Background

Individuals with sickle cell disease (SCD) experience poor clinical outcomes while transitioning from paediatric to adult care. Standards for SCD transition are needed. We established a Quality Improvement (QI) Collaborative that aimed to improve the quality of care for all young adults with SCD by establishing a standardised SCD transition process. This study evaluates the implementation of the Six Core Elements (6CE) of Health Care Transition, which was a fundamental component of the cluster-randomised Sickle Cell Trevor Thompson Transition Project (ST3P-UP) study.

Methods

A central QI team trained 14 ST3P-UP study sites on QI methodologies, 6CE and Got Transition’s process measurement tool (PMT). Site-level QI teams included a transition coordinator, clinic physicians/staff, patients/parents with SCD and community representatives. Sites completed the PMT every 6 months for 54 months and monthly audits of 10 randomly-selected charts to verify readiness/self-care assessments and emergency care plans.

Results

Of a possible 100, the aggregate mean (±SD) PMT score for paediatric clinics was 23.9 (±13.8) at baseline, 95.9 (±6.0) at 24 months and 98.9 (±2.1) at 54 months. The aggregate mean PMT score for adult clinics was 15.0 (±13.5) at baseline, 88.4 (±11.8) at 24 months and 95.8 (±6.8) at 54 months. The overall QI Collaborative PMT score improved by 402%. At baseline, readiness/self-care assessments were current for 38% of paediatric and 20% of adult patients; emergency care plans were current for 20% of paediatric and 3% of adult patients. Paediatric clinics had one median readiness assessment shift (76%) and four median emergency care plan shifts (65%, 77%, 79%, 84%). Adult clinics experienced three median self-care assessment shifts (58%, 63%, 70%) and two median emergency care plan shifts (57%, 70%).

Conclusions

The ST3P-UP QI Collaborative successfully embedded the 6CE of Health Care Transition into routine care and increased administration of assessments and emergency care plans for transition-aged patients with SCD.

Background

Pulmonary embolism (PE) is a potentially deadly disease and a diagnostic challenge in emergency departments (EDs). Established strategies exist for risk stratification and test stewardship for CT pulmonary angiography (CTPA). However, implementation of best practices has proven challenging, and rising CTPA utilisation increases costs, radiation exposure and ED crowding. We created a multimodal quality intervention to reduce excess CTPA studies and increase the use of d-dimer assays prior to CTPA. Balance measures included the rate of positive CTPA studies and ED returns within 72 hours of discharge.

Methods

This was an observational, pre–post interventional design at three EDs. The intervention included an institutional PE diagnostic guideline, educational sessions, an electronic clinical decision support tool and monthly feedback to individual providers. Consecutive patient data were analysed 1 year pre and 1 year post an intervention on 21 November 2021. Analyses used Pearson 2, logistic regression generalised linear models and XmR statistical process control (SPC).

Results

The study included 307 441 patient encounters, with 35 066 PE evaluations. CTPA utilisation decreased from 6.0% to 5.1% (p<0.01) of all patient encounters, and d-dimer use preceding CTPA increased from 36.6% to 56.3% (p<0.01). For both primary measures, SPC charts showed statistically significant special cause variation compared with the pre-intervention data. There was no significant change in the rate of positive CTPA studies (9.3% vs 10.4%, p=0.14) or 72-hour ED returns (3.0 vs 3.1%, p=0.6).

Conclusions

A multimodal intervention was associated with reduced CTPA utilisation and increased use of d-dimer as the initial test in PE diagnosis, without any negative associated impact on balance measures. This strategy could be reproduced and implemented at other institutions looking to change practice.

Background

Disparities have been identified in many aspects of the cancer care pathway for people from minority ethnic groups (MEGs). Adherence to systemic anticancer therapies (SACTs) has been shown to impact morbidity and mortality, and therefore, inequitable experiences can have a detrimental effect on outcomes.

Objectives

To identify interventions that focused on improving the experiences and clinical outcomes in people from MEG receiving SACT treatments.

Methods

A scoping review was conducted according to Arksey and O’Malley’s methodological framework to map the available literature. A comprehensive search was performed using three electronic databases (Medline, Embase and CINAHL). Standard scoping review methodology following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was used. Studies were included that assessed interventions to improve MEG patients’ experience with SACT. Study types included in the review were evaluation studies, randomised/non-randomised controlled trials and all observational studies. Exclusion criteria were applied to studies including opinion pieces, literature and systematic reviews, non-English studies, conference abstracts and studies that were not describing an intervention. Independent duplicate screening, study selection, data extraction and quality assessment were undertaken. Results of the studies were synthesised using a published equity framework.

Results

Searches yielded 1356 articles. Nine studies were included after exclusion criteria were applied. Studies described six digital, two in-person and one hybrid intervention employing different research methodologies, ranging from randomised controlled trials (RCTs), feasibility studies and mixed methods studies. The majority of interventions in this study were delivered remotely, using digital platforms such as websites, recorded educational training materials as well as social media. These interventions were conducted in the USA and primarily targeted patients with early breast cancer from African American backgrounds.

Conclusions

This scoping review showed that there has been a very small number of studies investigating interventions to optimise SACT treatment experiences in people from MEG. We found evidence of interventions incorporating the equity domains that reported improved patient engagement and experience. This new knowledge will help to implement future SACT interventions, addressing health inequities across the cancer continuum.