 36 (SD 14). Compliance with standards around timing of junior and senior review was highly variable. In almost all other standards only a small number of units achieved high reliability with compliance of more than 90%. CONCLUSION SAMBA provides a data set that can be used for local and national benchmarking and quality improvement work. Annual audit might be beneficial to track improvements.
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Affiliation(s)
- Christian P Subbe
- Bangor University School of Medical Sciences, Ysbyty Gwynedd, Penrhosgarnedd, LL57 2PW Bangor, UK.
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Mauger Rothenberg B, Marbella A, Pines E, Chopra R, Black ER, Aronson N. Closing the quality gap: revisiting the state of the science (vol. 6: prevention of healthcare-associated infections). Evid Rep Technol Assess (Full Rep) 2012:1-578. [PMID: 24422993 PMCID: PMC4781394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To update the Agency for Healthcare Research and Quality (AHRQ) Evidence Report Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6-Prevention of Healthcare-Associated Infections on quality improvement (QI) strategies to increase adherence to preventive interventions and/or reduce infection rates for central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), surgical site infections (SSI), and catheter-associated urinary tract infections (CAUTI). DATA SOURCES MEDLINE®, CINAHL®, and Embase® were searched from January 2006 to January 2012 for English-language studies with sample size ≥100 patients, a defined baseline period, and reported statistical analysis for adherence and/or infection rates. Articles from the previous report were screened and those meeting selection criteria were included. REVIEW METHODS We sought studies that evaluated the following QI strategies to improve adherence to evidence-based preventive interventions and/or reduce healthcare-associated infection (HAI) rates: audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems. Data were abstracted by a single reviewer and fact-checked by a second. Outcomes were adherence to preventive interventions, infection rates, adverse outcomes, and cost savings. Study quality was assessed using relative rankings based on study design, adequacy of statistical analysis, length of followup, reporting and analysis of baseline and postintervention adherence and infection rates, and implementation of the intervention independent of other QI efforts. Combinations of QI strategies were assessed, not individual strategies. Strength of evidence was judged according to the AHRQ Methods Guide. RESULTS Sixty-one articles yielded 71 analyses at the infection level, including 9 articles (10 analyses) from the 2007 report, which evaluated the use of one or more QI strategies to improve adherence or infection rates and also controlled for confounding or secular trend. Twenty-six analyses were performed on CLABSI, 19 on VAP, 15 on SSI, and 11 on CAUTI. There were 34 analyses on adherence, of which 31 (91%) showed significant improvement. There were 63 analyses of infection rates, of which 42 (67%) showed significant improvement. CONCLUSIONS There is moderate strength of evidence across all four infections that both adherence and infection rates improve when either audit and feedback plus provider reminder systems or audit and feedback alone is added to the base strategies of organizational change and provider education. There is low strength of evidence that adherence and infection rates improve when provider reminder systems alone are added to the base strategies. There was insufficient evidence for reduction of HAI in nonhospital settings, cost savings for QI strategies, and the nature and impact of the clinical contextual factors.
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