Patient Pathways and Diagnostic Value in Sierra Leone

What is the value of a diagnostic test? Most obviously for primary healthcare settings, laboratory tests can inform clinical decision making about treatment and patient management. Their predominant value in this context is therefore medical. But what about when that healthcare setting is chronically under-resourced, healthcare workers (including laboratory workers) are underpaid, and government supply chains fail to deliver basic laboratory supplies? In this contribution to the Field Notes section, we describe a Community Health Centre (CHC) in Sierra Leone where such conditions have given rise to a quasi-private laboratory service within the public health facility. Through detailed ethnographic description of patients’ diagnostic pathways through the facility, we examine and assess the impact on patient care when the medical and economic value of diagnostic tests diverge.

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Impact of multidisciplinary cancer care on the postoperative mortality and survival of patients with esophageal and esophagogastric junction cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.e15111 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. e15111-e15111

Author(s):

Maica Galán ◽

Leandre Farran ◽

Luisa Aliste ◽

Gloria Hormigo ◽

Mariona Calvo ◽

...

Keyword(s):

Multidisciplinary Approach ◽

Clinical Decision Making ◽

Health Centre ◽

Postoperative Mortality ◽

Clinical Decision ◽

University Hospital ◽

Curative Intent ◽

Oesophagogastric Junction ◽

Number Of Patients ◽

The Impact

e15111 Background: Modern management of Oesophageal and oesophagogastric junction (OGJ) cancers requires a multidisciplinary approach, which was implemented at our health centre in 2005. This study aimed to assess the impact of this change on clinical outcomes. Methods: A retrospective cohort study was conducted, covering all patients treated for oesophageal and OGJ cancer at the cancer centre established by the Bellvitge University Hospital and Catalonian Institute of Oncology, over two time periods, i.e., 2000-2004 and 2005-2008. Descriptive and multivariate analyses were performed using survival at 1 and 3 years as dependent variables. Results: Between 1 January 2000 and 31 December 2008, 586 patients were included. Number of patients with unknown stage at diagnosis was significantly reduced. Neoadjuvant strategies at the oesophageal location clearly increased in the recent period. A multidisciplinary approach resulted in a significant reduction in surgical mortality (11.8% vs. 2%) in the period 2005-2008. Analysis restricted to patients undergoing surgery with curative intent indicated a significant increase in 1- and 3-year survival in the latter period (68.4% vs. 89.8% and 38.2% vs. 57.1% respectively). Multivariate analysis showed that variables associated with improved survival were: age; tumour stage; radical intent of treatment (surgery and radical combined chemoradiotherapy); and therapeutic strategy. Conclusions: Better selection of patients for therapy together with improved staging resulted in a significant improvement in 1- and 3-year survival in cases undergoing surgery with curative intent. These changes would support the adoption of a multidisciplinary approach to clinical decision-making in cases of oesophageal and OGJ cancer.

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Religion and Medicine

10.1093/oso/9780190867355.001.0001 ◽

2020 ◽

Author(s):

Jeff Levin ◽

Stephen G. Post

Keyword(s):

Clinical Decision Making ◽

Well Being ◽

Clinical Decision ◽

Religion And Medicine ◽

Physical And Mental Health ◽

Faith Based ◽

Baylor University ◽

Wide Range ◽

History Of ◽

The Impact

In Religion and Medicine, Dr. Jeff Levin, distinguished Baylor University epidemiologist, outlines the longstanding history of multifaceted interconnections between the institutions of religion and medicine. He traces the history of the encounter between these two institutions from antiquity through to the present day, highlighting a myriad of contemporary alliances between the faith-based and medical sectors. Religion and Medicine tells the story of: religious healers and religiously branded hospitals and healthcare institutions; pastoral professionals involved in medical missions, healthcare chaplaincy, and psychological counseling; congregational health promotion and disease prevention programs and global health initiatives; research studies on the impact of religious and spiritual beliefs and practices on physical and mental health, well-being, and healing; programs and centers for medical research and education within major universities and academic institutions; religiously informed bioethics and clinical decision-making; and faith-based health policy initiatives and advocacy for healthcare reform. Religion and Medicine is the first book to cover the full breadth of this subject. It documents religion-medicine alliances across religious traditions, throughout the world, and over the course of history. It summarizes a wide range of material of relevance to historians, medical professionals, pastors and theologians, bioethicists, scientists, public health educators, and policymakers. The product of decades of rigorous and focused research, Dr. Levin has produced the most comprehensive history of these developments and the finest introduction to this emerging field of scholarship.

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Clinical Conundrums When Integrating the QbTest into a Standard ADHD Assessment of Children and Young People

Neuropediatrics ◽

10.1055/s-0040-1722674 ◽

2021 ◽

Author(s):

Carsten Vogt

Keyword(s):

Clinical Practice ◽

Clinical Decision Making ◽

Ecological Validity ◽

Neuropsychological Test ◽

Real Life ◽

Clinical Decision ◽

Hyperactivity Disorder ◽

Standard Clinical Practice ◽

Novel Method ◽

The Impact

AbstractThe uptake of the QbTest in clinical practice is increasing and has recently been supported by research evidence proposing its effectiveness in relation to clinical decision-making. However, the exact underlying process leading to this clinical benefit is currently not well established and requires further clarification. For the clinician, certain challenges arise when adding the QbTest as a novel method to standard clinical practice, such as having the skills required to interpret neuropsychological test information and assess for diagnostically relevant neurocognitive domains that are related to attention-deficit hyperactivity disorder (ADHD), or how neurocognitive domains express themselves within the behavioral classifications of ADHD and how the quantitative measurement of activity in a laboratory setting compares with real-life (ecological validity) situations as well as the impact of comorbidity on test results. This article aims to address these clinical conundrums in aid of developing a consistent approach and future guidelines in clinical practice.

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AAC Assessment and Clinical-Decision Making: The Impact of Experience

Augmentative and Alternative Communication ◽

10.3109/07434618.2012.704521 ◽

2012 ◽

Vol 28 (3) ◽

pp. 148-159 ◽

Cited By ~ 42

Author(s):

Aimee Dietz ◽

Wendy Quach ◽

Shelley K. Lund ◽

Miechelle McKelvey

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Clinical Decision ◽

The Impact

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Standardized Synoptic Cancer Pathology Reports — So What and Who Cares?: A Population-Based Satisfaction Survey of 970 Pathologists, Surgeons, and Oncologists

Archives of Pathology & Laboratory Medicine ◽

10.5858/arpa.2012-0656-oa ◽

2013 ◽

Vol 137 (11) ◽

pp. 1599-1602 ◽

Cited By ~ 37

Author(s):

Sara Lankshear ◽

John Srigley ◽

Thomas McGowan ◽

Marta Yurcan ◽

Carol Sawka

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Clinical Decision ◽

Physician Satisfaction ◽

Cross Sectional ◽

Cancer Pathology ◽

Report Turnaround Time ◽

Significant Difference ◽

Pathology Reporting ◽

The Impact

Context.—Cancer Care Ontario implemented synoptic pathology reporting across Ontario, impacting the practice of pathologists, surgeons, and medical and radiation oncologists. The benefits of standardized synoptic pathology reporting include enhanced completeness and improved consistency in comparison with narrative reports, with reported challenges including increased workload and report turnaround time. Objective.—To determine the impact of synoptic pathology reporting on physician satisfaction specific to practice and process. Design.—A descriptive, cross-sectional design was utilized involving 970 clinicians across 27 hospitals. An 11-item survey was developed to obtain information regarding timeliness, completeness, clarity, and usability. Open-ended questions were also employed to obtain qualitative comments. Results.—A 51% response rate was obtained, with descriptive statistics reporting that physicians perceive synoptic reports as significantly better than narrative reports. Correlation analysis revealed a moderately strong, positive relationship between respondents' perceptions of overall satisfaction with the level of information provided and perceptions of completeness for clinical decision making (r = 0.750, P < .001) and ease of finding information for clinical decision making (r = 0.663, P < .001). Dependent t tests showed a statistically significant difference in the satisfaction scores of pathologists and oncologists (t169 = 3.044, P = .003). Qualitative comments revealed technology-related issues as the most frequently cited factor impacting timeliness of report completion. Conclusion.—This study provides evidence of strong physician satisfaction with synoptic cancer pathology reporting as a clinical decision support tool in the diagnosis, prognosis, and treatment of cancer patients.

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Clinicians’ experiences of using and implementing a medical mobile phone app (QUiPP V2) designed to predict the risk of preterm birth and aid clinical decision making

BMC Medical Informatics and Decision Making ◽

10.1186/s12911-021-01681-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

N. Carlisle ◽

H. A. Watson ◽

J. Carter ◽

K. Kuhrt ◽

P. T. Seed ◽

...

Keyword(s):

Decision Making ◽

Preterm Birth ◽

Cultural Context ◽

Clinical Decision Making ◽

Qualitative Interviews ◽

Scale Up ◽

Clinical Decision ◽

Clinical Trial Registry ◽

Support Tool ◽

The Impact

Abstract Background As the vast majority of women who present in threatened preterm labour (TPTL) will not deliver early, clinicians need to balance the risks of over-medicalising the majority of women, against the potential risk of preterm delivery for those discharged home. The QUiPP app is a free, validated app which can support clinical decision-making as it produces individualised risks of delivery within relevant timeframes. Recent evidence has highlighted that clinicians would welcome a decision-support tool that accurately predicts preterm birth. Methods Qualitative interviews were undertaken as part of the EQUIPTT study (The Evaluation of the QUiPP app for Triage and Transfer) (REC: 17/LO/1802) which aimed to evaluate the impact of the QUiPP app on management of TPTL. Individual semi-structured telephone interviews were used to explore clinicians’ (obstetricians’ and midwives’) experiences of using the QUiPP app and how it was implemented at their hospital sites. Thematic analysis was chosen to explore the meaning of the data, through a framework approach. Results Nineteen participants from 10 hospital sites in England took part. Data analysis revealed three overarching themes which were: ‘experience of using the app’, ‘how QUiPP risk changes practice’ and ‘successfully adopting QUiPP: context is everything’. With these final themes we appeared to have achieved our aim of exploring the clinicians’ experiences of using and implementing the QUiPP app. Conclusion This study explored different clinician’s experiences of implementing the app. The organizational and cultural context at different sites appeared to have a large impact on how well the QUiPP app was implemented. Future work needs to be undertaken to understand how best to embed the intervention within different settings. This will inform scale up of QUiPP app use across the UK and ensure that clinicians have access to this free, easy-to-use tool which can positively aid clinical decision making when caring for women in TPTL. Clinical trial registry and registration number ISRCTN 17846337, registered 08th January 2018, https://doi.org/10.1186/ISRCTN17846337.

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Exploring the role of the Care and Health Information Exchange (CHIE) in clinical decision-making: a realist evaluation

10.1101/2020.08.13.20174276 ◽

2020 ◽

Author(s):

Philip Scott ◽

Elisavet Andrikopoulou ◽

Haythem Nakkas ◽

Paul Roderick

Keyword(s):

Decision Making ◽

Health Information ◽

Information Exchange ◽

Healthcare Professionals ◽

Clinical Decision Making ◽

Social Care ◽

Health Information Exchange ◽

Clinical Decision ◽

Health And Social Care ◽

The Impact

Background: The overall evidence for the impact of electronic information systems on cost, quality and safety of healthcare remains contested. Whilst it seems intuitively obvious that having more data about a patient will improve care, the mechanisms by which information availability is translated into better decision-making are not well understood. Furthermore, there is the risk of data overload creating a negative outcome. There are situations where a key information summary can be more useful than a rich record. The Care and Health Information Exchange (CHIE) is a shared electronic health record for Hampshire and the Isle of Wight that combines key information from hospital, general practice, community care and social services. Its purpose is to provide clinical and care professionals with complete, accurate and up-to-date information when caring for patients. CHIE is used by GP out-of-hours services, acute hospital doctors, ambulance service, GPs and others in caring for patients. Research questions: The fundamental question was How does awareness of CHIE or usage of CHIE affect clinical decision-making? The secondary questions were What are the latent benefits of CHIE in frontline NHS operations? and What is the potential of CHIE to have an impact on major NHS cost pressures? The NHS funders decided to focus on acute medical inpatient admissions as the initial scope, given the high costs associated with hospital stays and the patient complexities (and therefore information requirements) often associated with unscheduled admissions. Methods: Semi-structured interviews with healthcare professionals to explore their experience about the utility of CHIE in their clinical scenario, whether and how it has affected their decision-making practices and the barriers and facilitators for their use of CHIE. The Framework Method was used for qualitative analysis, supported by the software tool Atlas.ti. Results: 21 healthcare professionals were interviewed. Three main functions were identified as useful: extensive medication prescribing history, information sharing between primary, secondary and social care and access to laboratory test results. We inferred two positive cognitive mechanisms: knowledge confidence and collaboration assurance, and three negative ones: consent anxiety, search anxiety and data mistrust. Conclusions: CHIE gives clinicians the bigger picture to understand the patient's health and social care history and circumstances so as to make confident and informed decisions. CHIE is very beneficial for medicines reconciliation on admission, especially for patients that are unable to speak or act for themselves or who cannot remember their precise medication or allergies. We found no clear evidence that CHIE has a significant impact on admission or discharge decisions. We propose the use of recommender systems to help clinicians navigate such large volumes of patient data, which will only grow as additional data is collected.

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A New Monocyte Epigenetic Clock Reveals Effects of Alcohol Consumption on Epigenetic Aging in Three Independent Cohorts

10.1101/2021.03.22.436488 ◽

2021 ◽

Author(s):

Xiaoyu Liang ◽

Rajita Sinha ◽

Amy C. Justice ◽

Mardge H. Cohen ◽

Bradley E. Aouizerat ◽

...

Keyword(s):

Alcohol Consumption ◽

Hiv Infection ◽

Clinical Decision Making ◽

Clinical Decision ◽

Biological Age ◽

Biological Aging ◽

Epigenetic Clock ◽

Excessive Alcohol Consumption ◽

Epigenetic Age ◽

The Impact

AbstractBackgroundExcessive alcohol consumption increases the risk of aging-related comorbidities and mortality. Assessing the impact of alcohol consumption on biological age is important for clinical decision-making and prevention. Evidence shows that alcohol alters monocyte function, and age is associated with DNA methylome and transcriptomic changes among monocytes. However, no monocyte-based epigenetic clock is currently available. In this study, we developed a new monocyte-based DNA methylation clock (MonoDNAmAge) by using elastic net regularization. The MonoDNAmAge was validated by benchmarking using epigenetic age acceleration (EAA) in HIV infection. Using MonoDNAmAge clock as well as four established clocks (i.e., HorvathDNAmAge, HannumDNAmAge, PhenoDNAmAge, GrimDNAmAge), we then evaluated the effect of alcohol consumption on biological aging in three independent cohorts (N=2,242).ResultsMonoDNAmAge, comprised of 186 CpG sites, was highly correlated with chronological age (rtraining=0.96, p<2.20E-16; rtesting=0.86, p=1.55E-141). The MonoDNAmAge clock predicted an approximately 10-year age acceleration from HIV infection in two cohorts. Quadratic regression analysis showed a nonlinear relationship between MonoDNAmAge and alcohol consumption in the Yale Stress Center Community Study (YSCCS, pmodel=4.55E-08, px2 =7.80E-08) and in the Veteran Aging Cohort Study (VACS, pmodel=1.85E-02, px2 =3.46E-02). MonoDNAmAge and light alcohol consumption showed a negative linear relationship in the Women’s Interagency HIV Study (WIHS, β=-2.63, px=2.82E-06). Heavy consumption increased EAAMonoDNAmAge up to 1.60 years in the VACS while light consumption decreased EAAMonoDNAmAge to 2.66 years in the WIHS. These results were corroborated by the four established epigenetic clocks.ConclusionsWe observed a nonlinear effect of alcohol consumption on epigenetic age that is estimated by a novel monocyte-based “clock” in three distinct cohorts, highlighting the complex effects of alcohol consumption on biological age.

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Blood enterovirus polymerase chain reaction testing in young febrile infants

Archives of Disease in Childhood ◽

10.1136/archdischild-2020-321077 ◽

2021 ◽

pp. archdischild-2020-321077

Author(s):

Carla Pintos ◽

Santiago Mintegi ◽

Javier Benito ◽

Maitane Aranzamendi ◽

Leire Bonilla ◽

...

Keyword(s):

Antibiotic Treatment ◽

Clinical Decision Making ◽

Bacterial Pathogen ◽

Length Of Hospital Stay ◽

Clinical Decision ◽

Dipstick Test ◽

Urine Dipstick ◽

Young Infants ◽

Urine Dipstick Test ◽

The Impact

ObjectiveTo analyse the impact of blood enterovirus and human parechovirus PCR (ev-PCR) testing in young infants with fever without a source (FWS).DesignObservational study, subanalysis of a prospective registry.SettingPaediatric emergency department.PatientsInfants ≤90 days of age with FWS seen between September 2015 and August 2019 with blood ev-PCR, blood and urine cultures and urine dipstick test performed.Main outcome measuresPrevalence of invasive bacterial infection (IBI: bacterial pathogen in blood or cerebrospinal fluid) in infants with positive or negative ev-PCR test results. Secondarily, we also compared length of stay and antibiotic treatment in hospitalised infants.ResultsOf 703 infants, 174 (24.7%) had a positive blood ev-PCR and none of them were diagnosed with an IBI (vs 2.6% (95% CI 1.3% to 4.0%) of those with a negative result, p=0.02). Prevalence of non-IBI (mainly urinary tract infection) was also lower among infants with a positive blood ev-PCR (2.3% (95% CI 0.1% to 4.5%) vs 17.6% (95% CI 14.3% to 20.8%), p<0.01).Overall, 258 infants were hospitalised (36.6%) and 193 (74.8%) of them received antibiotics. Length of hospital stay and antibiotic treatment were shorter in those with a positive blood ev-PCR (median: 3 days vs 5 days and 1 day vs 5 days, respectively; p<0.01). Differences remained statistically significant among well-appearing infants >21 days old with normal urine dipstick.ConclusionBlood ev-PCR identifies a group of infants under 90 days of age with FWS at very low risk of IBI. This test may help to guide clinical decision making in young febrile infants.

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QOLP-03. MEASURING CHANGE IN HEALTH-RELATED QUALITY OF LIFE: THE ADDED VALUE OF ANALYSIS ON THE INDIVIDUAL PATIENT LEVEL IN GLIOMA PATIENTS IN CLINICAL DECISION MAKING

Neuro-Oncology ◽

10.1093/neuonc/noz175.823 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi197-vi198 ◽

Cited By ~ 1

Author(s):

Marijke Coomans ◽

Martin Taphoorn ◽

Neil Aaronson ◽

Brigitta Baumert ◽

Martin van den Bent ◽

...

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Clinical Decision ◽

Scale Item ◽

Individual Patient Level ◽

Patient Level ◽

Related Quality ◽

The Individual ◽

The Impact ◽

Over Time

Abstract BACKGROUND: Health-related quality of life (HRQoL) is an important outcome in glioma research, reflecting the impact of disease and treatment on a patient’s functioning and wellbeing. Data on changes in HRQoL scores provide important information for clinical decision-making, but different analytical methods may lead to different interpretations of the impact of treatment on HRQoL. This study aimed to study whether different methods to evaluate change in HRQoL result in different interpretations. Methods: HRQoL and sociodemographical/clinical data from 15 randomized clinical trials were combined. Change in HRQoL scores was analyzed: (1)at the group level, comparing mean changes in scale/item scores between treatment arms over time, (2)at the patient level per scale/item by calculating the percentage of patients that deteriorated, improved or remained stable on a scale/item per scale/item, and (3)at the individual patient level combining all scales/items. Results: Data were available for 3727 patients. At the group scale/item level (method 1), only the item ‘hair loss’ showed a significant and clinically relevant change (i.e. ≥10 points) over time, whereas change scores on the other scales/items showed a statistically significant change only (all p< .001, range in change score:0.1–6.2). Analyses on the patient level per scale (method 2) indicated that, while a large proportion of patients had stable HRQoL over time (range:27–84%), many patients deteriorated (range:6–43%) or improved (range:8–32%) on a specific scale/item. At the individual patient level (method 3), the majority of patients (86%) showed both deterioration and improvement, while only 1% of the patients remained stable on all scales. Conclusion: Different analytical methods of changes in HRQoL result in distinct interpretations of treatment effects, all of which may be relevant for clinical decision-making. Additional information about the joint impact of treatment on all outcomes may help patients and physicians to make the best treatment decision.

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