This article resulted from the public launch of the Rise to Health Coalition and includes quotes from IHI's President and CEO Dr. Kedar Mate.

The American Medical Association (AMA), the Institute for Healthcare Improvement (IHI), and Race Forward today called for a system-wide approach to health equity, formally announcing the launch of Rise to Health: A National Coalition for Equity in Health Care.

The FDA is requiring updates to the Boxed Warning and other information to ensure the prescribing information is made consistent across the entire class of these medicines to address continuing concerns of misuse, abuse, addiction, and overdose of prescription stimulants.

SD BioSensor is recalling some Pilot COVID-19 At-Home Tests for the risk that a bacteria contamination could harm users or cause false test results.

Draeger Seattle PAP Plus and some breathing circuit or anesthesia kits may have parts that loosen or detach, preventing needed breathing support.

This article discusses the importance of having end-of-life conversations with family members and includes commentary and resources from IHI's Kate DeBartolo and The Conversation Project.

Replacement batteries for ICU Medical’s Plum 360, Plum A+ and Plum A+3 large volume infusion pumps may have shorter than expected battery life.

San Juan, PR, Novis PR LLC is voluntarily recalling Lot D20911 Exp 10/25 of G-Supress DX Pediatric Drops to the consumer level. Some cartons of the product have been found to contain incorrect product inside. Incorrect product inside is an anesthetic/analgesic and not a brand of Novis PR LLC.

San Juan, PR, Novis PR LLC está retirando voluntariamente el lote D20911 Exp 10/25 de gotas pediátricas G-Supress DX a nivel de consumidor. Se ha encontrado que algunas cajas del producto contienen un producto incorrecto en su interior. El producto incorrecto en el interior es un anestésico/analgési

Objectives

To estimate the impact of altering referral thresholds from out-of-hours services on older patients’ further use of health services and risk of death.

Design

Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry.

Setting

Norway

Participants

491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016.

Analysis

Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.

Physicians’ proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable (‘physician referral preference’) for their threshold of referral for such patients whose clinical presentations were less clear cut.

Results

For older patients, whose referrals could be attributed to their physicians’ threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians’ threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97).

Conclusions

Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

Objectives

Landmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects.

Design

A sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings.

Setting

Changes in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online.

Data and participants

The six surgical trials were funded and published by England’s National Institute for Health Research’s Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area.

Results

The quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data.

Conclusion

While practice does not always change in the direction indicated by clinical trials, our results suggest that individuals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.

Background

Despite recommendations, documentation of indication on prescriptions and inpatient medication orders is not routinely practised. There has been a recent systematic review of indication documentation for antimicrobials, but not for interventions relating to indication documentation for medication more broadly. Our aims were to 1) identify, describe and synthesise the literature relating to effectiveness of interventions aimed at improving indication documentation and/or indication-based prescribing in both primary and secondary healthcare; 2) synthesise participant perspectives to identify barriers and facilitators to these interventions; and 3) make recommendations for both practice and research.

Methods

A systematic literature search was conducted using Medline, Embase and CINAHL using two search concepts: electronic prescribing systems, and indication documentation and/or indication-based prescribing. Qualitative, quantitative and mixed-methods studies were included; outcome measures and results were extracted to produce a narrative synthesis. Quality appraisal by two independent reviewers was undertaken using the Mixed Methods Appraisal Tool.

Results

We identified 21 studies evaluating interventions to aid indication documentation. Indication documentation was either via free-text, selection from a list, or by use of pre-defined indication-based order sentences for individual medications. For a number of outcomes, there was a mostly positive impact, including appropriateness of the medication order (6 of 8 studies), rates of prescribing error (2/2) and some less commonly reported clinical (2/4) and workflow-related outcomes (2/3). There was a less favourable impact on accuracy of indication documentation and rates of medication use, highlighting some unintended consequences that may occur when implementing new interventions. Participant insights from prescribers and other healthcare professionals complemented quantitative study results, highlighting both facilitators and barriers to indication documentation and the associated interventions. For example, barriers included long drop-down lists and the need to use workarounds to navigate approval systems due to time or knowledge constraints. Facilitating factors included the perceived benefits of indication documentation on communication among the healthcare team and with the patient.

Conclusion

Indication documentation has the potential to improve appropriate prescribing and reduce prescribing errors. However, further benefits to the prescriber, multidisciplinary team and patient may only be realised by developing methods of indication documentation that integrate more efficiently with prescriber workflows.

PROSPERO registration number

CRD42021278495.

The purpose of BMJ Quality and Safety is to encourage the science of improvement, debate and new thinking on improving the quality of healthcare.1 Equity is a key domain of healthcare quality—high quality, safe healthcare should be available to all who need it.2 However, systemic biases and barriers are widespread in healthcare,3 as well as more broadly, including within the processes around the publication of research.4 For example, lack of diversity among editors, reviewers and authors of published papers is likely to both reflect and exacerbate systemic sources of inequity among researchers but also among the intended beneficiaries of our research—patients and their healthcare providers. By ‘diversity’, we here include areas such as (but not limited to) socioeconomic status, sex, gender, race or ethnicity, first language, sexual orientation, religion, beliefs, disability status, age, nationality or citizenship, and place of residence. At...

Quality indicators are ubiquitous in healthcare and serve a variety of purposes for many different stakeholders. Few would question the value of monitoring the quality of care, but the increasing numbers of indicators and the resources consumed suggest that some reflection and refinement of approach may be required. For instance, the National Quality Forum catalogue in the USA lists 1167 indicators,1 and a recent study from the Netherlands showed that healthcare professionals from five clinical specialties collect data for 24 different stakeholders on 1380 different variables.2 Healthcare professionals in the latter study spent an average of 52 min per working day documenting for the wide range of required quality registrations, with only 36% of the indicators perceived as useful for improving the quality of care in daily practice.2

In this issue of BMJ Quality & Safety, Xu and colleagues report a study of the...

Trade-offs between patient safety and efficient use of healthcare services occur in clinical decisions across all forms of healthcare. In the case of acutely unwell older patients, decisions about referral to hospital involve trade-offs between the safety associated with inpatient hospital treatment and the burden on both the patient and health system associated with hospital admission. In many healthcare systems, these decisions are largely made by general practitioners (GPs), often without first-hand knowledge of the patient, especially when presentation is in an out-of-hours setting. This raises three questions: how much do practitioners vary in their decisions? is this variation systematic (ie, after adjusting for patient and context, do some practitioners have a greater or lesser tendency to refer than others?)? and are those who make fewer referrals making better decisions (ie, admitting those who will benefit, keeping at home those who will not)?

In this issue of BMJ Quality...