Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices

ObjectiveAtrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative.MethodsUsing the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018.ResultsWhen comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change.ConclusionImplementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.

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Decreased Overall and Inappropriate Antibiotic Prescribing in a Veterans Affairs Hospital Emergency Department following a Peer Comparison-Based Stewardship Intervention

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.01660-20 ◽

2020 ◽

Vol 65 (1) ◽

pp. e01660-20

Author(s):

Deanna J. Buehrle ◽

Rameez H. Phulputo ◽

Marilyn M. Wagener ◽

Cornelius J. Clancy ◽

Brooke K. Decker

Keyword(s):

Interrupted Time Series ◽

Antibiotic Use ◽

Baseline Period ◽

Veterans Affairs ◽

Antibiotic Prescribing ◽

Oral Antibiotic ◽

Intervention Period ◽

Time Series Regression ◽

Amoxicillin Clavulanate ◽

Ed Visits

ABSTRACTAntibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07 [95% confidence interval {CI}, −21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07 [95% CI, −20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (P < 0.001, P = 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, P = 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, P = 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.

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The influence of school accountability incentives on Advanced Placement access: Evidence from Pennsylvania

Education Policy Analysis Archives ◽

10.14507/epaa.27.4602 ◽

2019 ◽

Vol 27 ◽

pp. 138

Author(s):

Paul Beach ◽

Keith Zvoch ◽

Michael Thier

Keyword(s):

Advanced Placement ◽

Interrupted Time Series ◽

Baseline Period ◽

School Accountability ◽

Initial Increase ◽

Policy Intervention ◽

Intervention Period ◽

Demographic Differences ◽

Course Offerings

This study employed hierarchical piecewise growth modeling and two interrupted time series models to examine the effect of introducing an Advanced Placement (AP) school accountability incentive on AP access in Pennsylvania. Specifically, we examined whether adoption of an advanced course access accountability indicator was associated with an increase in AP course offerings initially and in the three years after the policy intervention. We also analyzed if the indicator differentially affected schools we hypothesized as sensitive or nonsensitive to the policy and examined demographic differences between those school groups. Pennsylvania’s AP accountability incentive was associated with an initial increase in schools’ AP course offerings, but the trajectory of change during the post-policy intervention period did not differ from the pre-policy baseline period. Also, the sizeable gap between schools with the most and fewest AP course offerings did not narrow across time. Instead, the gap widened. Our results suggest that adoption of AP school accountability incentives may not be a long-term solution to improving AP access for all schools or narrowing disparities in access between schools. We call for examinations in other states to determine if, and under what conditions, AP accountability incentives increase AP course offerings while narrowing access disparities.

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Oxygen radicals participate in alloxan-induced pulmonary EDEMA

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100159047 ◽

1990 ◽

Vol 48 (3) ◽

pp. 298-299

Author(s):

Tomoo Kawada ◽

Michio Arakawa ◽

Kenjiro Kambara ◽

Takashi Segawa ◽

Fumio Ando ◽

...

Keyword(s):

Pulmonary Edema ◽

Oxygen Radicals ◽

Bolus Injection ◽

Physiological Saline ◽

Baseline Period ◽

Alveolar Epithelial Cells ◽

Control Group ◽

Intervention Period ◽

Lung Water ◽

Electron Microscopic

We know that alloxan causes increased-permeability pulmonary edema and that alloxan generates oxygen radicals (H2O2, O2−, ·OH) in blood. Therefore, we hypothesize that alloxan-generated oxygen radicals damage pulmonary capillary endothelial cells, and, possibly, alveolar epithelial cells as well. We examined whether oxygen radical scavengers, such as catalase or dimethylsulfoxide (DMSO), protected against alloxaninduced pulmonary edema.Five dogs in each following group were anesthetized: control group: physiological saline (20ml/kg/h); alloxan group: physiological saline + alloxan (75mg/kg) bolus injection at the beginning of the experiment; catalase group: physiological saline + catalase (150,000u/kg) bolus injection before injection of alloxan; DMSO group: physiological saline + DMSO (0.4mg/kg) bolus injection before alloxan. All dogs had 30-min baseline period and 3-h intervention period. Hemodynamics and circulating substances were measured at the specific points of time. At the end of intervention period, the dogs were killed and had the lungs removed for electron microscopic study and lung water measurement with direct destructive method.

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New Drugs for Thromboembolic Prevention in Atrial Fibrillation

European Cardiology Review ◽

10.15420/ecr.2010.6.4.64 ◽

2010 ◽

Vol 6 (4) ◽

pp. 64

Author(s):

Jose L Merino ◽

Jose López-Sendón ◽

◽

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Negative Impact ◽

Vitamin K Antagonists ◽

Coagulation Factor ◽

Developed Countries ◽

New Drugs ◽

Risk Scores ◽

Bleeding Events ◽

Risk Patients

Atrial fibrillation (AF) is the most frequent sustained arrhythmia and its prevalence is increasing in developed countries. This progressive increase and the negative impact of this arrhythmia on the patient’s prognosis make AF one of the main healthcare problems faced today. This has led to intense research into the main aspects of AF, one of them being thromboembolism prevention. AF patients have a four to five times higher risk of stroke than the general population. Several factors increase thromboembolic risk in patients with AF and the use of risk scores, such as the Congestive Heart Failure, Hypertension, Age Greater than 75, Diabetes, and Prior Stroke or Transient Ischemic Attack (CHADS2), have been used to identify the best candidates for anticoagulation. Antithrombotic drugs are the mainstay of therapy for embolic prevention. The clinical use of these drugs is based on the risk–benefit ratio, where benefit is the reduction of stroke and systemic embolic events and risk is mostly driven by the increase in bleeding events. Generally, antiplatelets are indicated for low-risk patients in light of the fact anticoagulants are the drug of choice for moderate- or high-risk patients. Vitamin K antagonists have been the only option for oral anticoagulation for the last 50 years. However, these drugs have many pharmacodynamic and pharmacokinetic problems. The problems of anticoagulation with vitamin K antagonists have led to the investigation of new drugs that can be administered orally and have a better dose–response relationship, a shorter half-life and, in particular, higher efficacy and safety without the need for frequent anticoagulation controls. The drugs that have been studied most thoroughly in patients with AF are inhibitors of the activated coagulation factor X and inhibitors of coagulation factor II (thrombin), including ximelagatran and dabigatran. In addition, non-pharmacological therapies have been developed to prevent recurrent embolism in certain patient populations.

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Ion Channel Remodelling in Atrial Fibrillation

European Cardiology Review ◽

10.15420/ecr.2011.7.2.97 ◽

2011 ◽

Vol 7 (2) ◽

pp. 97 ◽

Cited By ~ 6

Author(s):

Niels Voigt ◽

Dobromir Dobrev ◽

◽

Keyword(s):

Atrial Fibrillation ◽

Ion Channel ◽

Antiarrhythmic Drugs ◽

Current Knowledge ◽

Bleeding Complications ◽

Large Size ◽

Cardiovascular Morbidity And Mortality ◽

Number Of Patients ◽

Life Threatening ◽

Underlying Mechanisms

Atrial fibrillation (AF) is the most common arrhythmia and is associated with substantial cardiovascular morbidity and mortality, with stroke being the most critical complication. Present drugs used for the therapy of AF (antiarrhythmics and anticoagulants) have major limitations, including incomplete efficacy, risks of life-threatening proarrhythmic events and bleeding complications. Non-pharmacological ablation procedures are efficient and apparently safe, but the very large size of the patient population allows ablation treatment of only a small number of patients. These limitations largely result from limited knowledge about the underlying mechanisms of AF and there is a hope that a better understanding of the molecular basis of AF may lead to the discovery of safer and more effective therapeutic targets. This article reviews the current knowledge about AF-related ion-channel remodelling and discusses how these alterations might affect the efficacy of antiarrhythmic drugs.

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Increasing Facemask Compliance among Healthcare Personnel during the COVID-19 Pandemic

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.205 ◽

2021 ◽

pp. 1-22

Author(s):

Rupak Datta ◽

Keith Glenn ◽

Anthony Pellegrino ◽

Jessica Tuan ◽

Brian Linde ◽

...

Keyword(s):

Care Center ◽

Tertiary Care ◽

Baseline Period ◽

Healthcare Personnel ◽

Structured Interviews ◽

Time Series Regression ◽

Multimodal Intervention ◽

Direct Observations ◽

Chi Squared ◽

Ancillary Staff

Abstract Objective: Prior studies of universal masking have not measured facemask compliance. We performed a quality improvement study to monitor and improve facemask compliance among healthcare personnel (HCP) during the coronavirus disease 2019 (COVID-19) pandemic. Design: Mixed-methods study Setting: Tertiary care center in West Haven, Connecticut Patients: HCP including physicians, nurses, and ancillary staff Methods: Facemask compliance was measured through direct observations during a 4-week baseline period after universal masking was mandated. Frontline and management HCP completed semi-structured interviews from which a multimodal intervention was developed. Direct observations were repeated during a 14-week period following implementation of the multimodal intervention. Differences between units were evaluated with chi-squared testing using the Bonferroni correction. Facemask compliance between baseline and intervention periods was compared using time series regression. Results: Among 1,561 observations during the baseline period, median weekly facemask compliance was 82.2% (range, 80.8%-84.4%). Semi-structured interviews were performed with 16 HCP. Qualitative analysis informed the development of a multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership. Among 2,651 observations during the intervention period, median weekly facemask compliance was 92.6% (range, 84.6%-97.9%). There was no difference in weekly facemask compliance between COVID-19 and non-COVID-19 units. The multimodal intervention was associated with an increase in facemask compliance (β=0.023, p=0.002) Conclusions: Facemask compliance remained suboptimal among HCP despite a facility-wide mandate for universal masking. A multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership was effective in increasing facemask compliance among HCP.

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