Objective: High data quality is essential to ensure the validity of clinical and research inferences based on it. However, these data quality assessments are often missing even though these data are used in daily practice and research. Our objective was to evaluate the data quality of our high-resolution electronic database (HRDB) implemented in our pediatric intensive care unit (PICU). Design: A prospective validation study of a HRDB. Setting: A 32-bed pediatric medical, surgical and cardiac PICU in a tertiary care freestanding maternal-child health center in Canada. Population: All patients admitted to the PICU with at least one vital sign monitored using a cardiorespiratory monitor connected to the central monitoring station. Interventions: None Measurements and Main Results: Between June 2017 and August 2018, data from 295 patient days were recorded from medical devices and 4,645 data points were video recorded and compared to the corresponding data collected in the HRDB. Statistical analysis showed an excellent overall correlation (R2=1), accuracy (100%), agreement (bias=0, limits of agreement=0), completeness (2% missing data) and reliability (ICC=1) between recorded and collected data within clinically significant pre-defined limits of agreement. Divergent points could all be explained. Conclusions: This prospective validation of a representative sample showed an excellent overall data quality.
Rationale aims and objectives Potentially preventable hospitalizations (PPH) are a challenge. What happens before hospital admission? Are there crucial tipping points before admissions in at-risk cohorts’ trajectories? HealthLinksChronicCare (HLCC) hospital risk-prediction algorithms using admission, diagnosis, and lifestyle data identifies at-patients. MW monitors HLCC patients with outbound phone calls using telehealth – the Patient Journey Record System with alerts representing a real-time anticipated risk of PPH. Health Coaches triage and intervene to optimize GP, hospital and community service utilization to reduce the risk of PPH. Aims To describe a time series of telehealth phone calls related to an acute admission ( 10 days) to investigate tipping points in self-reported biopsychosocial environmental concerns (total alerts) and or condition symptoms of concern (red alerts). Methods MW participants had an acute (non-surgical) admission and >44 calls between 23/12/16 - 11/10/17. The Patient Journey Record System (PaJR) and Victorian Admitted Episode Data/ Emergency Minimum Dataset provided longitudinal data. Descriptive time series analysis employed Pettitt’s homogeneity test to detect ‘tipping points’ using XLSTAT package. Findings One hundred three patients aged 74 ± 15.4 years, with 59% male and 61% female, provided 764 call records around admission(s) and 22,715 records over 10 months. Total alerts and red alerts were higher in the 10 days before and after admission. Total alerts significantly increased (tipped) at day 3 before hospitalisation persisting until 10 days. Red alerts increased (tipped) 1 day before admission and remained high following discharge. Discussion and Conclusion Self-report in phone calls describe a pre-hospital phase of ‘post-hospital syndrome’ (PHS), which began at least 10 days before admission and persisted after discharge. Wide-ranging health, psychosocial, and environmental concerns preceded a tipping point into acute symptoms. Telehealth monitoring of biopsychosocial, as well as disease, concerns require further investigation.
Rationale: Conventional models of cultural humility - even those extending analysis beyond the dyad of healthcare provider-patient to include concentric social influences such as families, communities and institutions that make the clinical relationship possible - aren’t conceptually or methodologically calibrated to accommodate shifts occurring in contemporary biomedical cultures. More complex models are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very cultural and material conditions of health care and its delivery structures, and thus how power manifests in clinical encounters. Methodological Intervention: In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine’s technologising turn. A second level of intervention invites experimentation to broaden the availability of methodological tools to analyse and assess the multidimensionality of technologies and their agentic effects in healthcare encounters. Drawing from new materialism theories, practices of care are approached “diffractively” as contingent and dynamic material-discursive events. Our neo-materialist framework for cultural humility expands analytical sight-lines beyond hierarchical relationships and dichotomies privileging humans (practitioner and/or patient) as sole actants in the clinical exchange. Attended to are the ongoing dynamics of practices entangling big-data driven knowledges and interventions, pharmacological technologies and material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients. We investigate the implications for clinical assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contextually emergent data moments and objects for analysis. Engaging evaluative inquiry diffractively allows for a different ethical practice of care, one that attends to the forms of patient and health provider accountability and responsibility emerging in the clinical encounter.
Rational, aims and objectives: This study aimed to assess knowledge, attitude and practice (KAP) of using insulin pen in diabetes and determine the related factors to the KAP, adverse drug reactions (ADRs) and glycemic control status. Methods: In our descriptive study, 148 patients with diabetes were interviewed by 16-item questions on knowledge and 8 questions on attitude, and were asked to present the insulin pen injection technique with a sample insulin pen. Results: Proportions of patient having a good knowledge, positive attitude, and good practice were 45.9%, 78.4%, and 44.6%, respectively. The three most incorrect steps were skipping to prime pen needle (90.9%), not removing the used needle from the pen after using (87.8), and not holding for specific count time before withdrawal of pen needle from skin (50.7%). Patients having duration of insulin one year or more had better knowledge (p=0.025), more positive attitude (p=0.017), and better practice of insulin (p=0.042). Patients using insulin combined with oral diabetic medications or having history of using insulin vials had more positive attitude of insulin role (0.038). Frequency of having good knowledge was statistically significantly higher in participants who received counseling from health professionals previously (p=0.001). The study also found a positive correlation between good knowledge of patients and good practical skills (p<0.001). Patients with poor practice of insulin were more likely to have ADRs at the injection sites (p = 0.013). The worse knowledge of patients was significant related to the higher risk of hypoglycemia (p=0.001). KAP levels did not correlate with glycemic control status. Conclusions: Positive attitude in patients was recorded at a significant rate; however, knowledge and practice needs improvement. This study was helpful to shape the patient education and target specific patients for education.
Rationale and objectives: Changes in, and predictors of, quality of life (QoL) among unstable angina patients are informative for both clinical and public health practice. However, there is little research on this topic, especially in healthcare settings with limited resources. This study aims to detect changes in QoL and its associated factors among patients with unstable angina after percutaneous coronary intervention. Methods: A quasi-experimental design was conducted with two repeated rounds of measurements, one month and three months after intervention, using the generic SF-36 questionnaire, in 120 patients from Vietnam National Heart Institute. A linear mixed-effects model was used to assess changes in patient QoL over time while adjusting for other covariates. Results: Only 2 out of 8 QoL subscales (social functioning and emotional well-being) declined after one month, but these tended to rise again after three months, while scores of all other QoL subscales increased. Adjusting for covariates, QoL increased slightly after one month of intervention (β=0.65, 95%CI=-0.86-2.16) but improved by almost 6 QoL points after 3 months (β=5.99, 95%CI=4.48-7.50). Four confounders significantly associated with a decline in QoL were older age, being retired, living in rural areas, and having abnormal troponin level. Conclusion: QoL of the patients with unstable angina improves significantly three months after intervention, rather than after one month. To increase QoL, it is important to address risk factors and to improve the quality of healthcare delivery.
Background and Objective Clinical Practice Guidelines (CPGs) provide evidence-based recommendations to healthcare professionals, policy makers, patients and other stakeholders. Mexico is the biggest producer of CPGs in Latin America and Caribbean countries. The National Healthcare Technology Excellence Center (acronym in Spanish: CENETEC) is responsible for the CPG development, adaptation and update. The aim of this study was to assess the Mexican CPG quality and adherence to the GRADE framework. Study design We conducted a descriptive cross-sectional study of 86 CPGs representing all the CPGs produced by CENETEC between 2015 and 2017 and published in an online database called “Catalogo Maestro”. We performed quality assessment with the online AGREE II tool and assessed the reporting on the GRADE framework. Results Of the 86 CPGs, 34 were published in 2015, 21 in 2016 and 31 in 2017. The overall quality by AGREE II proved a median of 16.6% (Min 16.6%, Max 50%). Of the 86 CPGs, 25 (29%) used the GRADE framework; adherence to GRADE standards was, however, inconsistent and generally poor. Conclusion CPGs produced by CENETEC during this period had a low score by AGREE II standards and low adherence to the GRADE framework. A concerted initiative could rapidly improve CENETEC guidelines.
Background: Lack of time has consistently been reported as a major barrier to effective research evidence-uptake into clinical practice. There has been no research to our knowledge that explores time as a barrier within the Transtheoretical model of Stages of Change (SoC), to better understand the processes of physiotherapists’ uptake of clinical practice guidelines (CPG). This paper explores the concept of lack of time as a barrier for CPG uptake for physiotherapists at different SoC. Methods: A 6-step process is presented to determine the best-fit SoC for 31 physiotherapy interviewees. This process used an amalgamation of interview findings and socio-demographic data, which was layered onto the SoC and previously identified time-barriers to CPG uptake (few staff; high workload; access to CPGs; evidence-based practice as priority in clinical practice; “time is money” attitude; and knowledge on the use of CPGs). Results: The analysis process highlighted the complexities of assigning individuals to a SoC. A model of time management for better CPG uptake is proposed which is a novel approach to assist evidence implementalists and clinicians alike to determine how to progress through the SoC and barriers to improve CPG uptake. Conclusions: To the authors’ knowledge, this is the first attempt at exploring the construct of (lack of) time for CPG-uptake in relation to the physiotherapists’ readiness to behaviour change. This study shows that ‘lack of time’ is a euphemism for quite different barriers, which map to different stages of readiness to embrace current best evidence into physiotherapy practice. By understanding what is meant by ‘lack of time’, it may indicate specific support required by physiotherapists at different stages of changing these behaviours.
Background: Most studies on the transition from pediatric to adult care focus on practices at a single institution. We examine the transition for young adults with type 1 diabetes across an entire Canadian province with a small, mostly rural population: Newfoundland and Labrador (NL). Our aim is to determine a comprehensive picture of how transition is occurring in one jurisdiction and explore potential methods for improvement. Methods: A provincial diabetes database and hospital admission data were reviewed for a cohort of young adults who transitioned into adult care to determine the number of transfers occurring, patient characteristics, and the number of diabetes-related hospitalizations. Semi-structured interviews with pediatric and adult diabetes providers were conducted to determine the current process of transition and identify ways for improvement, including the potential role of family physicians. Results: Between 2008 and 2013, 93 patients with type 1 diabetes transitioned into adult care. Fifteen interviews were conducted across the province’s four regional health authorities. Various models of transition care are being employed, reflecting staff and resource availability. While no structured transition program was identified, many providers were comfortable with their current transition processes. Suggested improvements included more structured processes, shared educational resources, and a dedicated transfer clinic. Conclusions: In a province with a relatively small number of patients who transition out of pediatric care annually, we found different approaches for transitioning them into adult care, but this variation may not negatively impact patient outcomes.
Rationale, aims and objectives. Applying traditional industrial Quality Improvement (QI) methodologies to primary care is often inappropriate because primary care is best thought of as a network of highly interconnected agents in a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. Methods. We report on changes in health system utilization by new refugee patients of the FHC from 2016-2017 and summarize relevant theoretical understandings of quality management in complex adaptive systems. Results. Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31% to 14% of the refugee patients). Our review of the literature demonstrates that traditional top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies made more sustainable as front-line clinicians use sensemaking to improve care processes. Conclusions and future directions. Recent reforms announced in primary care in Scotland, a few examples in the medical literature, and statements from some healthcare system leaders are examples of early adapters who are applying the principles of CAS to their QI efforts. Such initiatives and our example provide models for others to follow.
The onset of acute illness may be accompanied by a profound sense of disorientation for patients. Addressing this vulnerability is a key part of a physician’s purview, yet well-intended efforts to do so may be impeded by myriad competing tasks in clinical practice. Resolving this dilemma goes beyond appealing to altruism, as its limitless demands may lead to physician burnout, disillusionment, and a narrowed focus on the biomedical aspects of care in the interest of self-preservation. The authors propose an ethic of hospitality that may better guide physicians in attending to the comprehensive needs of patients that have entered “the kingdom of the sick”. Using philosophical methods, the authors explore what compels people to present to emergent medical attention and why altruism may not offer physicians a sustainable way to address the vulnerabilities that occur in such situations. They then present the concept of hospitality from a Derridean perspective and use it to interpret a narrative case of an on-call paediatrician caring for an infant with bronchiolitis to demonstrate how this approach may be practically implemented in the acute care hospital context. Hospitality allows physicians to acknowledge that clinical presentations that are routine in their world may be disorienting and frightening to patients experiencing them acutely. Further, it recognizes that the vulnerability that accompanies acute illness may be compounded by the unfamiliarity of the hospital environment in which patients have sought support. While it is unlikely that anything physicians do will make the hospital a place where patients and caregivers will desire to be, hospitality may focus their efforts upon making it less unwelcoming. Specifically, it offers an orientation that supports patients in navigating the disorienting and unfamiliar terrains of acute illness, the hospital setting in which help is sought, and engagement with the health care system writ large.
Academic journal publication is the currency of University faculty. It can go without saying that publications play an important role in securing an academic appointment and research grants, achieving promotion within the University, and more importantly, advancing knowledge, which is to me the primary purpose of any academic pursuit. Despite its importance, academics seem to receive little or no formal training in how to prepare a manuscript for publication or how to respond to reviewer criticism1. Quite often, such skills are acquired through mentorship during graduate training. Unfortunately, it is often the case that graduate students do not produce enough manuscripts during their training to develop expertise in how to translate completed research or scholarship into a published report. As an editor, I often see manuscripts that are diminished by how they are written, which often causes confusion in the reviewer, resulting in a recommendation for rejection. I do not profess to be an expert on writing for an academic audience. I have no idea exactly how I learned to get my work published (I assume it was through practice and good mentorship), nor do I have any idea if I am skilled at it – I am left to assume my level of expertise from my successes and failures. However, from reading several manuscripts each day, I have picked up on some common errors and have developed an appreciation for what editors and reviewers expect in a published manuscript. In what follows, I present a bit of what I have learned in my, albeit it short, time as an editor.2
Rationale, aims and objectives The article looks at how, during consultations, pregnant women identified as presenting an increased risk of giving birth to a child with an impairment, and practitioners in the field of prenatal diagnosis, decide whether or not to accept the risk of a miscarriage and proceed with a diagnostic examination. Methods We conducted 63 observations of consultations in France and 22 in England. Participants were women for whom an elevated risk of abnormality had been identified and the practitioners involved in their care. Our analytical approach consisted in suspending the normative concepts of non-directiveness and autonomy, and in drawing on Goffman’s (1974) notion of “frame” to take account of the experiential and structural aspects that the protagonists bring into the (inter)actions. Results We identified four frames: medico-scientific expertise, medical authority, religious authority and compassion. Observation of the ways in which the frames intertwine during consultations revealed configurations that facilitate or hinder the fluidity of the interactions and the decision-making process. The medico-scientific expertise frame, imposed by the guidelines, heavily dominated our observations, but frequently caused distress and misunderstanding. Temporary or sustained use of the compassion and/or medical authority frames could help to repair the discussion and create the conditions that enable women/couples to reach a decision. Variations in configuration highlighted the differences between practitioners in the two countries. Conclusions Combining frames allows protagonists to exert reflective abilities and to maintain/restore interactions. The frame analysis promotes a vision of autonomy that is sociological, relational and processual rather than philosophical. The frames are anchored in different structural conditions in England and France.
In the United States chronic illnesses have become a way of life for multiple generations – they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease. Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action. During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments. The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. We conclude by discussing how asset-based community development can promote social connectivity and improve health, and discuss how our approach reflects the emerging national consensus on the importance of place-based population system change.
Rationale, aims and objectives The main purpose of this paper is to measure the efficiency and ranking of medical diagnostic laboratories by applying a Network Data Envelopment Analysis. Methods In this study, each medical diagnostic laboratory is considered as a decision making unit (DMU) and a network data envelopment analysis (NDEA) model is utilized to calculate the efficiency of each medical diagnostic laboratory. Therefore, we design a series four-stage system composed of three main laboratory processes (the pre-test process, the test process and the post-test process). We also consider sustainability criteria in order to cover social, economic, and environmental problems of health care organizations. Results The results show that three of the 22 considered laboratories are efficient. Therefore, the network DEA approach can lead to performance scores and ultimately real ranking. Also, the average efficiency scores show that the decrease of the reception unit’s efficiency results in a decrease of the efficiency of each laboratory. Therefore, the laboratories can increase the number of patients. Along with the intermediate values of the reception unit and the sampling unit, the efficiency of the reception unit increases, which results in an increase for the overall efficiency of each laboratory. Conclusion The proposed model can appropriately help the administrators and managers to identify inefficient units in their laboratory and ultimately improve the laboratory performance.
Rationale, aims and objectives Creating networked business models is one of the innovative approaches that have the ability and potential for meeting market needs. The purpose of this study is to provide a decision making model for a fair profit sharing among the members of a diagnostic laboratory network while providing a distinctive value for the patients. Methods To identify the members of the network of laboratories, a suitable approach to calculate members’ efficiency scores is proposed. Then, the network members are classified into three groups based on their performance scores. The three groups help administrators identify eligible members, members who need to improve their performance in order to meet the minimum requirements, and members who do not qualify for admission to the network. Since the performance of the members should play a significant role in the fair profit sharing mechanism, the fair allocation of profits among network members is done by the use of Shapely’s value based on the efficiency scores of members. Results The results show that for such a fair mechanism, the efficiency and sample size (the number of samples (blood, urine) taken from the patients by the laboratories), as the two effective factors, have a decisive role in the share of profit of laboratory units of the network. In the Laboratory Services Network, members receive a number of samples according to their performance. As a result, the sample size received has a direct impact on the net income of each member. Conclusion In conclusion, it is evident that the use of Shapely value may help managers in the process of sharing profits among network members in a fair way, thereby improving network performance. In this way, incentive strategies may be created for the members of the network and long-term survival of the network may be achieved.