In USA, cancer outcomes have steadily improved but considerable disparities in outcomes persist.1 There is continued evidence that vulnerable patients (ie, those who are socially or economically disadvantaged) are less likely to receive high-quality care and subsequently have poorer outcomes.2 Since the release of the Institute of Medicine’s report Ensuring Quality Cancer Care in 1999, increased attention has been paid to the importance of measuring cancer care quality, understanding its effects on outcomes and identifying effective strategies for ensuring that all patients have access to high-quality cancer care.3 Studies have demonstrated that patient survival varies by hospital type (eg, community vs academic cancer centre), even after risk adjustment for tumour characteristics and comorbidities, and that patients treated at hospitals that perform worse on some cancer quality metrics have inferior survival.4–10
We all grow old. Even surgeons. We slow down, we weaken and our skills diminish. Although individuals differ and chronological age may not be an accurate guide to biological age, we cannot hold back the advancing years.
How long should we allow surgeons to keep operating? If public safety is the priority, as it must be, should there be a mandatory retirement age, as there is for pilots in the airline industry? Or is there a fair and equitable way of assessing those nearing the end of their career to ensure their competency is maintained?
The ageing surgeon poses daunting challenges. For the individuals concerned, the idea of ageing may trigger fears about loss of status, identity and livelihood. Patients may worry about the quality of their care. For healthcare systems struggling to meet growing demand, this issue raises questions about capacity.The scope of...
Effective teamwork and communication is now recognised as a critical component of safe and high-quality patient care. Researchers, policymakers and frontline providers are in search of strategies to improve teamwork in healthcare. The most frequently used strategy is teamwork training.1 Teamwork training involves a systematic process in which a team is guided (often by facilitators) to improve and master different skills for working together effectively. Single-centre teamwork training initiatives have demonstrated improvements in patient care, but these results have been challenging to reproduce at scale.2
In this issue of BMJ Quality and Safety, Lenguerrand et al report the results of a stepped-wedge randomised controlled trial in which PRactical Obstetric Multi-Professional Training (PROMPT), an interprofessional intrapartum training package, was implemented across 12 maternity units in Scotland.3 Each participating unit identified an in-house training team to travel to attend a 2-day PROMPT Train the Trainers...
Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.Methods
Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.Results
A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers.Conclusions and relevance
Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.
Unlike some other safety critical professions, there is no mandatory age of retirement for doctors, including surgeons. Medical regulators in Australia are implementing additional checks on doctors from the age of 70. We describe expert opinions on assuring performance and supporting career transitions among older surgeons.Methods
In this qualitative study, experts in four countries were purposively selected for their expertise in surgical governance. Experts responded to interviews (Australia, New Zealand and UK) or a survey (Canada). A tiered framework of interventions was developed by integrating findings with previous literature and responsive regulation theory.Results
52 experts participated. Participants valued the contribution of senior surgeons, while acknowledging that age-related changes can affect performance. Participants perceived that identity, relationships and finances influence retirement decisions. Experts were divided on the need for age-specific testing, with some favouring whole-of-career approaches to assuring safe care. A lack of validated tools for assessing performance of older surgeons was highlighted. Participants identified three options for addressing performance concerns—remediate, restrict or retire—and emphasised the need for co-ordinated and timely responses.Conclusion
Experts perceive the need for a staged approach to assessing the performance of older surgeons and tailoring interventions. Most older surgeons are seen to make decisions around career transitions with self-awareness and concern for patient safety. Some older surgeons may benefit from additional guidance and support from employers and professional colleges. A few poorly performing older surgeons, who are recalcitrant or lack insight, require regulatory action to protect patient safety. Developing robust processes to assess performance, remediate deficits and adjust scopes of practice could help to support safe career transitions at any age.
To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).Design
Stepped-wedge cluster randomised controlled trial.Setting
Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.Intervention
The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.Main outcome measures
The primary outcome was the proportion of term babies with Apgar<75mins.Results
87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the ‘intention-to-treat’ analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.Conclusions
PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.Trial registration number
Handoffs are often framed as the co-construction of a shared understanding relying on narrative storytelling. We investigated how narratives are constructed and used during resident and nurse handoff conversations.Method
We audio-recorded resident (n=149) and nurse (n=126) handoffs in an inpatient medicine unit. Qualitative analysis using grounded theory was conducted to identify and characterise the structure of resident and nursing handoff narratives.Results
Handoff conversations among both residents and nurses used three types of narratives: narratives on creating clinical imagery, narratives on coordinating care continuity and narratives on integrating contextual aspects of care. Clinical imagery narratives were common during patient introductions: residents used a top-down approach relying on overarching patient clinical situations (eg, ‘a liver patient’), whereas nurses used a bottom-up approach using patient-specific identifying information. Narratives on the coordination of care continuity for residents focused on managing internal and external coordination activities, whereas nurse narratives focused on internal coordination, emphasising their role as an interface between patients and their physicians. Both resident and nurse narratives on the contextual aspects of care had considerable focus on highlighting ‘heads up’ anticipatory information and personal patient information; such information was often not present in patient charts, but was important for ensuring effective care management.Discussion
The presence of narrative structures highlights the need for new perspectives for the design of handoff tools that allow for both informational and cognitive support and shared awareness among conversational partners during handoff conversations. We discuss the implications of the use of narratives for patient safety and describe specific design considerations for supporting narrative interactions during handoffs.
To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge.Design, setting, participants
Multicentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015.Primary outcome measure
Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information: hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated.Results
1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases (‘possible’ and ‘probable’) were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced ‘definite’ MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge: age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool’s discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches.Conclusions
The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool’s evaluation in other settings.
There is wide recognition that promoting healthcare value involves decreasing ‘low-value’ services—care without clinical benefit, little benefit compared with cost or disproportionate potential harm.1 While low-value care has been presumed to be a problem predominantly in the USA in the context of an expensive, fragmented, multipayer, fee-for-service system, recent evidence suggests low-value services are pervasive even in government-funded healthcare systems with universal coverage and interoperability.2 Accordingly, low-value care is garnering attention across the globe.3
In response, policymakers, insurers and individual healthcare systems must work together to create and track measures of low-value care. In the USA, a number of states have begun to use such measures to characterise low-value care delivered by healthcare provider organisations.4–6 Many of the existing measures have been derived from the national Choosing Wisely campaign7 with examples such as cervical cancer...
Clostridioides difficile infection (CDI) remains an important healthcare-associated infection and threat to patient safety since the height of the NAP1/027 epidemic in the early part of the millennium. In 2011, C. difficile caused almost half a million infections and 29 000 deaths in the USA alone, with 24% of those cases occurring in hospital settings.1 The US Centres for Disease Control identifies C. difficile as one of three pathogens that poses ‘an immediate antibiotic resistance threat that requires urgent and aggressive action’.2 Many jurisdictions now require public reporting of hospital CDI rates. In some countries, hospitals face financial penalties for elevated CDI rates. CDI rates are also top priorities on hospital quality agendas, often associated with ambitious reduction targets. Some institutions even aim for complete elimination of healthcare-associated CDI—a goal referred to as ‘getting to zero’.
There is no argument that healthcare-associated CDI is a significant...
Current methods used to evaluate the effects of healthcare improvement efforts have limitations. Designs with strong causal inference—such as individual patient or cluster randomisation—can be inappropriate and infeasible to use in single-centre settings. Simpler designs—such as prepost studies—are unable to infer causal relationships between improvement interventions and outcomes of interest, often leading to spurious conclusions regarding programme success. Other designs, such as regression discontinuity or difference-in-difference (DD) approaches alone, require multiple assumptions that are often unable to be met in real world improvement settings. We present a case study of a novel design in improvement and implementation research—a hybrid regression discontinuity/DD design—that leverages risk-targeted improvement interventions within a hospital readmission reduction programme. We demonstrate how the hybrid regression discontinuity-DD approach addresses many of the limitations of either method alone, and represents a useful method to evaluate the effects of multiple, simultaneous heath system improvement activities—a necessary capacity of a learning health system. Finally, we discuss some of the limitations of the hybrid regression discontinuity-DD approach, including the need to assign patients to interventions based upon a continuous measure, the need for large sample sizes, and potential susceptibility of risk-based intervention assignment to gaming.
Many maternal and perinatal deaths in low-resource settings are preventable. Inadequate access to timely, quality care in maternity facilities drives poor outcomes, especially where women deliver at home with traditional birth attendants (TBA). Yet few solutions exist to support TBA-initiated referrals or address reasons patients frequently refuse facility care, such as disrespectful and abusive treatment. We hypothesised that deploying accompaniers—obstetric care navigators (OCN)—trained to provide integrated patient support would facilitate referrals from TBAs to public hospitals.Methods
This project built on an existing collaboration with 41 TBAs who serve indigenous Maya villages in Guatemala’s Western Highlands, which provided baseline data for comparison. When TBAs detected pregnancy complications, families were offered OCN referral support. Implementation was guided by bimonthly meetings of the interdisciplinary quality improvement team where the OCN role was iteratively tailored. The primary process outcomes were referral volume, proportion of births receiving facility referral, and referral success rate, which were analysed using statistical process control methods.Results
Over the 12-month pilot, TBAs attended 847 births. The median referral volume rose from 14 to 27.5, meeting criteria for special cause variation, without a decline in success rate. The proportion of births receiving facility-level care increased from 24±6% to 62±20% after OCN implementation. Hypertensive disorders of pregnancy and prolonged labour were the most common referral indications. The OCN role evolved to include a number of tasks, such as expediting emergency transportation and providing doula-like labour support.Conclusions
OCN accompaniment increased the proportion of births under TBA care that received facility-level obstetric care. Results from this of obstetric care navigation suggest it is a feasible, patient-centred intervention to improve maternity care.