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BMJ Open Jun 2024Oncologists need competence in clinical prognostication to deliver appropriate care to patients with cancer. Most studies on prognostication have been restricted to...
How accurate is clinical prognostication by oncologists during routine practice in a general hospital and can it be improved by a specific prognosis training programme: a prospective interventional study.
OBJECTIVES
Oncologists need competence in clinical prognostication to deliver appropriate care to patients with cancer. Most studies on prognostication have been restricted to patients in palliative care settings. This paper investigates (1) the prognostic accuracy of physicians regarding a broad cohort of patients with cancer with a median life expectancy of >2 years and (2) whether a prognosis training can improve prognostication.
DESIGN
Prospective single-centre study comprising 3 phases, each lasting 1 month.
SETTING
Large teaching hospital, department of oncology and haematology, Germany.
PARTICIPANTS
18 physicians with a professional experience from entry level to 34 years. 736 patients with oncological and malignant haematological diseases.
INTERVENTIONS
Baseline prognostication abilities were recorded during an 'untrained' phase 1. As an intervention, a specific prognosis-training programme was implemented prior to phases 2 and 3. In phase 3, physicians had to provide additional estimates with the inclusion of electronic prognostic tools.
OUTCOME MEASURES
Prognostic estimates (PE) were collected using 'standard' surprise question (SQ), 'probabilistic' SQ (both for short-term prognostication up to 6 months) and clinician prediction of survival (CPS) (for long-term prognostication). Estimated prognoses were compared with observed survival. Phase 1 was compared with phases 2 and 3.
RESULTS
We included 2427 PE for SQ, 1506 for CPS and 800 for probabilistic SQ. Median OS was 2.5 years. SQ accuracy improved significantly (p<0.001) from 72.6% in phase 1 to 84.3% in phase 3. Probabilistic SQ in phase 3 showed 83.1% accuracy. CPS accuracy was 25.9% and could not be significantly improved. (Electronic) prognostic tools-used alone-performed significantly worse (p<0.0005) than physicians and-used by the clinicians-did not improve their performance.
CONCLUSION
A specific prognosis-training programme could improve short-term and intermediate-term prognostication. Improvement of long-term prognostication was not possible. Inexperienced residents as well as experienced oncologists benefited from training.
Topics: Humans; Prospective Studies; Prognosis; Male; Female; Middle Aged; Clinical Competence; Neoplasms; Germany; Aged; Hospitals, General; Adult; Oncologists; Medical Oncology
PubMed: 38890134
DOI: 10.1136/bmjopen-2023-081661 -
Laryngoscope Investigative... Jun 2024The course of sedation during drug-induced sleep endoscopy (DISE) depends on the application pattern of the sedative drug. The depth of sedation should imitate light and...
OBJECTIVE
The course of sedation during drug-induced sleep endoscopy (DISE) depends on the application pattern of the sedative drug. The depth of sedation should imitate light and deep sleep as well. Moreover, there should be as many breathing cycles as possible available for observation during light and deep sedation. The aim of the study was to evaluate different rates of propofol application with respect to the achieved depth and length of the course of sedation.
METHODS
Sixty-three consecutive patients with obstructive sleep apnea and/or snoring undergoing DISE were randomly sedated by propofol perfusion at seven different application patterns: 14, 16, 18, 19, 20, 22 mg/kg/h (0.233, 0.267, 0.3, 0.317, 0.333, 0.367 mg/kg/min) per perfusor and individual bolus application 10 mg each. Sedation depth was monitored by BiSpectral Index™ (BIS). The influence of baseline parameters and the courses of sedation were analyzed.
RESULTS
The application rate was the only factor that influenced the depth of sedation. Basic parameters (gender, age, body mass index, apnea-hypopnea index) had no influence on the depth of sedation. The sedation depth was dependent on the rate of propofol application. Regimes at 14 and 16 mg/kg/h as well as bolus application did not reach BIS levels below 50 representing deep sleep. Propofol doses of more than 20 mg/kg/h led to rapid decreases of sedation levels below deep sleep niveau. Propofol rates between 18 and 20 mg/kg/h enable BIS levels below 50 representing deep sleep and providing enough breathing cycles for observation.
CONCLUSION
Lower application rates of propofol provide slower courses of sedation and shallower depths of sedation. A rate of 14 mg/kg/h might be appropriate to reach a sedation plateau at light sleep. A rate of 18 mg/kg/h leads to a sedation, corresponding to deep sleep. The combination of both rates might be a suitable pattern for performing sedation-controlled DISE.
LEVEL OF EVIDENCE
2: Randomized trial.
PubMed: 38887705
DOI: 10.1002/lio2.1258 -
BMC Palliative Care Jun 2024Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. Illness-related decisions are best guided by patients' values,...
BACKGROUND
Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. Illness-related decisions are best guided by patients' values, but healthcare and homelessness service providers need support in facilitating these discussions. The Serious Illness Conversation Guide (SICG) is a communication tool to guide discussions but has not yet been adapted for OAEH.
METHODS
We aimed to adapt the SICG for use with OAEH by nurses, social workers, and other homelessness service providers. We conducted semi-structured interviews with homelessness service providers and cognitive interviews with OAEH using the SICG. Service providers included nurses, social workers, or others working in homeless settings. OAEH were at least 50 years old and diagnosed with a serious illness. Interviews were conducted and audio recorded in shelters, transitional housing, a hospital, public spaces, and over Zoom. The research team reviewed transcripts, identifying common themes across transcripts and applying analytic notetaking. We summarized transcripts from each participant group, applying rapid qualitative analysis. For OAEH, data that referenced proposed adaptations or feedback about the SICG tool were grouped into two domains: "SICG interpretation" and "SICG feedback". For providers, we used domains from the Toolkit of Adaptation Approaches: "collaborative working", "team", "endorsement", "materials", "messages", and "delivery". Summaries were grouped into matrices to help visualize themes to inform adaptations. The adapted guide was then reviewed by expert palliative care clinicians for further refinement.
RESULTS
The final sample included 11 OAEH (45% Black, 61 ± 7 years old) and 10 providers (80% White, 8.9 ± years practice). Adaptation themes included changing words and phrases to (1) increase transparency about the purpose of the conversation, (2) promote OAEH autonomy and empowerment, (3) align with nurses' and social workers' scope of practice regarding facilitating diagnostic and prognostic awareness, and (4) be sensitive to the realities of fragmented healthcare. Responses also revealed training and implementation considerations.
CONCLUSIONS
The adapted SICG is a promising clinical tool to aid in the delivery of serious illness conversations with OAEH. Future research should use this updated guide for implementation planning. Additional adaptations may be dependent on specific settings where the SICG will be delivered.
Topics: Humans; Qualitative Research; Male; Female; Middle Aged; Aged; Ill-Housed Persons; Communication; Interviews as Topic
PubMed: 38886741
DOI: 10.1186/s12904-024-01485-5 -
BMC Health Services Research Jun 2024The population is aging, leading to an increased need for palliative care and end-of-life care. There is a lack of research on the use of video consultations for...
BACKGROUND
The population is aging, leading to an increased need for palliative care and end-of-life care. There is a lack of research on the use of video consultations for knowledge transfer between specialist and general palliative care. The aim of this study was to describe healthcare professionals' experiences of video consultations in palliative care in community homecare and nursing homes in rural areas.
METHODS
Individual interviews (n = 11) were conducted with five community nurses, one occupational therapist, two specialist palliative nurses, and three specialist palliative care physicians. The data were analysed using reflexive thematic analysis.
RESULTS
The analysis identified three themes: feeling comfortable with increased availability of specialist expertise; seeing each other facilitates communication; and being supported by physically present care professionals is essential.
CONCLUSION
HCPs suggest that video consultations are an effective way to increase access to specialist palliative care and provide more equal care to patients with palliative care needs in rural community care.
Topics: Humans; Palliative Care; Female; Male; Rural Health Services; Attitude of Health Personnel; Home Care Services; Qualitative Research; Interviews as Topic; Middle Aged; Adult; Videoconferencing; Nursing Homes; Rural Population; Referral and Consultation; Health Personnel
PubMed: 38886714
DOI: 10.1186/s12913-024-11196-5 -
Scientific Reports Jun 2024Patients diagnosed with hepatocellular carcinoma (HCC) often present with multimorbidity, significantly contributing to adverse outcomes, particularly in-hospital...
Patients diagnosed with hepatocellular carcinoma (HCC) often present with multimorbidity, significantly contributing to adverse outcomes, particularly in-hospital mortality. This study aimed to develop a predictive nomogram to assess the impact of comorbidities on in-hospital mortality risk in HCC patients undergoing palliative locoregional therapy. We retrospectively analyzed data from 345 hospitalized HCC patients who underwent palliative locoregional therapy between January 2015 and December 2022. The nomogram was constructed using independent risk factors such as length of stay (LOS), hepatitis B virus (HBV) infection, hypertension, chronic obstructive pulmonary disease (COPD), anemia, thrombocytopenia, liver cirrhosis, hepatic encephalopathy (HE), N stage, and microvascular invasion. The model demonstrated high predictive accuracy with an AUC of 0.908 (95% CI: 0.859-0.956) for the overall dataset, 0.926 (95% CI: 0.883-0.968) for the training set, and 0.862 (95% CI: 0.728-0.994) for the validation set. Calibration curves indicated a strong correlation between predicted and observed outcomes, validated by statistical tests. Decision curve analysis (DCA) and clinical impact curves (CIC) confirmed the model's clinical utility in predicting in-hospital mortality. This nomogram offers a practical tool for personalized risk assessment in HCC patients undergoing palliative locoregional therapy, facilitating informed clinical decision-making and improving patient management.
Topics: Humans; Carcinoma, Hepatocellular; Nomograms; Liver Neoplasms; Male; Female; Hospital Mortality; Middle Aged; Aged; Palliative Care; Retrospective Studies; Risk Factors; Comorbidity; Risk Assessment; Aged, 80 and over
PubMed: 38886455
DOI: 10.1038/s41598-024-64457-y -
Australian Critical Care : Official... Jun 2024Despite substantial evidence documenting physical, psychological, and cognitive problems experienced by intensive care unit (ICU) survivors, few studies explore...
BACKGROUND
Despite substantial evidence documenting physical, psychological, and cognitive problems experienced by intensive care unit (ICU) survivors, few studies explore interventions supporting recovery after hospital discharge. Individualised recovery goal setting, the standard of care across many rehabilitation areas, is rarely used for ICU survivors. Digital health technologies may help to address current service fragmentation and gaps. We developed and implemented a digital ICU recovery pathway using the aTouchaway e-health platform.
OBJECTIVES
The objective of this study was to explore recovery barriers and challenges; recovery goals set and achieved; self-reported patient outcomes; and healthcare costs of patients enrolled on a 12-week digital ICU recovery pathway after hospital discharge.
METHODS
We conducted a prospective observational single-centre cohort study (June 2021 to May 2023) at a 90-bed tertiary critical care service in London, UK. We enrolled adults ventilated for ≥3 days who were able to participate in recovery activities. We ascertained baseline recovery challenges and identified recovery goals and achievement over 12 weeks. We collected patient-reported outcomes at 2-4, 12-14, 26-28 weeks and healthcare utilisation monthly for 28 weeks.
RESULTS
We enrolled 105 participants (35% of eligible patients). Common rehabilitation challenges were standing balance (60%), walking indoors (56%), and washing (64%) and dressing (47%) abilities. Of 522 home recovery goals, 63% weekly, 48% monthly, and 38% aspirational goals were achieved. Most goals related to self-care: ability to move outside (91 goals, 55% achieved) and inside (45 goals, 47% achieved) the home and community access (65 goals, 48% achieved). Nottingham Extended Activities of Daily Living Scale scores improved from timepoints 1 to 2 (median [interquartile range]: 15 [7, 19] versus 19 [15, 21], P = 0.01). Total healthcare costs were £240,017 (median [interquartile range] cost per patient: £784 [£125, £4419]).
CONCLUSIONS
This study found multiple ongoing functional deficits, challenges achieving recovery goals, and limited improvements in self-reported outcomes, with moderate healthcare costs after hospital discharge indicate substantial ongoing rehabilitative needs.
PubMed: 38886140
DOI: 10.1016/j.aucc.2024.05.006 -
Gastric Cancer : Official Journal of... Jul 2024
PubMed: 38884884
DOI: 10.1007/s10120-024-01520-7 -
Learning Health Systems Jun 2024Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health...
INTRODUCTION
Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health System. Care partners commonly navigate CHIT demands alongside persons with complex health and social needs, but their role is not well specified.
METHODS
We assemble evidence and concepts from the literature describing interpersonal communication, relational coordination theory, and systems-thinking to develop an integrative framework describing the care partner's role in applied CHIT innovations. Our framework describes pathways through which systematic engagement of the care partner affects longitudinal work processes and multi-level outcomes relevant to Learning Health Systems.
RESULTS
Our framework is grounded in relational coordination, an emerging theory for understanding the dynamics of coordinating work that emphasizes role-based relationships and communication, and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Cross-cutting work systems geared toward explicit and purposeful support of the care partner role through CHIT may advance work processes by promoting frequent, timely, accurate, problem-solving communication, reinforced by shared goals, shared knowledge, and mutual respect between patients, care partners, and care team. We further contend that systematic engagement of the care partner in longitudinal work processes exerts beneficial effects on care delivery experiences and efficiencies at both individual and organizational levels. We discuss the utility of our framework through the lens of an illustrative case study involving patient portal-mediated pre-visit agenda setting.
CONCLUSIONS
Our framework can be used to guide applied embedded CHIT interventions that support the care partner role and bring value to Learning Health Systems through advancing digital health equity, improving user experiences, and driving efficiencies through improved coordination within complex work systems.
PubMed: 38883870
DOI: 10.1002/lrh2.10408 -
MedRxiv : the Preprint Server For... Jun 2024Late predictions of hospitalized patient deterioration, resulting from early warning systems (EWS) with limited data sources and/or a care team's lack of shared...
IMPORTANCE
Late predictions of hospitalized patient deterioration, resulting from early warning systems (EWS) with limited data sources and/or a care team's lack of shared situational awareness, contribute to delays in clinical interventions. The COmmunicating Narrative Concerns Entered by RNs (CONCERN) Early Warning System (EWS) uses real-time nursing surveillance documentation patterns in its machine learning algorithm to identify patients' deterioration risk up to 42 hours earlier than other EWSs.
OBJECTIVE
To test our a priori hypothesis that patients with care teams informed by the CONCERN EWS intervention have a lower mortality rate and shorter length of stay (LOS) than the patients with teams not informed by CONCERN EWS.
DESIGN
One-year multisite, pragmatic controlled clinical trial with cluster-randomization of acute and intensive care units to intervention or usual-care groups.
SETTING
Two large U.S. health systems.
PARTICIPANTS
Adult patients admitted to acute and intensive care units, excluding those on hospice/palliative/comfort care, or with Do Not Resuscitate/Do Not Intubate orders.
INTERVENTION
The CONCERN EWS intervention calculates patient deterioration risk based on nurses' concern levels measured by surveillance documentation patterns, and it displays the categorical risk score (low, increased, high) in the electronic health record (EHR) for care team members.
MAIN OUTCOMES AND MEASURES
Primary outcomes: in-hospital mortality, LOS; survival analysis was used. Secondary outcomes: cardiopulmonary arrest, sepsis, unanticipated ICU transfers, 30-day hospital readmission.
RESULTS
A total of 60 893 hospital encounters (33 024 intervention and 27 869 usual-care) were included. Both groups had similar patient age, race, ethnicity, and illness severity distributions. Patients in the intervention group had a 35.6% decreased risk of death (adjusted hazard ratio [HR], 0.644; 95% confidence interval [CI], 0.532-0.778; P<.0001), 11.2% decreased LOS (adjusted incidence rate ratio, 0.914; 95% CI, 0.902-0.926; P<.0001), 7.5% decreased risk of sepsis (adjusted HR, 0.925; 95% CI, 0.861-0.993; P=.0317), and 24.9% increased risk of unanticipated ICU transfer (adjusted HR, 1.249; 95% CI, 1.093-1.426; P=.0011) compared with patients in the usual-care group.
CONCLUSIONS AND RELEVANCE
A hospital-wide EWS based on nursing surveillance patterns decreased in-hospital mortality, sepsis, and LOS when integrated into the care team's EHR workflow.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03911687.
PubMed: 38883706
DOI: 10.1101/2024.06.04.24308436 -
Frontiers in Medicine 2024
PubMed: 38882669
DOI: 10.3389/fmed.2024.1426187