Rationale, aims and objectives The concept of patient or case complexity is relevant – and widely used – at all levels and stages of mental health service provision, but there have been few methodologically robust attempts to define this term. This study aimed to establish a consensus on factors contributing to patient complexity in adult psychological services using Delphi Methodology. Method Applied psychologists in a single urban/suburban UK National Health Service setting took part in a three-round modified Delphi study. Twenty-eight respondents in round one gave qualitative data on factors they considered when assessing complexity, which was subject to thematic analysis. Twenty-five respondents in round two rated how central/peripheral each theme was to their judgement using Likert scales. In a third round, twenty respondents addressed discrepancies and possible utilities of the emerging framework. Results Thirteen factors contributing to patient/case complexity (Active Severe/Enduring Mental Health, Current Coping/Functioning, Engagement, Forensic History, Iatrogenic Factors, Interpersonal Functioning, Neuro-Cognitive Functioning, Physical Health, Problematic Substance Use, Risk, Severity/Chronicity of Presenting Problems, Systemic and Socio-Economic Factors and Trauma) were identified with a high degree of consensus. All were rated as central to complexity. Conclusions We conclude that applied psychologists do have a shared understanding of complexity and make recommendations for further research validating, developing and applying this empirically derived framework. Keywords: psychological, complexity, definition, operationalising, framework development, clinical judgement
Rationale, aims and objectives: Increased incidence of chronic illnesses coupled with physician shortages have yielded strain on primary care providers (PCP) to meet care demands. Interdisciplinary providers such as nurse practitioners and physician assistants have increasingly been embedded into primary care teams to alleviate some workload demand. Little evidence exists about the impact of interdisciplinary PCP care delivery models on provider outcomes. The objective of this study was to investigate the impact of interdisciplinary PCP care delivery on provider burnout, job satisfaction and intention to leave current position. Methods: We conducted a cross sectional mail survey using Dillman methodology of primary care practices (e.g., internal medicine) across New York State. A random sample of interdisciplinary PCPs (physicians, nurse practitioners, and physician assistants) (n=333) responded. The Provider Co-management Index (α = .85) was used to measure how well interdisciplinary dyads co-management care delivery attributes (effective communication; mutual respect and trust; shared philosophy of care). Provider outcomes were measured with validated AHRQ and HRSA items for burnout, job satisfaction and intention to leave position. Descriptive statistics, logistic regression models, crude and adjusted odds ratios were calculated, controlling for participant and practice characteristics. Results: Almost 30% of participants reported burnout with three times the odds of intending to leave their current position within one year. With each unit increase in effective co-management between interdisciplinary dyads there was 15% less burnout and 10% less odds of intention to leave position. Conclusion: Incorporating interdisciplinary specialties in primary care appears promising to alleviate some adverse provider outcomes. Organizations contemplating delivery models to promote well-being and retention may consider co-management. Cost effectiveness research is needed to determine financial sustainability of interdisciplinary care delivery.
Rationale, aims and objectives: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. Method: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analyzed according to a realist review approach. Results: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable.At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models effectiveness. Conclusion: We conclude by providing advice for creating effective home care system change through rational and participatory design and evaluation alongside public dialogue about the purpose and future of home care.
The well-known clinical axiom stating that “common things are common” attests to the pivotal role of probability in diagnosis. Despite the popularity of this and related axioms, there is no operationalized definition of a common disease, and no practicable way of incorporating actual disease frequencies into differential diagnosis. In this expository essay, we aim to reduce the ambiguity surrounding the definition of a common (or rare) disease and show that incidence – not prevalence – is the proper metric of disease frequency for diagnosis. We explore how a numerical estimates of disease frequencies based on incidence can be incorporated into differential diagnosis as well as the inherent limitations of this method. These concepts have important implications for diagnostic decision making and medical education, and hold promise as a method to improve diagnostic accuracy.
Rationale, aims and objectives: Clinical incident reports are the primary means by which UK hospitals are alerted to avoidable harm in healthcare. However, data demonstrating the patterns in real-world reporting by healthcare workers have never been published in the UK. Though this journal has previously published survey data describing the discrepancies between respondents’ own behaviour compared to the incidence of perceived avoidable harm, we set out to collect data on actual reporting patterns between healthcare workers. Given the concerns raised by Robert Francis following the Mid-Staffordshire Inquiry, we specifically wished to examine the rate of reporting of doctors compared to other healthcare workers. Methods: We selected for incidents causing at least ‘moderate’ levels of harm, theorising that such levels of harm are most likely to be noticed by doctors. Data from 2011 to 2019 from the clinical governance departments of 2 NHS hospitals was requested and all available data subsequently charted. Results: This is the first study examining NHS incident reporting patterns in the medical profession. We demonstrated a stark level of underreporting of clinical incidents causing harm ranging from ‘moderate’ to death by doctors. This was particularly dramatic at the non-consultant grade level. In 1 hospital, only 2 deaths were reported by non-consultant grade doctors in 6 years. Notably 1 hospital had not stored any incident reporting data until 2017. Conclusion: The reporting behaviour of doctors has not significantly changed despite the Francis Reports. This could be improved by creating incentives for doctors to engage with patient safety initiatives and disclosure of error, as well as the use of automated systems.
i. Rationale, Aims and Objectives: Despite guideline recommendations against their use, clinicians prescribe benzodiazepines for various symptoms to patients with posttraumatic stress disorder (PTSD). Clinicians’ reasons in making these decisions are not fully understood. This qualitative study sought to characterize factors identified by prescribing clinicians in clinical decision making in PTSD regarding the use of benzodiazepines. ii. Methods: The descriptive study involved semi-structured interviews with 26 prescribing clinicians across thirteen VA medical centers. Our overall aim in the study was to explore clinicians’ benzodiazepine practices in veterans with a PTSD diagnosis. We audio-recorded, transcribed, and analyzed the interviews using grounded theory methodology. iii. Results: Facilitators and barriers that contribute to benzodiazepine prescribing to veterans with PTSD included organizational, provider, and patient aspects. Most providers interviewed indicated that they inherited patients already on these medications initiated by other clinicians. These providers, as well as others interviewed, voiced concerns that tapering benzodiazepines may cause more harm than the risks of maintenance, particularly in older patients. Clinicians who noted consistent treatment practices among their hospital colleagues found it easier to decrease both new and maintenance benzodiazepine prescribing. iv. Conclusions: Patients with PTSD at increased risk of harms, such as older patients, are still receiving benzodiazepines suggesting that innovative solutions are now needed to decrease use. Specific protocols for inherited patient caseloads, increased dissemination of effective psychotherapies for symptoms such as insomnia and anxiety and the use of direct to consumer educational materials should help to foster needed culture change and increased evidence-based PTSD practice.
Rationale, aims & objectives: This evaluation was carried out in order to determine the efficacy of the Norfolk and Waveney Adult ADHD Service. With the service not commissioned to offer non-pharmacological support, and with a gap in the research literature, evidence on whether the service model was effective at reducing the impact of ADHD symptoms on service users was needed in order to justify longer term commissioning. Method: Case notes of 113 individuals going through their medication titration process were observed. Scores from the Weiss Functional Impairment Rating Scale (WFIRS), which was routinely collected in the service pre- and post- titration onto ADHD medication, were recorded for comparison. Results: A T test revealed significant improvements in functioning across all domains of the WFIRS after successful titration onto ADHD medication. However, 19.5% of the sample disengaged from the service prior to completing titration. A further 12.5% of the sample did not complete titration due to various factors discussed. Conclusion: While medication has been shown to be effective at improving impairment of functioning in adults with ADHD, high levels of disengagement suggest that more needs to be offered to this population.
Objective: To investigate concordance in perceptions of communication among participants in family discussions and assess the importance of different domains of communication in a neurocritical care unit. Methods: Prospective observational study conducted in a neurocritical care unit. Our study involved family discussions regarding plan of care for patients admitted to the unit. All participants completed a survey. The first 4 questions rated understanding of the discussion and general satisfaction; the remaining questions were open-ended to assess quality of communication by the physician leading the discussion. Responses were scored and compared among participants using a Likert scale. A difference of < 1 in scores among participants was rated as concordance, while > 2 was designated as discordance. All open-ended responses were classified into six domains. Results: We observed 35 family discussions. Questions 1-3 yielded 99 cross-comparisons per question (total of 297 compared responses). Most responses were either “Strongly Agree” or “Agree”; with “Neutral” or “Disagree” responses being more prevalent in Question 2. Overall concordance of responses between participants was 88%. Education was the most frequently cited domain of communication in response to open-ended questions. Among family and neutral observers, empathy was frequently listed, while providers more often listed family engagement. Conclusion: Overall, satisfaction was high among providers, families, and the observer regarding quality of communication during family discussions in the unit. Perceptual differences emerged over whether this communication impacted healthcare decision-making during that encounter.
Diagnostic failure has emerged as one of the most significant threats to patient safety, and it is important to understand the antecedents of such failures. A consensus has developed in the literature that the majority are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is due to cognitive and affective biases, however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound assessment of the context surrounding the diagnostic process itself. The present qualitative study uses a detailed narrative account of selected actual cases of diagnostic error to explore the effect of biases in the ‘real world’ emergency medicine (EM) context. Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error producing conditions, knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the study was the identification of specific cognitive and affective biases – through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. 5-6 biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen error-producing conditions (EPCs) were identified. Knowledge-based errors were rare, occurring in only 5 definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This study provides a base-line for understanding the critical role that biases play in clinical decision making and sheds light on important aspects of the diagnostic process.
Objective: The choice between neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC) remains controversial in the treatment of non-small cell lung cancer (NSCLC). There is no significant difference in NAC and AC’s effectiveness. We investigate the cost-effectiveness of NAC versus AC for NSCLC. Method: A decision tree model was designed from a payer perspective to compare NAC and AC treatments for NSCLC. Parameters included overall survival (OS), surgical complications, chemotherapy adverse event (AE), treatment initiation probability, treatment time frame, treatment cost, and quality of life (QOL). Sensitivity analyses were performed to characterize model uncertainty in the base cases. Result: With the same overall survival, AC treatment strategy produces a cost saving of ￥618.90 and an incremental quality-adjusted life-years (QALY) of 0.10 years per patient. If median OS of NAC is 1.4 months more than AC, NAC would be cost effective (CE) at a ￥35446/QALY threshold. The model was robust enough to handle variations to all input parameters except the overall survival. In the probability sensitivity analysis, AC remained dominant in 54.6% of simulations. Conclusion: The modeled cost effectiveness analysis indicates that with operable NSCLC, AC treatment is more cost effective compared to NAC. If NAC provides a longer survival advantage, this treatment strategy may be cost-effective. The OS is the main factor that influences cost-effectiveness analysis.
Introduction and aim of the study: Hospital readmissions represent an increasing and highly expensive cost for National Health Services. Aim of this retrospective case-control study was to compare patients who required one or more repeated hospitalizations to those who had only one, in the year 2018 at the Department of Internal Medicine of Pontedera Hospital (Pisa, Italy). Materials and Methods: All the data were retrieved matching data from our electronic health record with our diagnosis-related group (DRG) software system. Continuous variables were defined means ± standard deviation; categorical variables were given as percentage. The independent sample t test was used for the continuous variables and chi-square test for categorical variables. Significance was inferred for p < 0.05. Results: In 2018 a total of 3012 patients were hospitalized. Among these, 14.1% (n=426; mean age 79.7±11,9; range 23-100) were defined as revolving: data were compared with controls (n=420; 13.9%; mean age 75.9±14.7; range 22-99) who had only one hospitalization. Patients main provenance was in both groups a Home-based health care. Revolving patients showed higher mean age, higher rate of chronic comorbidities and mortality. Cancer was equally distributed in both groups. Sepsis was the most relevant factor associated with re-hospitalizations and mortality. Skin ulcers were present in about half of revolving patients, but they were coded as DRG only in an absolute minority. Conclusions: readmissions to Internal Medicine Departments are frequent and mainly related to the severity of chronic diseases affecting the patients. Sepsis was the most relevant condition associated with readmissions, leading to a very high mortality rate. Skin ulcers affected about half of revolving patients, but their DRG were significantly underestimated. Preventing sepsis and investing resources in chronic diseases assistance, represent a key challenge for the future, especially in an outpatient setting.
Background and Aim: We aimed to investigate the effects of anxiety or social support on sleep quality in patients with COVID-19 who were older than 65 years of age and undergoing quarantine process. Material and Method: The study included the patients ≥65 years of age who had a quarantine process for 14 days during the COVID-19 outbreak. The sociodemographic features and comorbidities were recorded in all patients. Geriatric Anxiety Scale (GAS), Multidimensional Perceived Social Support Scale (SS), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were applied. Results: Totally 198 patients (123 male and 75 female) were included in the study. Among patients, 115 (58.1%) patients were living in a nursing home. All GAS scores and the total PSQI were significantly higher and all SS scores were significantly lower in PCR positive patients compared with the negative ones (p:0.001). Moreover, All GAS scores and the total PSQI were significantly higher and all SS scores were significantly lower in patients living in nursing homes compared with the others (p:0.001). Conclusion: In elderly patients faced with the COVID-19, social support was negatively associated with the sleep disturbances. We suggest that, increasing social support is important in elderly patients in the clash against COVID-19.
Aim: To investigate the difference in both numbers and acuity of presentations to the Paediatric Emergency Department (PED) during the peak time period of the current global SARS-CoV-2 pandemic. Design: This single centre retrospective observational study used routinely collected electronic health data to compare patient presentation characteristics between 21st March and 26th April 2020 compared to the equivalent time period in 2019. Results: There was a 90% decrease in attendances to PED, with a 10.23% reduction re-attendance rate. Children presenting were younger during the pandemic, with a median age difference of 2 years. They were more likely to present in an ambulance (9.63%), be admitted to hospital (5.75%) and be assigned the highest two Manchester triage categories (6.26%). There was a non-significant trend towards longer lengths of stay. The top 10 presenting complaints remained constant (although the order changed) between time periods. There was no difference in mortality or admission to PICU. Implications: Our data demonstrates that there has been a significant decrease in numbers of children seeking emergency department care. It suggests that presenting patients were proportionally sicker during the pandemic; however, we would argue that this is more in keeping with appropriate acuity for PED presentations, as there were no differences in PICU admission rate or mortality. We explore some of the possible reasons behind the decrease in presentations and the implications for service planning ahead of the winter months.
Rationale, aims and objectives Patients with anterior crucial ligament injury are faced with a choice between surgery or non-surgical treatment with intensive rehabilitation. Evidence shows that surgical treatment is not superior to non-surgical treatment. To offer patients a treatment meeting their individual values, lifestyle and conditions, patients must be involved in the decision-making. The aim of the study was to develop and evaluate a patient decision aid to support shared decision-making. Method Development of the patient decision aid was based on international criteria, current literature, and former patients’ experiences and suggestions on how to optimize the decision-making process. The patient decision aid was evaluated by the SDM-Q9 questionnaire and semi-structured interviews with patients and doctors. Results A patient decision aid for patients with and an anterior crucial ligament injury was developed. On a scale from 0-5, patients experienced a high degree of shared decision-making in their treatment decision both before (score 4.3) and after (score 4.3) implementation of the patient decision aid. No statically significant difference was found (p=0.72). From interviews, patients expressed that they found the patient decision aid very useful. Especially, reflection time was important for some patients. Doctors reported that the patient decision aid improved shared decision-making by supporting the dialogue clarifying patients’ values concerning issues important for treatment choices. Conclusion No statically significant difference in the SDM Q9 -score was found between patients’ perceptions of shared decision-making before and after implementation of a patient decision aid. However, patients experienced the decision aid as very useful when making treatment decisions, and doctors reported that it improved the dialogue clarifying patients’ values important for the treatment options. Keywords patient-centered care, evaluation, person-centered medicine
Introduction: Banned and harmful medicines can affect patient’s health, safety and life. There are two medicines available in Aden community pharmacies (phenolphthalein (PP) and ketoconazole (KZ)) that are globally banned. The objective of this study was to evaluate the availability and dispensing of banned phenolphthalein and ketoconazole by community pharmacists. Methods: A preliminary cross-sectional simulated patients method was carried out. The study gathered data on dispensing behavior. Simulated patients were trained to access the availability of banned drugs existing in the community pharmacies (CP). The availability of these two banned drugs was observed and recorded. The pharmacists were asked about the availability of a PP laxative for treating constipation called in Yemen a khat laxative (Sharbat Alkhat) and KZ for fungal infections in 50 convenient samples of CPs that were selected based on ease of access by the simulated patients. Results: PP was found in 3/50 (6%) pharmacies, while 31/50 (62%) pharmacies kept KZ in the premise. Conclusion: The availability of these drugs in Yemeni pharmacies is worrisome. It can affect the safety of the public.
Rationale, aims and objectives: The participation of all health professionals is essential for ensuring a quality and successful national postmarketing surveillance program. The aim of this study was to assess the knowledge, attitudes, and practices (KAP) among Yemeni community pharmacists (CPs) regarding medication safety in a poor-resource setting. Methods: A survey was conducted among CPs in Aden governorate. The tool comprised of: demographic profile, knowledge-, attitude- and practice-aspects of medication safety. The survey also studied the opinion about future and benefits of ADR reporting in Yemen. The data collected from the questionnaires was analyzed using the Statistical Package for Social Science version 21.0. Descriptive statistics such as frequencies, percentages, and means (SD) were used in the analysis. Results: A total of 450 CPs were enrolled in the study. Most of the participants were males (75%) with a bachelor’s degree (91.9%) and between 3-6 years of experience (28%). The majority of CPs had good knowledge regarding the perception and objectives of PV as well as ADRs. Approximately 41% of participants knew the purpose of PV as an essential system for public health and safety with regard to drug use. Additionally, the Yemeni pharmacists had a positive attitude towards the reporting system. Approximately 84% of responders admitted that PV is the responsibility of the pharmacists. The majority of the participants (80%) declared that there is no reporting form available at their workplace. According to CPs, 59% said that ADR reporting in Yemen is not widely promoted by relevant authorities, and 57% replied that lack of information provided by the patient is an obstacle in the reporting system. Approximately 89% of the CPs believed that reporting ADRs would improve patient safety. Conclusions: The CPs have a positive attitude towards PV and an acceptable degree of knowledge. However, the practice level should be upraised.
Rationale, Aims, and Objectives Quick diagnosis units, a paradigmatic innovative model of hospital ambulatory medicine in Spain, are suggested to be cost-effective. While former studies have been conducted as cost analyses of single units or comparative analyses between these patients and inpatients hospitalized for the same condition, how cost outcomes compare between units of different hospitals and different levels of complexity is unknown. Using micro-costing, the costs of patients managed at quick diagnosis units from a tertiary and a secondary hospital were compared. Methods The study population included 407 patients from each unit who were evaluated over 8 years. Through a bottom-up approach, we analyzed all single cost components that contributed to the mean total cost per patient in both units. Results Patients from the tertiary hospital unit were more likely than those from the secondary hospital to be referred for cancer suggestive symptoms, to have a diagnosis of cancer, and to be referred from the emergency department. Although the ratio of successive/first visits was 3.098 ± 0.6584 in the tertiary vs. 2.123 ± 0.2171 in the secondary hospital unit (P=0.0064), the time to diagnosis was significantly longer in the latter. With a similar mean cost per visit, the cost per patient was \euro577.5 ± \euro219.6 in the tertiary vs. \euro394.7 ± \euro92.58 in the secondary hospital unit (P=0.0559). Personnel and indirect costs including both the monetary estimate and their percent contribution to the mean cost per patient accounted for the main differences between units. Conclusion The ratio of successive/first visits was the main driver of cost differences. A greater complexity of patients from the unit of the tertiary hospital and the inherent characteristics of this type of hospital including volume of patients and staff and staff time justified the differences in the ratio of visits and the cost outcomes.
Introduction Accurate coding is essential to ensure remuneration for clinical procedures. However, coders are non-clinical and use operative and discharge notes to infer what they think to be appropriate codes. As plastic surgery encompasses a huge variety of procedures the codes used may not reflect the procedures performed. Method Electronic records from July/August 2019 were consulted to identify commonly performed procedures on elective lists which were then reviewed retrospectively by a coding auditor and a clinician. Procedures chosen to reflect a range of plastic surgery: 1) hands, 2) breast, 3) general plastics. The changes to the clinical codes (Procedural and Diagnostic) and HRG tariff implications were analysed. The audit loop was completed in July 2020 after the introduction of clinical coding improvement strategies. Results 65 relevant cases were included. Changes were made in 31 cases (24 OPCS-4 code changes and 7 ICD-10 code changes). Significant remunerative implications for the department were noted (average £209 per patient). Conclusion This study demonstrated a clear need for collaboration between clinicians and coders. Increased surgeon awareness of clinical coding and clear documentation is essential. We have presented strategies of improving coding that is part of as part of a continued quality improvement programme.