AMA, IHI, Other Collaborators Launch Nationwide Equity Coalition for Systemic Change, Structural Impact Across Health Care
FDA Updating Warnings to Improve Safe Use of Prescription Stimulants Used to Treat ADHD and Other Conditions.
SD BioSensor, Inc. Recalls Certain Pilot COVID-19 At-Home Tests for Potential Bacteria Contamination
Draeger Medical Recalls Seattle PAP Plus and Breathing Circuit/Anesthesia Kits for Risk of Loose or Detached Components That Can Restrict Breathing Support
Stop Putting off the End-of-Life Talk with Your Aging Loved Ones.
ICU Medical Recalls Replacement Batteries for Plum 360, Plum A+, and Plum A+3 Infusion Systems Due to Diminished Battery Life that May Impact Infusion Delivery
Novis PR LLC Issues Voluntary Recall of G-Supress DX Pediatric Drops Due to Incorrect Packaging
Novis PR LLC Emite Retiro Voluntario de Gotas Pediátricas G-Supress DX Debido a Empaque Incorrecto
Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study
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
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.
Surgical implementation gap: an interrupted time series analysis with interviews examining the impact of surgical trials on surgical practice in England
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.
Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis
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
Advancing equity, diversity and inclusion at BMJ Quality and Safety
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...
Measuring what matters: refining our approach to quality indicators
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...
Understanding the consequences of GP referral thresholds: taking the instrumental approach
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...
Making it happen: engaging the power of many in translating research into practice
Randomised controlled trials (RCTs) are considered the gold standard for the rigorous evaluation of healthcare interventions because, when feasible, they generate the least biased estimate of treatment effect. However, completion of a trial is not the end game; that is, the continuum of translating science into practice does not end with publication of the RCT. Rather, active efforts must be made to translate the research findings into general practice. Indeed, the science of implementation, defined holistically as the study of ways to promote, enhance and ensure the sustained integration of research evidence into frontline practice, has shown us the complexity of achieving this goal. In the absence of active dissemination and implementation efforts, new knowledge and practices are often taken up through diffusion of innovation, and adoption is dependent primarily on attributes of the innovation. Thus, if we just focus on ‘letting it happen’ instead of ‘helping it happen’...
Prescribing medications with indications: time to flip the script
Drug indications are the link between a drug and the patient. Indications link the evidence-based benefit of a drug for a specific population to a particular patient’s clinical condition. Unfortunately, in prescribing they are more often the ‘missing link’, with explicit documentation of the indication usually missing from the prescription, despite considerable evidence and recommendations (dare we say exhortations) that documenting the indication would make the entire medication use process safer.1–4 Patients want to, need to and have a right to know what each of their medications is for.
This issue of BMJ Quality and Safety includes a paper urging incorporation of drug indication into the prescription order, which follows several pieces recently published in BMJ Quality & Safety.5–7 In this case, Feather and colleagues conducted a systematic review and narrative synthesis identifying 21 articles...
Approach to systematically examine the usefulness of quality measures in practice: Minnesotas nursing home quality indicators and scoring approach
Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity.Methods
We analysed 19 risk-adjusted, facility-level QIs over the 2012–2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs.Results
Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs).Conclusion
We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.