Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme

2020 ◽  
Author(s):  
William K. Gray ◽  
Jamie Day ◽  
Tim W. R. Briggs ◽  
Simon Harrison
Keyword(s):  
Clinical Practice ◽  
Administrative Data ◽  
Healthcare Providers ◽  
Unwarranted Variation ◽  
First Time ◽  
Over Time

scholarly journals Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes

2021 ◽  
pp. 219256822110648
Author(s):  
Juliëtte J. C. M. Van Munster ◽  
Vera de Weerdt ◽  
Ilan J. Y. Halperin ◽  
Amir H. Zamanipoor Najafabadi ◽  
Peter Paul G. van Benthem ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Clinical Practice ◽  
Literature Review ◽  
Degenerative Disc Disease ◽  
Practice Variation ◽  
Case Mix ◽  
Disc Disease ◽  
Explanatory Variables ◽  
Unwarranted Variation ◽  
Over Time

Study Design Literature review. Objective To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time. Methods Literature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman’s rho was used to determine the association between the Extreme Quotient (EQ) and year of publication. Results We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= −.33, P= .09). Conclusions Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

scholarly journals SP4.1.6 Introduction of Concentric digital and remote consent into clinical practice during the COVID-19 pandemic

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Edward St John ◽  
Dafydd Loughran
Keyword(s):  
Quality Improvement ◽  
Clinical Practice ◽  
Royal College ◽  
Healthcare Providers ◽  
Patient Feedback ◽  
High Satisfaction ◽  
Average Patient ◽  
Unwarranted Variation ◽  
Form Information

Abstract Introduction Paper-based consent processes are associated with errors of omission, illegibility and unwarranted variation. During the COVID-19 pandemic the Royal College of Surgeons (England) released guidelines supporting the use of remote consent. The aim was to evaluate the introduction of Concentric, a digital consent application, into clinical practice. Method Between April 2020-Jan 2021, Concentric was used optionally for medical consent during registered service evaluations. Data was obtained from Concentric analytics. User and patient feedback was obtained via optional satisfaction surveys. Results 3417 Concentric consent episodes for 356 unique procedures were performed by 170 clinicians across 16 specialties from 13 healthcare providers. Patients were aged 7-101years, (median 58, IQR 30). Of the completed consent episodes (n = 2799), consent was given; remotely in 23% of episodes, and on the day of surgery in 67%. Consent form information was shared digitally with 82% of patients. Average patient user experience was 8.8 out of 10 (1 very poor - 10 excellent, n = 594). 546/594 (91.9%) patients agreed that Concentric provided all the information they needed to know. Clinicians (n = 23) rated the quality of the consent process with Concentric as 4.8 out of 5 with all supporting the use of Concentric across the Trust. Conclusion Concentric has been successfully introduced into clinical practice. Patients and clinicians report high satisfaction scores. Remote consent is feasible and trends in consent practice, such as day of surgery consent can be easily identified and can guide quality improvement work. The introduction of digital consent solutions should be considered for all units.

scholarly journals P34 Characteristics, diagnosis and management of Cushing’s disease - A systematic review and meta-analysis

BJS Open ◽  
2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Chan Hee Koh ◽  
Danyal Z Khan ◽  
Ronneil Digpal ◽  
Hugo Layard Horsfall ◽  
Hani J Marcus ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Cushing’S Disease ◽  
Meta Analysis ◽  
A Priori ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Cushing's Disease ◽  
Diagnosis And Management ◽  
Over Time

Abstract Introduction The clinical practice and research in the diagnosis and management of Cushing’s disease remains heterogeneous and challenging to this day. We sought to establish the characteristics of Cushing’s disease, and the trends in diagnosis, management and reporting in this field. Methods Searches of PubMed and Embase were conducted. Study protocol was registered a-priori. Random-effects analyses were conducted to establish numerical estimates. Results Our screening returned 159 papers. The average age of adult patients with Cushing’s disease was 39.3, and 13.6 for children. The male:female ratio was 1:3. 8% of patients had undergone previous transsphenoidal resection. The ratio of macroadenomas: microadenomas:imaging-undetectable adenomas was 18:53:29. The most commonly reported preoperative biochemical investigations were serum cortisol (average 26.4µg/dL) and ACTH (77.5pg/dL). Postoperative cortisol was most frequently used to define remission (74.8%), most commonly with threshold of 5µg/dL (44.8%). Average remission rates were 77.8% with recurrence rate of 13.9%. Median follow-up was 38 months. Majority of papers reported age (81.9%) and sex (79.4%). Only 56.6% reported whether their patients had previous pituitary surgery. 45.3% reported whether their adenomas were macroadenoma, microadenoma or undetectable. Only 24.1% reported preoperative cortisol, and this did not improve over time. 60.4% reported numerical thresholds for cortisol in defining remission, and this improved significantly over time (p = 0.004). Visual inspection of bubbleplots showed increasing preference for threshold of 5µg/dL. 70.4% reported the length of follow up. Conclusion We quantified the characteristics of Cushing’s disease, and analysed the trends in investigation and reporting. This review may help to inform future efforts in forming guidelines for research and clinical practice.

scholarly journals Ten-year trends in epidemiology and outcomes of pediatric kidney replacement therapy in Europe: data from the ESPN/ERA-EDTA Registry

2021 ◽  
Author(s):  
Marjolein Bonthuis ◽  
Enrico Vidal ◽  
Anna Bjerre ◽  
Özlem Aydoğ ◽  
Sergey Baiko ◽  
...  
Keyword(s):  
Replacement Therapy ◽  
Cox Regression ◽  
Patient Survival ◽  
Healthcare Providers ◽  
Resource Planning ◽  
Policy Makers ◽  
Age Related ◽  
Kidney Replacement Therapy ◽  
Over Time ◽  
Related Population

Abstract Background For 10 consecutive years, the ESPN/ERA-EDTA Registry has included data on children with stage 5 chronic kidney disease (CKD 5) receiving kidney replacement therapy (KRT) in Europe. We examined trends in incidence and prevalence of KRT and patient survival. Methods We included all children aged <15 years starting KRT 2007–2016 in 22 European countries participating in the ESPN/ERA-EDTA Registry since 2007. General population statistics were derived from Eurostat. Incidence and prevalence were expressed per million age-related population (pmarp) and time trends studied with JoinPoint regression. We analyzed survival trends using Cox regression. Results Incidence of children commencing KRT <15 years remained stable over the study period, varying between 5.5 and 6.6 pmarp. Incidence by treatment modality was unchanged over time: 2.0 for hemodialysis (HD) and peritoneal dialysis (PD) and 1.0 for transplantation. Prevalence increased in all age categories and overall rose 2% annually from 26.4 pmarp in 2007 to 32.1 pmarp in 2016. Kidney transplantation prevalence increased 5.1% annually 2007–2009, followed by 1.5% increase/year until 2016. Prevalence of PD steadily increased 1.4% per year over the entire period, and HD prevalence started increasing 6.1% per year from 2011 onwards. Five-year unadjusted patient survival on KRT was around 94% and similar for those initiating KRT 2007–2009 or 2010–2012 (adjusted HR: 0.98, 95% CI:0.71–1.35). Conclusions We found a stable incidence and increasing prevalence of European children on KRT 2007–2016. Five-year patient survival was good and was unchanged over time. These data can inform patients and healthcare providers and aid health policy makers on future resource planning of pediatric KRT in Europe.

scholarly journals Quality of life assessments in clinical practice using either the EORTC-QLQ-C30 or the SEIOQL-DW: a randomized study

2021 ◽  
Vol 5 (1) ◽  
Author(s):  
Åsa Kettis ◽  
Hanna Fagerlind ◽  
Jan-Erik Frödin ◽  
Bengt Glimelius ◽  
Lena Ring
Keyword(s):  
Quality Of Life ◽  
Clinical Practice ◽  
Significant Difference ◽  
Patient Reported ◽  
Health Related Qol ◽  
Health Related ◽  
Secondary Outcomes ◽  
The Impact ◽  
Over Time

Abstract Background Effective patient-physician communication can improve patient understanding, agreement on treatment and adherence. This may, in turn, impact on clinical outcomes and patient quality of life (QoL). One way to improve communication is by using patient-reported outcome measures (PROMs). Heretofore, studies of the impact of using PROMs in clinical practice have mostly evaluated the use of standardized PROMs. However, there is reason to believe that individualized instruments may be more appropriate for this purpose. The aim of this study is to compare the effectiveness of the standardized QoL-instrument, the European Organization for Research and Treatment of Cancer Quality of Life C-30 (EORTC-QOL-C30) and the individualized QoL instrument, the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW), in clinical practice. Methods In a prospective, open-label, controlled intervention study at two hospital out-patient clinics, 390 patients with gastrointestinal cancer were randomly assigned either to complete the EORTC-QOL-C30 or the SEIQoL-DW immediately before the consultation, with their responses being shared with their physician. This was repeated in 3–5 consultations over a period of 4–6 months. The primary outcome measure was patients’ health-related QoL, as measured by FACIT-G. Patients’ satisfaction with the consultation and survival were secondary outcomes. Results There was no significant difference between the groups with regard to study outcomes. Neither intervention instrument resulted in any significant changes in health-related QoL, or in any of the secondary outcomes, over time. This may reflect either a genuine lack of effect or sub-optimization of the intervention. Since there was no comparison to standard care an effect in terms of lack of deterioration over time cannot be excluded. Conclusions Future studies should focus on the implementation process, including the training of physicians to use the instruments and their motivation for doing so. The effects of situational use of standardized or individualized instruments should also be explored. The effectiveness of the different approaches may depend on contextual factors including physician and patient preferences.

scholarly journals Prolonged efficacy of pembrolizumab in a patient presenting a multi-treated metastatic hepatocholangiocarcinoma

2020 ◽  
Vol 13 ◽  
pp. 175628482093518 ◽  
Author(s):  
Angélique Saint ◽  
Maxime Benchetrit ◽  
Sébastien Novellas ◽  
Denis Ouzan ◽  
Alexander Tuan Falk ◽  
...  
Keyword(s):  
Therapeutic Strategy ◽  
Complete Response ◽  
It Management ◽  
Tumor Control ◽  
Line Treatment ◽  
Viral Hepatitis C ◽  
Programmed Cell Death 1 ◽  
First Time ◽  
Inhibitor Treatment ◽  
Over Time

Introduction: Hepatocholangiocarcinoma (HCC-ICC) is a rare tumor presenting the histologic characteristics of both hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). As there is no consensus on it management, the therapeutic strategy rests on the specific treatments for HCC or ICC. Programmed cell death 1 (PD-1) inhibitors showed encouraging results in the second line treatment of HCC after sorafenib but it efficacy in HCC-ICC has never been reported. Methods and results: We present the case of a 72-year-old male patient treated for metastatic HCC-ICC due to a viral hepatitis C cirrhosis in progression after two lines of treatment. Tumor was characterized by a PDL-1 status of 85%. Patient received pembrolizumab at doses of 200 mg every 21 days by intravenous infusion. After one injection he was presented an immediate clinical benefit, a partial response was observed after two months of treatment and a complete response two months later. This response was maintained over time along with toxicity-free tumor control after 18 months treatment. Conclusion: To our knowledge, we reported for the first time the efficacy of a PD1 inhibitor treatment in a patient presenting metastatic HCC-ICC due to viral cirrhosis and overexpressing PDL-1 after failure of two lines of treatment.

scholarly journals Rehabilitation Therapy Utilization in Patients with Parkinson’s Disease in Korea

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
Han Gil Seo ◽  
Sang Jun Park ◽  
Jiah Seo ◽  
Seong Jun Byun ◽  
Byung-Mo Oh
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Health Insurance ◽  
Clinical Practice ◽  
Patient Characteristics ◽  
National Sample ◽  
Present Evidence ◽  
Rehabilitation Therapy ◽  
Swallowing Therapy ◽  
Over Time

Objective. Although evidence and guidelines recommend appropriate rehabilitation from the beginning of diagnosis in patients with Parkinson’s disease (PD), there is a lack of data addressing the utilization of rehabilitation therapies for these patients in practice. The aim of this study is to investigate the rate of rehabilitation therapy utilization over time in patients with PD using a nationwide cohort in Korea. Methods. Patients were identified using the registration code for PD in the program for rare, intractable disease from the National Health Insurance Service-National Sample Cohort database, which consists of 979,390 Korean residents. Data were divided into four periods: 2004–2006, 2007–2009, 2010–2012, and 2013–2015. We assessed the utilization of rehabilitation therapies and the associated patient characteristics. Results. The numbers of patients with PD were 384 in 2004, 855 in 2007, 1,023 in 2010, and 1,222 in 2013. The numbers of physiatrist visits per person were 0.58, 0.96, 1.97, and 2.91, in the respective periods. Among the patients, 35–40% had claims for physical therapy, 16–19% for occupational therapy, and 4–6% for swallowing therapy. There were no remarkable differences between these rates between the study periods. Sex, age, income, disability, and levodopa-equivalent dose were significantly associated with the utilization of rehabilitation therapy. Conclusion. This study demonstrated that the rate of rehabilitation therapy utilization did not change remarkably in patients with PD from 2004 to 2015 in Korea although the number of physiatrist visits increased dramatically. The present evidence and guidelines may have not been adequately integrated into clinical practice during the period of study. Additional efforts may be warranted to provide adequate rehabilitation therapies in clinical practice for patients with PD.

Abstract P35: The Trend of Stroke Rehabilitation Utilization Between 2014- 2019 in a Community Based Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Daniel Uhm ◽  
Esther Olasoji ◽  
Alexis N Simpkins ◽  
Carolyn Geis ◽  
Keyword(s):  
Clinical Practice ◽  
Trend Analysis ◽  
Significant Proportion ◽  
Inpatient Rehabilitation ◽  
Outpatient Rehabilitation ◽  
Rehabilitation Services ◽  
Institutional Review ◽  
Ischemic Attack ◽  
Over Time

Introduction: Stroke is the leading cause of long-term disability in adults, resulting in significant impairments in motor, sensory, and/ or cognitive that often requires continued rehabilitation services, which vary from intensive acute inpatient rehabilitation to outpatient rehabilitation services. Efforts to reduce disability have advanced rapidly over the past several years. Our data analysis was undertaken to assess whether recent changes in clinical practice have impacted the proportion of stroke patients receiving inpatient versus outpatient rehabilitation over time between 2014-2019 at our institution, which serves a diverse mix of rural, suburban, and urban populations. Methods: Our Institutional Review Board approved retrospective stroke database, including adult patients discharged to receive rehabilitation services data from 2014-2019, was used for analysis. Cochran-Armitage trend analysis was used to assess for differences type of rehabilitation services used over time and regression analysis was used to identify clinical factors associated with discharge type over time. Results: A total of 3467 patients were included in the analysis, 50% woman, 1% Asian, 20% Black, 75% White, 4% undetermined race, 17% intracerebral hemorrhage, 65% ischemic stroke, 11% subarachnoid hemorrhage, 3% transient ischemic attack, 3% other cerebrovascular disease. In this community population, 65% were discharged to inpatient rehab. Trend analysis demonstrated a significant increase in the proportion of patients being discharged home with rehab services, p<.0001. In comparison to those discharged home, patients discharged to rehab were older (odds ratio (OR) 1.02, confidence interval (CI) 1.02-1.03), with a higher NIHSS (OR 1.16, CI 1.14-1.18), discharged in 2014 (OR 1.72, CI 1.23-2.39) or 2016 (OR 1.46, CI 1.05-2.05) versus 2019. There was no association with race, gender, or discharge in 2015, 2017, or 2018. Discussion: Our findings demonstrate the community impact of recent changes in clinical practice guidelines for stroke. The increasing trend of home discharges is encouraging, but the significant proportion of those still not discharged home suggests there is still more work to be done to reduce stroke associated disability in adults.

CHARACTERISTICS OF AGE-DEPENDENT CHANGES IN THE URINE'S PROTEOM COMPOSITION OF THE HEALTHY PERSONS (EXPERIMENTAL AND THEORETICAL STUDY)

2020 ◽  
pp. 735-740
Author(s):  
Л. Х. Пастушкова ◽  
Д. Н. Каширина ◽  
А. Г. Гончарова ◽  
Н. Б. Захарова ◽  
Е. С. Тийс ◽  
...  
Keyword(s):  
Signaling Pathway ◽  
Insulin Signaling ◽  
Defense Mechanisms ◽  
Theoretical Study ◽  
Clinical Manifestations ◽  
Age Dependent ◽  
First Time ◽  
Healthy Persons ◽  
Over Time

Впервые описаны белки, достоверно увеличивающиеся и уменьшающиеся в моче с возрастом в интервале 20-60 лет. Охарактеризованы комбинации белков, связанных с изменением иммунных процессов, нарушением реологии крови, в том числе риском коагулопатии, противоопухолевых защитных механизмов, инсулинового сигнального пути, с изменением характеристик клеточного деления и качества новообразованной ткани. Таким образом, возрастная динамика основных процессов запускает каскад реакций, проявляющихся в замыкании «патологических биохимических кругов», которые формируют предпосылки к развитию заболеваний и, с течением времени, клинические проявления. For the first time proteins are described, reliably increasing and decreasing in urine with age in the range of 20 to 60 years. The combinations of proteins associated with changes in immune processes, violation of blood reology, including the risk of coagulopathy, anticancer defense mechanisms, insulin signaling pathway, changes in cell characteristics are characterized division and quality of the newly formed fabric. Thus, the age dynamics of the main processes triggers a cascade of reactions manifested in the closure of «pathological biochemical circles» that form the prerequisites for the development of diseases and, over time, clinical manifestations.

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