Workplace Violence Among Health Care Professionals in Public and Private Health Facilities in Bangladesh

Objectives: The main objectives of this study were to examine the prevalence of workplace violence (WPV), its associated factors and explore the experiences of healthcare workers.Methods: A hospital-based cross-sectional study design used a nationally representative sample of 1,081 healthcare workers covering eight administrative divisions of Bangladesh. Logistic regression analysis was employed to estimate the adjusted effect of independent factors on WPV among healthcare workers.Results: Of the participants, 43% (468) experienced some form of WPV. Of those, 84% reported experiencing nonphysical violence, and 16% experienced physical violence in the past year. About 65% of victims claimed no action was taken to investigate the incident, and 44% reported no consequence for perpetrators. Four factors: being married (AOR = 1.63; CI: 1.12–2.39); public sector healthcare worker (AOR = 2.74; CI:1.99–3.76); working in an emergency department (AOR = 2.30; CI:1.03–5.12); and undertaking shift work (AOR = 1.52; CI: 1.10–2.11) were found to be significantly associated with WPV. One-third of the participants were worried about violence in their workplace.Conclusion: WPV is highly prevalent among healthcare workers in Bangladesh. Formal guidelines for reporting and managing WPV are urgently needed at the individual, hospital, and national levels.

Inequality of access to advanced therapies for patients with inflammatory arthritis: a postcode lottery?

Objectives Advanced therapies (AT) including biologics, biosimilars and JAK inhibitors have dramatically improved the quality of life of patients with Rheumatoid arthritis (RA), Psoriatic Arthritis (PsA) and Axial spondyloarthritis (axSpA). Evidence-based criteria for prescribing these drugs in England and Wales is formulated by the National Institute for Health and Care Excellence (NICE) through Health Technology Appraisals (HTAs) and guidelines with the aim of providing equitable access to AT for patients with severe or resistant disease. Similar bodies exist in some, but not all European countries with disparities in AT access between countries in AT access for RA. We examined whether this disparity was mirrored in England for RA, PsA and axSpA despite the NHS in England and Wales being legally obliged to provide funding for AT recommended by NICE’s HTA board, through commissioning bodies, Clinical Commissioning Groups (CCGs). Methods We requested AT pathways from CCGs in England. Where these were not available, individual hospital Trusts were contacted using Freedom of Information (FOI) requests. Results We found marked variability in the way that CCGs in England interpret NICE guidance. We found 41, 29 and 25 different pathways for RA, PsA and axSpA respectively. Similar disparities existed with sequential prescribing where one AT did not work, with limits on numbers of sequential AT in 54%, 59% and 59% of CCGs for RA, PsA and axSpA respectively, with these limits being different for the same condition between CCGs. Conclusion While patients at identical stages of their disease course should have access to the same NICE approved AT, we found this is not the case for large parts of England. Inequality of access was found between regions mirroring the variability which occurs between countries throughout Europe. Harmonisation of access needs to be addressed by policymakers, ensuring fairness in the way that clinicians and patients can access AT.

Lower limb trauma outcome measuresLimb salvage and amputation

The management of lower limb-threatening injuries is complex. Advances over the last few decades have provided the ability to salvage complex limb trauma but also have raised concerns that successful complex salvage surgery may not result in overall benefit for the patient. Surgical factors such as bony union, flap success, and a lack of complications are important but are not the sole factors upon which one can guide the patient toward their decision. The patient needs to know how the different treatments may affect their recovery, rehabilitation, return to work, and outcome. This chapter examines the indications and evidence for amputation and salvage by considering the importance of patient and injury-specific factors, biological and physiological variables, quality of life, patient satisfaction, and cost to the individual, hospital, and healthcare provider.

Provision and standards of care for treatment and follow-up of patients with Autoimmune Hepatitis (AIH)

BackgroundAutoimmune hepatitis (AIH) is a substantial UK health burden, but there is variation in care, facilities and in opinion regarding management. We conducted an audit of service provision and care of patients with AIH in 28 UK hospitals.MethodsCentres provided information about staffing, infrastructure and patient management (measured against predefined guideline-based standards) via a web-based data collection tool.ResultsHospitals (14 university hospitals (UHs), 14 district general hospitals (DGHs)) had median (range) of 8 (3–23) gastroenterologists; including 3 (0–10) hepatologists. Eight hospitals (29%, all DGHs) had no hepatologist. In individual hospital departments, there were 50% (18–100) of all consultants managing AIH: in DGH’s 92% (20–100) vs 46% (17–100) in UHs. Specialist nurses managed AIH in only 18%. Seventeen (61%) hospitals had a histopathologist with a liver interest, these were more likely to find rosettes than those without (172/795 vs 50/368; p<0.001).Of 999 steroid-treated patients with ≥12 months follow-up, 25% received steroids for <12 months. After 1 year of treatment, 82% of patients achieved normal serum alanine aminotransaminase (ALT); this was higher in UHs than DGHs. Three-monthly liver blood tests were inadequately recorded in 26%. Of potentially eligible patients with liver decompensation, transplantation was apparently not considered in 5% (n=7). The same standards were attained in different types of hospital.ConclusionManagement of AIH in UK hospitals is often shared between most gastroenterologists. Blood test monitoring and treatment duration are not always in line with recommendations. Some eligible patients with decompensation are not discussed with transplant teams. Care might be improved by expanding specialist input and management by fewer designated consultants.

Abstract P829: Bi-Directional Quality Review in a Large Telestroke Network: Improving Stroke Care Through Mutual Learning

Introduction: Our hub and spoke telestroke (TS) network consists of 26 sites across 6 states, with >1000 consults/year. Without a shared EMR, patient outcomes are often unknown. We aimed to improve communication of patient outcomes and patient care by implementing multi-disciplinary quality review across multiple health systems. Methods: To determine interest in and format of the review, we first conducted interviews with coordinators from 3 highly engaged sites of varying sizes and capabilities. We had strong consensus that a bi-directional quality review would be helpful and that group-based discussion was preferred over single site review. Coordinators chose review flags of long process metrics, missed treatments, thrombectomies, complications, and mortalities with sentinel events reviewed immediately, off-cycle. A case review sheet is uploaded to HIPAA-compliant Box drive and neuroimaging to PACS. Hub and spoke present cases over Zoom using standard SOAR format: Situation, Outcome, Assessment, Recommendation. The group grades each case as standard of care (SOC) met, exceeded, or not met, +/- opportunities for improvement (OFI). Discussion includes recommendations to the individual hospital or network. Results: From 4/2019-7/2020, we conducted 8 bi-directional case reviews of 21 TS cases with 9 spokes (mean 4.3 spokes/review, range 2-6). Of 47 spoke participants, 43% were stroke coordinators, 34% were ED managers, with rare hospitalists present. Hub participants were 8 vascular neurologists/fellows and 3 TS coordinators/managers. Case content was 33% recognition, 49% acute treatment, and 19% disposition. SOC was rated as met or exceeded in 86% of cases with OFI noted in 100%. The Table details discussion themes. Conclusion: A bi-directional quality review can share knowledge and best practices across a large TS network, improving inter-facility communication and site engagement. We hope next to increase physician attendance and engage more sites.

10-year comparative follow up of familial versus multifactorial chylomicronemia syndromes

Context The relative incidence of acute pancreatitis, ischemic cardiovascular disease and diabetes in hyperchylomicronemic patients exhibiting familial chylomicronemia syndrome (FCS), or multifactorial chylomicronemia syndrome (MCS), is unknown. Objective The objective was to study the occurrence of these events in FCS and MCS patients compared with the general population. Methods Twenty-nine FCS and 124 MCS patients, with genetic diagnosis, in four lipid clinics were matched with 413 controls. Individual hospital data linked to the national claims database were collected between 2006 and 2016. The occurrence of complications was retrospectively assessed before follow-up and during a median follow-up time of 9.8 years, for 1500 patient years of follow-up. Results FCS were younger than MCS (34.3 ± 13.6 vs 45.2 ± 12.6 years, p&lt;0.01). During the study period, 58.6% of the FCS patients versus 19.4% of the MCS patients had at least one episode of acute hypertriglyceridemic pancreatitis (AHP) (HR=3.6; p&lt;0.01). Conversely, the ischemic risk was lower in FCS than in MCS (HR=0,3; p=0.05). The risk of venous thrombosis was similar in both groups. The incidence of diabetes was high in both groups compared with matched controls (OR=22.8; p&lt;0.01 in FCS and OR=30.3; p&lt;0.01 in MCS). Conclusion The incidence of AHP was much higher in FCS than in MCS patients, whereas the incidence of ischemic cardiovascular events was found increased in MCS both versus FCS and a representative matched control group. Differences in both triglycerides-rich lipoprotein metabolism and comorbidities in MCS vs FCS drive the occurrence of different patterns of complications.

Economies of Scale and Scope in Hospitals: An Empirical Study of Volume Spillovers

General hospitals across the world are becoming larger (i.e., admitting more patients each year) and more complex (i.e., offering a wider range of services to patients with more diverse care needs). Prior work suggests that an increase in patient volume in a hospital service is associated with reduced costs per patient in that service. However, it is unclear how volume changes in one service affect the costs of the other services in the same hospital. This paper investigates such volume-cost spillover effects between elective and emergency admissions and across specialties, using condition-level panel data comprising all acute hospital trusts in England over a period of 10 years. We provide evidence that increased elective volume at a hospital is associated with an increase in the cost of emergency care (a negative spillover). Furthermore, for emergency admissions, we find evidence that increased emergency activity in one specialty is associated with lower costs of emergency care in other specialties (a positive spillover). By contrast, we find no evidence of spillover effects across specialties for elective admissions. We discuss the implications of these findings for individual hospital growth strategies and for the regional organization of hospital systems. This paper was accepted by David Simchi-Levi, operations management.

Joint force of individual, hospital, government: Simulation of the spread of 2019 novel coronavirus by multi-agents complex adaptive system

Early forecasting is important for health officials and decision-makers to respond to public health emergencies such as the 2019 novel coronavirus (COVID-19) outbreak. The spread of epidemic is mainly impacted by the interaction among agents, i.e., individual, hospital and government. In an effort to efficiently mitigate the impact of the virus, this original study designed a multi-agents complex adaptive system model of COVID-19 to detect the trend of the spread in 8 countries by simulating the adaptation and interaction among the agents. The results show that there should be 127,726 infections in China, 12,000 in South Korea, 729,377 in the USA, 176,623 in Italy, 194,359 in Spain, 165,122 in Germany, 177,462 in France and 149,540 in UK. It is impossible to screen and report all the cases, and the detection rate may be 82% in Italy, 65% in China, 55% in the USA, and 41% in UK on April 8, 2020. Scenario simulation results imply that action time is the most important factor in containing the spread of epidemic. If China had locked down Wuhan city five days later, the total infection would be tripled. The forces of individual, hospital and government should be united in fighting the virus.