The effect of the employment of consultants in the Emergency Department on quality of care and equity

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M B Lindstroem ◽  
O Andersen ◽  
T Kallemose ◽  
L J H Rasmussen ◽  
S Rosthoej ◽  
...  
Keyword(s):  
Socioeconomic Status ◽  
Quality Of Care ◽  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Clinical Decision ◽  
Cox Proportional Hazards ◽  
Medical Patients ◽  
Negative Effect

Abstract Background Hospitals struggle with increasing acute admissions and crowding in Emergency Departments (EDs) negatively affect length of hospitalisation, in-hospital mortality, patient safety and flow. In response to this, the Danish Health Authorities have recommended the presence of consultants in the ED to expedite the clinical decision-making process. In 2016, consultant-led triage and continuous presence of consultants was introduced at the ED at Hvidovre Hospital, Denmark. However, little is known on the effect of consultants in the ED, and how it affects care for patients of varying socioeconomic status. This study investigated whether the employment of consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of admission, readmission, and mortality, and how this effect was distributed across socioeconomic status in patients. Methods Admission data was collected during two 7-month periods, one prior to and one after the organisational intervention, with 9,869 adult medical patients admitted for up to 48 hours in the ED. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education and employment status were applied. Results Following the employment of consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by a consultant with a reduced mean length of admission by 1.4 hours (95% CI: 1.0 - 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusions Consultants in the ED was found to reduce length of admission without a negative effect on the quality of care for ED admitted medical patients in general, or for patients with lower socioeconomic status. To reduce readmission and mortality among acutely admitted patients, other means must be initiated. Key messages Consultants in the ED may reduce length of admission without a negative effect on the quality of care. To reduce readmission and mortality among acutely admitted patients, other means must be initiated.

scholarly journals The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

2019 ◽  
Author(s):  
Mette Bendtz Lindstroem ◽  
Ove Andersen ◽  
Thomas Kallemose ◽  
Line Jee Hartmann Rasmussen ◽  
Susanne Rosthoej ◽  
...  
Keyword(s):  
Socioeconomic Status ◽  
Quality Of Care ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Negative Impact ◽  
Cox Proportional Hazards ◽  
Medical Patients

Abstract Background Crowding and bed occupancy are challenging issues in the hospitals with increasing acute admissions, caused by an aging population. Crowding in Emergency Departments (EDs) has a negative impact on length of hospitalisation, in-hospital mortality, patient safety, and flow. Thus, the Danish Health Authorities recommend the presence of specialist doctors in the ED who are dedicated to execute the clinical decision-making process. Thus, in 2016, the model of acute care was changed in the ED at Hvidovre Hospital, Denmark, to include consultant-led triage and continuous presence of consultants, referred to as Acute Medical Consultants. However, there is little evidence concerning the effect of consultants treating patients in the ED, and how it affects care for patients of varying socioeconomic status compared with other models of ED staffing. This study investigated whether the employment of Acute Medical Consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of stay, readmission, mortality, and secondly how this effect was distributed across socioeconomic status in patients. Methods Admission data for 9,869 adult medical patients admitted for up to 48 hours in the ED was collected in two separate 7-month periods, one prior to and one after the organisational intervention. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education, and employment status were applied. Results Following the employment of Acute Medical Consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by an Acute Medical Consultant with a reduced mean length of stay by 1.4 hours (95% CI: 1.0 – 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusion The employment of Acute Medical Consultants in the ED was associated with reduced length of admission without a negative effect on the quality of care for ED-admitted medical patients in general, or for patients with lower socioeconomic status. Yet, in order to reduce readmission and mortality among acutely admitted patients, other means must be initiated.

scholarly journals Prognostic Factors and a Nomogram Predicting Overall Survival in Patients with Limb Chondrosarcomas: A Population-Based Study

2021 ◽  
Vol 2021 ◽  
pp. 1-17
Author(s):  
Xinjie Wu ◽  
Yanlei Wang ◽  
Wei Sun ◽  
Mingsheng Tan
Keyword(s):  
Overall Survival ◽  
Prognostic Factors ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Cox Regression ◽  
Training Group ◽  
Clinical Decision ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Predictive Values

Introduction. We aimed to develop and validate a nomogram for predicting the overall survival of patients with limb chondrosarcomas. Methods. The Surveillance, Epidemiology, and End Results (SEER) program database was used to identify patients diagnosed with chondrosarcomas, from which data was extracted from 18 registries in the United States between 1973 and 2016. A total of 813 patients were selected from the database. Univariate and multivariate analyses were performed using Cox proportional hazards regression models on the training group to identify independent prognostic factors and construct a nomogram to predict the 3- and 5-year survival probability of patients with limb chondrosarcomas. The predictive values were compared using concordance indexes ( C -indexes) and calibration plots. Results. All 813 patients were randomly divided into a training group ( n = 572 ) and a validation group ( n = 241 ). After univariate and multivariate Cox regression, a nomogram was constructed based on a new model containing the predictive variables of age, site, grade, tumor size, histology, stage, and use of surgery, radiotherapy, or chemotherapy. The prediction model provided excellent C -indexes (0.86 and 0.77 in the training and validation groups, respectively). The good discrimination and calibration of the nomograms were demonstrated for both the training and validation groups. Conclusions. The nomograms precisely and individually predict the overall survival of patients with limb chondrosarcomas and could assist personalized prognostic evaluation and individualized clinical decision-making.

Discovery and validation of a cross-platform 21-gene prognostic signature in neuroblastoma.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 10035-10035
Author(s):  
Mehul Gupta ◽  
Sunand Nageswaran Kannappan ◽  
Aru Narendran ◽  
Pinaki Bose
Keyword(s):  
Machine Learning ◽  
Risk Stratification ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Risk Model ◽  
Learning Algorithm ◽  
Clinical Decision ◽  
Gene Signature ◽  
Cox Proportional Hazards ◽  
Transcriptomic Signature

10035 Background: Neuroblastoma (NB) is the most common extracranial solid tumor in children. Despite the development of risk stratification tools to improve prognostication, prediction of patient survival outcomes in NB remains poor. In this study we used an unbiased machine-learning algorithm to develop and validate a transcriptomic signature capable of predicting 5-year overall (OS) and event-free survival (EFS) in these patients. Methods: The TARGET-Neuroblastoma dataset (n = 243) was used as the training set. Two independent NB cohorts, E-MTAB-179 (n = 478) and GSE85047 (n = 266) were used as validation sets. Elastic net regression was employed to identify transcripts associated with EFS. Association of the developed signature with EFS and OS was evaluated using univariate Cox proportional hazards (CoxPH), Kaplan-Meier, and 5-year receiver-operator characteristic curves in validation cohorts. Further, the independent prognostic value of the signature was assessed using multivariate CoxPH models with relevant clinicopathologic variables including age, INSS stage, and N-Myc amplification status in both validation sets. Finally, a nomogram was developed to integrate the signature with prognostic clinicopathologic variables to evaluate their combined efficacy for prediction of 5-year EFS and OS. Results: We identified a 21-gene signature that demonstrates significant association with EFS and OS in both E-MTAB-178 and GSE49710 validation cohorts. Moreover, the signature is independent of clinicopathological variables and can be effectively incorporated into a risk model, improving the prognostic performance. Several genes within the signature have been previously implicated in NB, including ECEL1, HOXC9 and ARAF1. Conclusions: To the best of our knowledge, we are the first to use an unbiased machine learning approach to generate a transcriptomic gene signature for neuroblastoma prognosis externally validated in multiple cohorts across platforms. This 21-gene transcriptomic signature significantly associated with EFS and OS in this disease. Combining this signature with current prognostic clinicopathologic variables will improve risk stratification of affected patients and may inform effective clinical decision-making.[Table: see text]

scholarly journals Predicting Clustered Dental Implant Survival Using Frailty Methods

2006 ◽  
Vol 85 (12) ◽  
pp. 1147-1151 ◽  
Author(s):  
S.-K. Chuang ◽  
T. Cai
Keyword(s):  
Risk Factors ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Smoking Status ◽  
Joint Probability ◽  
Frailty Model ◽  
Clinical Decision ◽  
Cox Proportional Hazards ◽  
Implant Survival ◽  
Survival Status

The purpose of this study was to predict future implant survival using information on risk factors and on the survival status of an individual’s existing implant(s). We considered a retrospective cohort study with 677 individuals having 2349 implants placed. We proposed to predict the survival probabilities using the Cox proportional hazards frailty model, with three important risk factors: smoking status, timing of placement, and implant staging. For a non-smoking individual with 2 implants placed, an immediate implant and in one stage, the marginal probability that 1 implant would survive 12 months was 85.8% (95%CI: 77%, 91.7%), and the predicted joint probability of surviving for 12 months was 75.1% (95%CI: 62.1%, 84.7%). If 1 implant was placed earlier and had survived for 12 months, then the second implant had an 87.5% (95%CI: 80.3%, 92.4%) chance of surviving 12 months. Such conditional and joint predictions can assist in clinical decision-making for individuals.

scholarly journals Nomogram to Predict the Overall Survival of Colorectal Cancer Patients: A Multicenter National Study

2021 ◽  
Vol 18 (15) ◽  
pp. 7734
Author(s):  
Nasrin Borumandnia ◽  
Hassan Doosti ◽  
Amirhossein Jalali ◽  
Soheila Khodakarim ◽  
Jamshid Yazdani Charati ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Overall Survival ◽  
Family History ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Clinical Decision ◽  
Tumor Stage ◽  
Cox Proportional Hazards ◽  
National Study ◽  
Historical Cohort

Background: Colorectal cancer (CRC) is the third foremost cause of cancer-related death and the fourth most commonly diagnosed cancer globally. The study aimed to evaluate the survival predictors using the Cox Proportional Hazards (CPH) and established a novel nomogram to predict the Overall Survival (OS) of the CRC patients. Materials and methods: A historical cohort study, included 1868 patients with CRC, was performed using medical records gathered from Iran’s three tertiary colorectal referral centers from 2006 to 2019. Two datasets were considered as train set and one set as the test set. First, the most significant prognostic risk factors on survival were selected using univariable CPH. Then, independent prognostic factors were identified to construct a nomogram using the multivariable CPH regression model. The nomogram performance was assessed by the concordance index (C-index) and the time-dependent area under the ROC curve. Results: The age of patients, body mass index (BMI), family history, tumor grading, tumor stage, primary site, diabetes history, T stage, N stage, and type of treatment were considered as significant predictors of CRC patients in univariable CPH model (p < 0.2). The multivariable CPH model revealed that BMI, family history, grade and tumor stage were significant (p < 0.05). The C-index in the train data was 0.692 (95% CI, 0.650–0.734), as well as 0.627 (0.670, 0.686) in the test data. Conclusion: We improved a novel nomogram diagram according to factors for predicting OS in CRC patients, which could assist clinical decision-making and prognosis predictions in patients with CRC.

scholarly journals TB case fatality and recurrence in a private sector cohort in Mumbai, India

2021 ◽  
Vol 25 (9) ◽  
pp. 738-746
Author(s):  
S. Huddart ◽  
P. Ingawale ◽  
J. Edwin ◽  
V. Jondhale ◽  
M. Pai ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Private Sector ◽  
Treatment Duration ◽  
Proportional Hazards ◽  
Case Fatality ◽  
Cox Proportional Hazards ◽  
Post Treatment ◽  
Private Provider ◽  
Recurrence Rates

BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0–8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7–3.0) and the recurrence rate was 1.9% (95% CI 1.3–2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02–1.03), clinical diagnosis (HR 0.61, 95% CI 0.45–0.84), treatment duration (HR 0.09, 95% CI 0.06–0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79–0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.

Predictors of stopping chemotherapy early and short survival in patients with potentially platinum sensitive (PPS) recurrent ovarian cancer (ROC) who have had ≥3 lines of prior chemotherapy: The GCIG symptom benefit study (SBS).

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. 5575-5575
Author(s):  
Felicia Roncolato ◽  
Florence Joly ◽  
Rachel O'Connell ◽  
Anne Lanceley ◽  
Florian Heitz ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Recurrent Ovarian Cancer ◽  
Clinical Decision ◽  
Cox Proportional Hazards ◽  
Variable Response ◽  
Platinum Sensitive ◽  
Response To Chemotherapy ◽  
Gi Symptoms

5575 Background: PPS ROC is defined by a platinum free interval > 6 months. Women starting ≥3 lines of chemotherapy for PPS ROC are however a heterogeneous group with variable response to chemotherapy and OS. We sought to identify baseline characteristics (health related quality of life [HRQL] and clinical features) that were associated with stopping chemotherapy early and shorter OS to improve patient selection for palliative chemotherapy. Methods: 378 women with PPS ROC starting ≥3 lines chemotherapy enrolled in GCIG SBS. HRQL was assessed with EORTC QLQ-C30/QLQ-OV28. Associations with stopping chemotherapy early (by 8 weeks) were assessed with logistic regression. Associations with OS were assessed with Cox proportional hazards regression. Variables significant in univariable analysis (p < 0.05) were included as candidates for multivariable analyses using backward elimination to select those independently significant at p < 0.05. Results: Median age was 64 years. The line of chemotherapy was third in 40%, fourth in 29%, and ≥ fifth in 31%. Chemotherapy was stopped early in 45/378 (12%) and their median OS was 3.4 months. Poor physical function (PF) and global health status (GHS) at baseline were significant univariable predictors of stopping chemotherapy early (p < 0.008); PF remained significant in a multivariable model adjusting for clinical factors (haemoglobin [Hb], ascites, abdominal cramps, neutrophil: lymphocyte≥5, platelets, log CA125); p = 0.03. Median OS in the whole group was 16.6 months. PF, role function, GHS and abdominal/GI symptoms were significant univariable predictors of OS (p < 0.001); PF and GHS remained significant predictors of OS in multivariable models including Hb, ascites, neutrophil: lymphocyte≥5, platelets, log CA125, ECOG and BMI (p < 0.007). Conclusions: In women with PPS ROC ≥3 lines chemotherapy, baseline PF and GHS are independent significant predictors of stopping chemotherapy early and short OS. HRQOL is easily measured, prognostic and may improve clinical trial stratification, patient-doctor communication and support clinical decision making. Clinical trial information: 12607000603415.

scholarly journals As Normas de Orientação Clínica em Portugal e os Valores dos Doentes

2015 ◽  
Vol 28 (6) ◽  
pp. 754 ◽  
Author(s):  
Paulo Santos ◽  
Isabel Nazaré ◽  
Carlos Martins ◽  
Luísa Sá ◽  
Luciana Couto ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Clinical Guidelines ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Value Systems ◽  
Patient Centered ◽  
Centered Care ◽  
The Individual ◽  
Satisfaction Rates

<strong>Introduction:</strong> Clinical guidelines are support tools, aiming to improve quality of the clinical practice. Patient centered care allows best satisfaction rates, with greater health self-management, and potential gains in quality with fewer costs.<br /><strong>Objective:</strong> To evaluate the integration of patients’ values in Portuguese guidelines.<br /><strong>Material and Methods:</strong> We reviewed the 18 guidelines about cardiovascular diseases published in Portugal from 2011 to 2013, searching for the integration of patients’ ideas, fears, expectations and preferences.<br /><strong>Results:</strong> Eight guidelines were related to diagnosis approach and 10 with treatment. We found references to patients’ values in 5 (28%) guidelines, all about treatment aspects. The incorporation of patients’ expectations was the most present feature. Reference to financial costs was present in 78% of the guidelines.<br /><strong>Discussion:</strong> Clinical guidelines are health technology instruments available to practitioners in order to improve the quality of care provided to patients, who are the real users of these tools. As in other countries, there is a tendency to disregard the users’ value systems in the conception of the guidelines, giving the privilege to a population logic, not always applicable to the individual, and to financial arithmetic with low support in cost-effectiveness assessments. In the Portuguese case, the way guidelines were proposed conditioned also some suspicion both in the professionals and in the users.<br /><strong>Conclusion: </strong>Portuguese guidelines have low incorporation of references to patients’ values. This is more evident when questions about diagnosis are addressed, placing patients in a secondary role in the clinical decision-making process with potential losses in quality of care and eventual increase in costs.

scholarly journals Nomogram to Predict the Benefit of Radiation for Older Patients With Breast Cancer Treated With Conservative Surgery

2012 ◽  
Vol 30 (23) ◽  
pp. 2837-2843 ◽  
Author(s):  
Jeffrey M. Albert ◽  
Diane D. Liu ◽  
Yu Shen ◽  
I-Wen Pan ◽  
Ya-Chen Tina Shih ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Older Women ◽  
Older Patients ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Estrogen Receptor Status ◽  
Clinical Decision ◽  
Conservative Surgery ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Models

Purpose The role of radiation therapy (RT) after conservative surgery (CS) remains controversial for older patients with breast cancer. Guidelines based on recent clinical trials have suggested that RT may be omitted in selected patients with favorable disease. However, it is not known whether this recommendation should extend to other older women. Accordingly, we developed a nomogram to predict the likelihood of long-term breast preservation with and without RT. Methods We used Surveillance, Epidemiology, and End Results–Medicare data to identify 16,092 women age 66 to 79 years treated with CS between 1992 and 2002, using claims to identify receipt of RT and subsequent mastectomy. Time to mastectomy was estimated using the Kaplan-Meier method. Cox proportional hazards models determined the effect of covariates on mastectomy-free survival (MFS). A nomogram was developed to predict 5- and 10-year MFS, given associated risk factors, and bootstrap validation was performed. Results With a median follow-up of 7.2 years, the overall 5- and 10-year MFS rates were 98.1% (95% CI, 97.8% to 98.3%) and 95.4% (95% CI, 94.9% to 95.8%), respectively. In multivariate analysis, age, race, tumor size, estrogen receptor status, and receipt of RT were predictive of time to mastectomy and were incorporated into the nomogram. Nodal status was also included given a significant interaction with RT. The resulting nomogram demonstrated good accuracy in predicting MFS, with a bootstrap-corrected concordance index of 0.66. Conclusion This clinically useful tool predicts 5- and 10-year MFS among older women with early breast cancer using readily available clinicopathologic factors and can aid individualized clinical decision making by estimating predicted benefit from RT.

scholarly journals A Narrative Review of Clinical Decision Support for Inpatient Clinical Pharmacists

2021 ◽  
Vol 12 (02) ◽  
pp. 199-207
Author(s):  
Liang Yan ◽  
Thomas Reese ◽  
Scott D. Nelson
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Decision Support ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Controlled Trials ◽  
Clinical Pharmacists ◽  
Randomized Controlled ◽  
The Impact

Abstract Objective Increasingly, pharmacists provide team-based care that impacts patient care; however, the extent of recent clinical decision support (CDS), targeted to support the evolving roles of pharmacists, is unknown. Our objective was to evaluate the literature to understand the impact of clinical pharmacists using CDS. Methods We searched MEDLINE, EMBASE, and Cochrane Central for randomized controlled trials, nonrandomized trials, and quasi-experimental studies which evaluated CDS tools that were developed for inpatient pharmacists as a target user. The primary outcome of our analysis was the impact of CDS on patient safety, quality use of medication, and quality of care. Outcomes were scored as positive, negative, or neutral. The secondary outcome was the proportion of CDS developed for tasks other than medication order verification. Study quality was assessed using the Newcastle–Ottawa Scale. Results Of 4,365 potentially relevant articles, 15 were included. Five studies were randomized controlled trials. All included studies were rated as good quality. Of the studies evaluating inpatient pharmacists using a CDS tool, four showed significantly improved quality use of medications, four showed significantly improved patient safety, and three showed significantly improved quality of care. Six studies (40%) supported expanded roles of clinical pharmacists. Conclusion These results suggest that CDS can support clinical inpatient pharmacists in preventing medication errors and optimizing pharmacotherapy. Moreover, an increasing number of CDS tools have been developed for pharmacists' roles outside of order verification, whereby further supporting and establishing pharmacists as leaders in safe and effective pharmacotherapy.

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