The Impact of Changes in Clinical Guideline on Practice Patterns and Healthcare Utilizations for Kawasaki Disease in Japan

Abstract Background Despite significant policy concerns about the role of inpatient resource utilization on rising medical costs, little information is provided to residents regarding their practice patterns and the effect on resource use. Improved knowledge about their practice patterns and costs might reduce resource utilization and better prepare physicians for today's health care market. Methods We surveyed residents in the internal medicine residency at the Hospital of the University of Pennsylvania. Based on needs identified via the survey, discussions with experts, and a literature review, a curriculum was created to help increase residents' knowledge about benchmarking their own practice patterns and using objective performance measures in the health care market. Results The response rate to our survey was 67%. Only 37% of residents reported receiving any feedback on their utilization of resources, and only 20% reported receiving feedback regularly. Even fewer (16%) developed, with their attending physician, a concrete improvement plan for resource use. A feedback program was developed that included automatic review of the electronic medical record to provide trainee-specific feedback on resource utilization and outcomes of care including number of laboratory tests per patient day, laboratory cost per patient day, computed tomography scan ordering rate, length of stay, and 14-day readmission rate. Results were benchmarked against those of peers on the same service. Objective feedback was provided biweekly by the attending physician, who also created an action plan with the residents. In addition, an integrated didactic curriculum was provided to all trainees on the hospitalist service on a biweekly basis. Conclusions Interns and residents do not routinely receive feedback on their resource utilization or ways to improve efficiency. A method for providing objective data on individual resource utilization in combination with a structured curriculum can be implemented to help improve resident knowledge and practice. Ongoing work will test the impact on resource utilization and outcomes.

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The Impact of the COVID-19 Pandemic and Telemedicine Implementation on Practice Patterns and Electronic Health Record Utilization in an Academic Rheumatology Practice

JCR Journal of Clinical Rheumatology ◽

10.1097/rhu.0000000000001751 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Mithu Maheswaranathan ◽

Philip Chu ◽

Andrew Johannemann ◽

Lisa Criscione-Schreiber ◽

Megan Clowse ◽

...

Keyword(s):

Electronic Health Record ◽

Practice Patterns ◽

Health Record ◽

Electronic Health ◽

The Impact ◽

Rheumatology Practice

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Comparing practice patterns and outcomes for early-stage hormone receptor-positive and node-positive breast cancer patients with high-intermediate-risk Oncotype Dx scores in the National Cancer Database.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e12520 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e12520-e12520

Author(s):

Keerthi Tamragouri ◽

Ethan M. Ritz ◽

Ruta D. Rao ◽

Cristina O'Donoghue

Keyword(s):

Breast Cancer ◽

Cancer Patients ◽

Predictive Value ◽

Practice Patterns ◽

Early Stage ◽

Oncotype Dx ◽

Breast Cancer Patients ◽

Node Positive ◽

The Impact ◽

Positive Breast Cancer

e12520 Background: Oncotype Dx (ODX) is a commercial diagnostic test primarily used to predict the likely benefit from chemotherapy in ER+, HER2-, and node negative breast cancer. The prognostic value (recurrence risk) has also been demonstrated to apply to early stage lymph node positive (LN+) disease in a number of retrospective and prospective studies. The ongoing RxPONDER trial aims to clarify the predictive value of RS in LN+ population. In light of the initial results, we analyzed the practice patterns and outcomes for HR+/Her2 -/node positive breast cancer patients receiving ODX testing in the years from 2010-2017 with RS 14-25 in a retrospective observational study of the NCDB. Methods: Women with HR+/Her2 -/node positive breast cancer receiving ODX testing from 2010-2017 were identified in the NCDB using TAILORx and RxPONDER patients’ inclusion criteria: ages 18-75, 6-50mm invasive tumors, N1, M0, ER+/HER2 -. The impact of ODX results in the high-intermediate range (14-25) and other clinico-pathologic variables on the receipt of chemotherapy were compared. Additionally, we examined the impact of chemotherapy on overall survival (OS). Frequencies, Kaplain-Meier analysis, and changepoint analysis using the Contal and O’Quigley method were utilized. Results: There were 109,652 T1-2 and N1 patients of whom 32,506 (29.6%) received ODX testing. 13,461 (41.4%%) women had scores in the high-intermediate (14-25) range. The majority tended to have only 1 LN involved (1LN: 77.2%, 2LNs: 17.5%, 3LNs: 5.3%), had a mean age of 57.8y, were Caucasian (86.4%), and were preferentially tested at academic or comprehensive community cancer programs (79.2%). 6,610 (49.3%) patients were recommended chemotherapy, the median ODX score for all women who were recommended chemotherapy was 20 compared to 17 for those whom chemotherapy was not recommended. 5,068 (76.7%) women had documentation of receiving chemotherapy which correlated with improved OS regardless of age. Conclusions: In the group of women with HR+/Her2 -/node positive breast cancer, clinicians appear to utilize ODX testing in less than one-third of patients, possibly finding RS to be most useful in guiding adjuvant therapy recommendations when only 1LN is involved. Both the recommendation and receipt of chemotherapy correlated linearly with increasing RS, as expected based on the current NCCN guideline recommendations. We identified an OS benefit when chemotherapy was administered, regardless of patient age. Long-term follow-up in the RxPONDER trial will likely continue to clarify the predictive value of RS < 25 in the ER+/HER2-/node positive breast cancer population.

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P42 The impact of a change to hospital guidelines on prescribing practices of nebulised 3% w/v ‘hypertonic’ saline

Archives of Disease in Childhood ◽

10.1136/archdischild-2017-314584.51 ◽

2018 ◽

Vol 103 (2) ◽

pp. e1.47-e1 ◽

Cited By ~ 1

Author(s):

Semple Diarmaid ◽

McNally Paul ◽

Fitzpatrick Anne ◽

Adeyemi Kenny ◽

McGrory Niamh ◽

...

Keyword(s):

Hypertonic Saline ◽

Clinical Guideline ◽

Controlled Trial ◽

Inappropriate Prescribing ◽

Prescribing Patterns ◽

List Type ◽

Guideline Compliance ◽

Significant Difference ◽

Before And After ◽

The Impact

AimsRecent conclusive evidence has suggested that, contrary to previous limited evidence, there is no benefit to the use of 3% hypertonic saline (3% HS) in the treatment of bronchiolitis in infants.1,2 This led to a change in the clinical guideline during the 2015/2016 bronchiolitis season. We hypothesised that the use of hypertonic saline was preventing the use of other un-necessary treatments and that inappropriate prescribing would increase following the advice not to give hypertonic saline.The primary aim of the study was to determine if the removal of 3% hypertonic saline from the institutional clinical guideline would result in reduced prescribing patterns. A secondary aim was to evaluate the overall prescribing compliance with the guideline including in the prescribing of antibiotics and bronchodilators, and identify if the change in the clinical guideline impacted the prescribing of other agents in children admitted with a diagnosis of bronchiolitis.MethodsData on medical treatments and hospital outcomes were prospectively collected on all infants in the 2015/2016 season both before and after the change in guideline. Details of all medicines prescribed on the patients Medication Record particularly bronchodilators, antimicrobials and inhaled agents were collected. Patient demographics were collected from medical notes. Results were analysed using chi square and Mann Whitney in Excel and Stata.Results128 children (86 before, 42 after the change in guideline) were recruited to the study. Baseline demographics were similar except for a higher proportion of children with RSV in the pre-group. Overall guideline compliance was achieved by 2 infants pre, and 3 infants post guideline change (4%). The use of hypertonic saline decreased significantly after the change in guideline but did not cease (90% pre, 71% post p<0.01). Bronchodilators were used in one in 4 infants and antibiotics in one in 3 infants, and there was no significant difference in these rates before or after the change in guidelines.ConclusionThe change to the guideline reduced the use of 3%HS, however overall guideline compliance in children with bronchiolitis is poor. Hypertonic saline use decreased when the guideline changed but a significant portion of children before and after the guideline change received medications not indicated in the treatment of bronchiolitis, including bronchodilators and antibiotics. It appears that it remains difficult to ‘do nothing’ for bronchiolitis. Poor clinical practice remains and education of clinical staff is necessary in this regard.ReferencesGuidance: Bronchiolitis in children: diagnosis and management, NICE (NG9) Published date: June 2015.Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: A randomised controlled trial. Paediatrics2015;136:1036–1043.

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Neuropsychologists' practice patterns in assessing the impact of multicultural factors on the neuropsychological evaluation

Archives of Clinical Neuropsychology ◽

10.1093/arclin/12.4.407 ◽

1997 ◽

Vol 12 (4) ◽

pp. 407-407

Author(s):

L. Smith-Seemiller ◽

M. D. Franzen ◽

L. R. Prieto ◽

E. J. Burgess

Keyword(s):

Practice Patterns ◽

Neuropsychological Evaluation ◽

The Impact

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Impact of clinical guidance and rapid molecular pathogen detection on evaluation and outcomes of febrile or hypothermic infants

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.317 ◽

2020 ◽

Vol 41 (11) ◽

pp. 1285-1291

Author(s):

Jennifer Crook ◽

Meng Xu ◽

James C. Slaughter ◽

Jeremy Willis ◽

Whitney Browning ◽

...

Keyword(s):

Emergency Department ◽

Clinical Guideline ◽

Young Infant ◽

Tertiary Care ◽

Admission Rate ◽

Entire Study ◽

Clinical Guidance ◽

Period 2 ◽

Ancillary Test ◽

The Impact

AbstractObjective:To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants.Design:Before-and-after intervention study.Setting:Tertiary-care children’s hospital.Patients:Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED).Methods:The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis.Results:Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29–60 days old being managed without antibiotics.Conclusions:Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.

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