Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits

Background The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. Methods In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. Results The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. Discussion The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

Adolescent health

Many recent shifts are propelling adolescence into the forefront of global public health. There is a youth bulge with 1.8 billion, 10–24-year-olds comprising over a quarter of the global population. Nearly 90% live in low- and middle-income countries (LMIC). Dramatic declines in mortality and disease burden in infancy and early childhood in many countries have resulted in a focus on growing adolescent health problems including mental disorders, the consequences of unsafe sexuality, the growing rates of non-communicable disease risks, and the impact of injuries and violence on this age group. Youth-friendly health services have the potential to promote equity, effectiveness, accessibility, acceptability, and appropriateness of care, including early interventions for major health risks. Prevention frameworks have integrated life-course epidemiology with strategies developed in the social and behavioural sciences. There is some evidence that involving young people in the conceptualization and implementation of some of these interventions improves the outcomes.

Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients

Background Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda

In Uganda, >50% of sick children receive treatment from primary level-private health facilities (HF). We assessed the appropriateness of care for common infections in under-five-year-old children and explored perspectives of healthcare workers (HCW) and policymakers on the quality of healthcare at low-level private health facilities (LLPHF) in western Uganda. This was a mixed-methods parallel convergent study. Employing multistage consecutive sampling, we selected 110 HF and observed HCW conduct 777 consultations of children with pneumonia, malaria, diarrhea or neonatal infections. We purposively selected 30 HCW and 8 policymakers for in-depth interviews. Care was considered appropriate if assessment, diagnosis, and treatment were correct. We used univariable and multivariable logistic regression analyses for quantitative data and deductive thematic analysis for qualitative data. The proportion of appropriate care was 11% for pneumonia, 14% for malaria, 8% for diarrhea, and 0% for neonatal infections. Children with danger signs were more likely to receive appropriate care. Children with diarrhea or ability to feed orally were likely to receive inappropriate care. Qualitative data confirmed care given as often inappropriate, due to failure to follow guidelines. Overall, sick children with common infections were inappropriately managed at LLPHF. Technical support and provision of clinical guidelines should be increased to LLPHF.

Evaluating the appropriateness of elective surgery: The case of spinal fusion (arthrodesis)

Introduction Appropriateness is an essential element of quality of care. Several methods and tools have been developed to measure the appropriateness of care, however, none of these could be used to systematically support providers in keeping the appropriateness under control. Our study aimed to develop a framework to evaluate the appropriateness of care that took into account four dimensions of appropriateness: clinical dimension, equity, service delivery model, outcome. Methods We employed mixed-method approaches. These included a retrospective analysis of administrative data collected from Kinetika Sardinia (Italy) and a qualitative analysis of stakeholders’ experiences and perspectives aimed at supporting data collection, identification of improvement actions and definition of performance indicators. We used arthrodesis as a paradigmatic example of potentially inappropriate elective surgery. Results We collected data from 2,584 patients that underwent arthrodesis between January 1, 2010 and April 30, 2015. Based on the analysis and the exchanges with professionals, we identified 11 improvement actions. Monitoring and evaluation actions were finally conducted for 171 patients that underwent spinal fusion during the first semester of 2016 in order to assess if the improvement actions identified were put into practice and acquired desirable outcomes. Conclusions Our work provides a definition of appropriateness that goes beyond the clinical perspective and includes other perspectives (equity, service delivery and outcome); develops a framework and an approach that can be a valid help to systematically assess the appropriateness of elective surgery, adopt improvement actions, and monitor their impact; discusses what are the competencies necessary for measuring the appropriateness.

Non-Trauma Service Admissions: Should We Care?

The American College of Surgeons Committee on Trauma requires that trauma centers with greater than 10 per cent injured patients admitted to non-trauma services (NTSs) have processes to review these for appropriateness of care. We previously described an algorithm to determine the appropriateness of NTS admissions. Our objective was to determine if the outcome and process of care was similar between TS- and NTS-admitted patients. We conducted a retrospective analysis of our trauma registry. NTS-appropriate patients by algorithm were included. Differences between patients admitted to a TS and an NTS were compared. Nine hundred forty-one patients met the algorithm criteria as appropriate for the NTS; 694 were admitted to TS and 247 to NTS. Contact with TS was the most common association with admission to TS. NTS patients were older and had similar Injury Severity Scores, and a similar proportion had three or greater pre-existing comorbidities. NTS-admitted patients had similar risk for mortality and complications, but longer length of stay, and were less likely to have a desirable discharge disposition. Minimally injured elderly patients constitute most of NTS and a large proportion of TS admissions. NTS admission seems appropriate with respect to mortality and complications. Differences in the care process may have accounted for longer length of stay and differences in disposition destination.

A bureaucracy of care in managing Hampi World Heritage Site

In this paper I examine the ‘heritage regime’ instituted at Hampi, Karnataka, India, consequent to its inscription as World Heritage, by analysing everyday material practices of conservation-management at the site through the lens of ‘care’. I argue that the regime is undoubtedly a bureaucracy as popularly imagined – but of care premised on knowledge and not of apathy. I suggest that various ongoing contestations amongst social actors are over the appropriateness of care, based on a particular visual aesthetic, which results in spatio-temporal material alienation of resident communities. Confusing consequence for cause, practice seeks to ‘engage’ with people whose alienation from ‘official’ heritage they are party to inevitably leads to everyday ‘heartbreak’ for experts, disillusionment among residents, and a conflicted position for local heritage agencies, albeit unintentionally.

CareTrack Aged: the appropriateness of care delivered to Australians living in residential aged care facilities: a study protocol

IntroductionThe aged population is increasing rapidly across the world and this is expected to continue. People living in residential aged care facilities (RACFs) represent amongst the sickest and frailest cohort of the aged population, with a high prevalence of chronic conditions and complex comorbidities. Given the vulnerability of RACF residents and the demands on the system, there is a need to determine the extent that care is delivered in line with best practice (‘appropriate care’) in RACFs. There is also a recognition that systems should provide care that optimises quality of life (QoL), which includes support for physical and psychological well-being, independence, social relationships, personal beliefs and a caring external environment. The aims ofCareTrack Agedare to develop sets of indicators for appropriate care and processes of care for commonly managed conditions, and then assess the appropriateness of care delivered and QoL of residents in RACFs in Australia.Methods and analysisWe will extract recommendations from clinical practice guidelines and, using expert review, convert these into sets of indicators for 15 common conditions and processes of care for people living in RACFs. We will recruit RACFs in three Australian states, and residents within these RACFs, using a stratified multistage sampling method. Experienced nurses, trained in theCareTrack Agedmethods (‘surveyors’), will review care records of recruited residents within a 1-month period in 2019 and 2020, and assess the care documented against the indicators of appropriate care. Surveyors will concurrently assess residents’ QoL using validated questionnaires.Ethics and disseminationThe study has been reviewed and approved by the Human Research Ethics Committee of Macquarie University (5201800386). The research findings will be published in international and national journals and disseminated through conferences and presentations to interested stakeholder groups, including consumers, national agencies, healthcare professionals, policymakers and researchers.