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BMC Gastroenterology Apr 2020The fecal immunochemical test (FIT) is the second most commonly used colorectal cancer (CRC) screening modality in the United States; yet, follow-up of abnormal FIT...
BACKGROUND
The fecal immunochemical test (FIT) is the second most commonly used colorectal cancer (CRC) screening modality in the United States; yet, follow-up of abnormal FIT results with diagnostic colonoscopy is underutilized. Our objective was to determine patient-reported barriers to diagnostic colonoscopy following abnormal FIT in an academic healthcare setting.
METHODS
We included patients age 50-75 with an abnormal FIT result between 1/1/2015 and 10/31/2017 and no documented follow-up diagnostic colonoscopy. We abstracted demographic data from the electronic health record (EHR). Study personnel conducted telephone surveys with patients to confirm colonoscopy completion and elicit data on notification of FIT results and barriers to colonoscopy. We also provided brief verbal education about diagnostic colonoscopy. We calculated frequencies of demographic data and survey responses and compared survey responses by interest in colonoscopy after education.
RESULTS
We surveyed 67 patients. Fifty-one were aware of the abnormal FIT result, and a majority learned of the abnormal FIT result by direct communication with providers (19, 37.3%) or EHR messaging (11, 21.6%). Overall, fifty-three patients (79.1%) confirmed lack of colonoscopy, citing provider-related (19, 35.8%), patient-related (16, 30.2%), system-related (1, 1.9%), or multifactorial (17, 32.1%) reasons. Lack of knowledge of FIT result (14, 26.4%) was most common. After brief education, 20 (37.7%) patients requested colonoscopy.
CONCLUSION
Patients with an abnormal FIT reported various multi-level barriers to diagnostic colonoscopy after abnormal FIT, including knowledge of FIT results. When provided with brief education, participants expressed interest in diagnostic colonoscopy. Future efforts will evaluate interventions to improve colonoscopy follow-up.
Topics: Aged; Anxiety; Appointments and Schedules; Colonoscopy; Colorectal Neoplasms; Directive Counseling; Early Detection of Cancer; Fear; Female; Health Knowledge, Attitudes, Practice; Humans; Immunochemistry; Male; Middle Aged; Occult Blood; Patient Acceptance of Health Care; Patient Education as Topic; Retrospective Studies; Surveys and Questionnaires
PubMed: 32306919
DOI: 10.1186/s12876-020-01262-7 -
Applied Clinical Informatics Mar 2020Failure to complete recommended diagnostic tests may increase the risk of diagnostic errors.
BACKGROUND
Failure to complete recommended diagnostic tests may increase the risk of diagnostic errors.
OBJECTIVES
The aim of this study is to develop and evaluate an electronic monitoring tool that notifies the responsible clinician of incomplete imaging tests for their ambulatory patients.
METHODS
A results notification workflow engine was created at an academic medical center. It identified future appointments for imaging studies and notified the ordering physician of incomplete tests by secure email. To assess the impact of the intervention, the project team surveyed participating physicians and measured test completion rates within 90 days of the scheduled appointment. Analyses compared test completion rates among patients of intervention and usual care clinicians at baseline and follow-up. A multivariate logistic regression model was used to control for secular trends and differences between cohorts.
RESULTS
A total of 725 patients of 16 intervention physicians had 1,016 delayed imaging studies; 2,023 patients of 42 usual care clinicians had 2,697 delayed studies. In the first month, physicians indicated in 23/30 cases that they were unaware of the missed test prior to notification. The 90-day test completion rate was lower in the usual care than intervention group in the 6-month baseline period (18.8 vs. 22.1%, = 0.119). During the 12-month follow-up period, there was a significant improvement favoring the intervention group (20.9 vs. 25.5%, = 0.027). The change was driven by improved completion rates among patients referred for mammography (21.0 vs. 30.1%, = 0.003). Multivariate analyses showed no significant impact of the intervention.
CONCLUSION
There was a temporal association between email alerts to physicians about missed imaging tests and improved test completion at 90 days, although baseline differences in intervention and usual care groups limited the ability to draw definitive conclusions. Research is needed to understand the potential benefits and limitations of missed test notifications to reduce the risk of delayed diagnoses, particularly in vulnerable patient populations.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Care; Diagnostic Errors; Electronic Mail; Female; Humans; Male; Middle Aged; Radiology; Young Adult
PubMed: 32294771
DOI: 10.1055/s-0040-1708530 -
JMIR Public Health and Surveillance Apr 2020The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) and Public Health England (PHE) have successfully worked together on the...
Emergence of a Novel Coronavirus (COVID-19): Protocol for Extending Surveillance Used by the Royal College of General Practitioners Research and Surveillance Centre and Public Health England.
BACKGROUND
The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) and Public Health England (PHE) have successfully worked together on the surveillance of influenza and other infectious diseases for over 50 years, including three previous pandemics. With the emergence of the international outbreak of the coronavirus infection (COVID-19), a UK national approach to containment has been established to test people suspected of exposure to COVID-19. At the same time and separately, the RCGP RSC's surveillance has been extended to monitor the temporal and geographical distribution of COVID-19 infection in the community as well as assess the effectiveness of the containment strategy.
OBJECTIVES
The aims of this study are to surveil COVID-19 in both asymptomatic populations and ambulatory cases with respiratory infections, ascertain both the rate and pattern of COVID-19 spread, and assess the effectiveness of the containment policy.
METHODS
The RCGP RSC, a network of over 500 general practices in England, extract pseudonymized data weekly. This extended surveillance comprises of five components: (1) Recording in medical records of anyone suspected to have or who has been exposed to COVID-19. Computerized medical records suppliers have within a week of request created new codes to support this. (2) Extension of current virological surveillance and testing people with influenza-like illness or lower respiratory tract infections (LRTI)-with the caveat that people suspected to have or who have been exposed to COVID-19 should be referred to the national containment pathway and not seen in primary care. (3) Serology sample collection across all age groups. This will be an extra blood sample taken from people who are attending their general practice for a scheduled blood test. The 100 general practices currently undertaking annual influenza virology surveillance will be involved in the extended virological and serological surveillance. (4) Collecting convalescent serum samples. (5) Data curation. We have the opportunity to escalate the data extraction to twice weekly if needed. Swabs and sera will be analyzed in PHE reference laboratories.
RESULTS
General practice clinical system providers have introduced an emergency new set of clinical codes to support COVID-19 surveillance. Additionally, practices participating in current virology surveillance are now taking samples for COVID-19 surveillance from low-risk patients presenting with LRTIs. Within the first 2 weeks of setup of this surveillance, we have identified 3 cases: 1 through the new coding system, the other 2 through the extended virology sampling.
CONCLUSIONS
We have rapidly converted the established national RCGP RSC influenza surveillance system into one that can test the effectiveness of the COVID-19 containment policy. The extended surveillance has already seen the use of new codes with 3 cases reported. Rapid sharing of this protocol should enable scientific critique and shared learning.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)
DERR1-10.2196/18606.
Topics: Betacoronavirus; COVID-19; Coronavirus; Coronavirus Infections; Disease Notification; Disease Outbreaks; England; Female; Humans; Male; Medical Records Systems, Computerized; Pandemics; Pneumonia, Viral; Public Health; Public Health Surveillance; SARS-CoV-2; Sentinel Surveillance
PubMed: 32240095
DOI: 10.2196/18606 -
Pediatric Quality & Safety 2019Efficient access to pediatric mental health services is a growing concern as the number of patients increases and outpaces efforts to expand services. This study...
UNLABELLED
Efficient access to pediatric mental health services is a growing concern as the number of patients increases and outpaces efforts to expand services. This study outlines interventions implemented using quality improvement (QI) science and methodology to demonstrate how a clinic embedded in a large children's hospital can improve access to the first appointment for a population seeking pain management services.
METHODS
A process improvement project started with a QI team, whose members designed interventions to change scheduling practices. Initial changes involved decreased time between calls to families, and efforts to streamline notifications among clinicians. Additional interventions included a close examination of waitlist assignment based on appropriateness and assessing patient interest in treatment.
RESULTS
Within 3 months of implementation, a significant decline in wait time occurred for patients seeking services for pain management, from 106 to 48 days. This change remained stable for 6 months. In light of a sharp increase in referrals and wait time during the study period, efforts to engage additional clinicians in managing referrals resulted in wait time to stabilize at an average of 63 days to the first appointment. This change remained for 10 months. Scheduling changes did not negatively affect other providers.
CONCLUSIONS
This study demonstrates the application of QI science to improve patient access to mental health care. Future directions will focus on enhancing the use of the electronic health record, along with previsit family engagement.
PubMed: 32010866
DOI: 10.1097/pq9.0000000000000240 -
Obstetrics and Gynecology Feb 2020To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.
OBJECTIVE
To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.
DATA SOURCES
We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE.
METHODS OF STUDY SELECTION
Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews.
TABULATION, INTEGRATION, RESULTS
Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms.
CONCLUSION
Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.
Topics: Female; Gynecology; Humans; Obstetrics; Pregnancy; Prenatal Care; Quality of Health Care; Randomized Controlled Trials as Topic; Telemedicine
PubMed: 31977782
DOI: 10.1097/AOG.0000000000003646 -
Saudi Journal of Gastroenterology :... 2020To study the impact of computer-aided detection (CADe) system on the detection rate of polyps and adenomas in colonoscopy. (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND/AIM
To study the impact of computer-aided detection (CADe) system on the detection rate of polyps and adenomas in colonoscopy.
MATERIALS AND METHODS
A total of 1026 patients were prospectively randomly scheduled for colonoscopy with (the CADe group, CADe) or without (the control group, CON) the aid of the CADe system, together with visual notification and voice alarm, so as to compare the detection rate of polyp.
RESULTS
Compared with group CON, the detection rate of adenomas increased in group CADe, the average number of adenomas increased, the number of small adenomas increased, the number of proliferative polyps increased, and the differences were statistically significant (P < 0.001), but the comparison for the number of larger adenomas showed no significant difference between the groups (P> 0.05).
CONCLUSIONS
The CADe system is feasible for increasing the detection of polyps and adenomas in colonoscopy.
Topics: Adenoma; Adult; Artificial Intelligence; Colonic Polyps; Colonoscopy; Diagnosis, Computer-Assisted; Female; Humans; Male; Middle Aged; Prospective Studies
PubMed: 31898644
DOI: 10.4103/sjg.SJG_377_19 -
Healthcare Informatics Research Oct 2019Ecological momentary assessment (EMA) methods are known to have validity for capturing momentary changes in variables over time. However, data quality relies on the...
OBJECTIVES
Ecological momentary assessment (EMA) methods are known to have validity for capturing momentary changes in variables over time. However, data quality relies on the completion rates, which are influenced by both participants' characteristics and study designs. This study applied an EMA method using a mobile application to assess momentary moods and stress levels in patients with Moyamoya disease to examine variables associated with EMA completion rates.
METHODS
Adults with Moyamoya disease were recruited from a tertiary hospital in Seoul. Patients with cognitive impairment were excluded. The EMA survey was loaded as a mobile application onto the participants' personal smartphones. Notifications were sent at semi-random intervals four times a day for seven consecutive days. Daily completion rates were calculated as the percentage of completed responses per day; overall completion rates were calculated as the proportion of completed responses per total of the 28 scheduled measures in the study and assessed through a descriptive analysis, -test, ANOVA, and regression analysis, with mixed modeling to identify the point at which the daily completion rate significantly decreased.
RESULTS
A total of 98 participants responded (mean age, 41.00 ± 10.30 years; 69.4% female; 75.5% married). The overall completion rate was 70.66%, with no gender or age differences found. The daily completion rate decreased significantly after day 5 ( = 0.029).
CONCLUSIONS
Obtaining a good completion rate is essential for quality data in EMA methods. Strategic approaches to a study design should be established to encourage participants throughout a study to improve completion rates.
PubMed: 31777677
DOI: 10.4258/hir.2019.25.4.332 -
Archives of Pathology & Laboratory... Jun 2020The phlebotomy clinic, which sees on average 900 patients a day, was faced with issues of congestion and noise due to inefficient workflow and processes. The staff...
CONTEXT.—
The phlebotomy clinic, which sees on average 900 patients a day, was faced with issues of congestion and noise due to inefficient workflow and processes. The staff called each patient name for his or her turn, and patients were unsure of wait time and position in line. These factors led to unfavorable patient satisfaction regarding wait times and courtesy of the staff.
OBJECTIVE.—
To improve patients' experience of wait times and courtesy in the phlebotomy clinic through an electronic sign-in and notification system, redesign of the area, and training of employees.
DESIGN.—
An electronic sign-in and notification system was implemented in the phlebotomy clinic. Several sign-in stations and whiteboard wall monitors were installed in the clinic, along with a redesign of the patient flow. A Press Ganey survey was given to patients after their visit which included 3 questions related to wait times, courtesy, and information about delays, respectively. The mean responses for each month between March 2016 and December 2018 were aggregated and compared for each measure.
RESULTS.—
Overall, wait time saw a 7.7% increase in satisfaction score, and courtesy saw a 1.0% increase in satisfaction score during the course of the several interventions that were introduced. The operational efficiency of the clinic also saw a veritable increase because the percent of patients processed within 20 minutes increased by 27%, from 62% (8212 of 13 245 blood draws) to 89% (11 703 of 13 143 blood draws).
CONCLUSIONS.—
The interventions implemented proved to increase the patient satisfaction in each of the measures. The electronic sign-in and whiteboards provided valuable information to both patients and staff.
Topics: Ambulatory Care Facilities; Computer Systems; Humans; Patient Satisfaction; Phlebotomy; User-Computer Interface; Waiting Lists
PubMed: 31755777
DOI: 10.5858/arpa.2019-0139-OA -
BMJ Open Nov 2019Rotavirus vaccines were introduced into the Australian National Immunisation Program in 2007. Despite this, Northern Territory Indigenous children continue to be...
The ORVAC trial protocol: a phase IV, double-blind, randomised, placebo-controlled clinical trial of a third scheduled dose of Rotarix rotavirus vaccine in Australian Indigenous infants to improve protection against gastroenteritis.
INTRODUCTION
Rotavirus vaccines were introduced into the Australian National Immunisation Program in 2007. Despite this, Northern Territory Indigenous children continue to be hospitalised with rotavirus at a rate more than 20 times higher than non-Indigenous children in other Australian jurisdictions, with evidence of waning protection in the second year of life. We hypothesised that scheduling an additional (third) dose of oral human rotavirus vaccine (Rotarix, GlaxoSmithKline) for children aged 6 to <12 months would improve protection against clinically significant all-cause gastroenteritis.
METHODS AND ANALYSIS
This Bayesian adaptive clinical trial will investigate whether routinely scheduling an additional dose of Rotarix for Australian Indigenous children aged 6 to <12 months old confers significantly better protection against clinically important all-cause gastroenteritis than the current two-dose schedule at 2 and 4 months old. There are two coprimary endpoints: (1) seroconversion from baseline serum anti-rotavirus immunoglobulin A (IgA) titre <20 U/mL prior to an additional dose of Rotarix/placebo to serum anti-rotavirus IgA titre >20 U/mL following the administration of the additional dose of Rotarix/placebo and (2) time from randomisation to medical attendance (up to age 36 months old) for which the primary reason is acute gastroenteritis/diarrhoea. Secondary endpoints include the change in anti-rotavirus IgA log titre, time to hospitalisation for all-cause diarrhoea and for rotavirus-confirmed gastroenteritis/diarrhoea, and rotavirus notification. Analysis will be based on Bayesian inference with adaptive sample size.
ETHICS, REGISTRATION AND DISSEMINATION
Ethics approval has been granted by Central Australian Human Research Ethics Committee (HREC-16-426) and Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-2016-2658). Study investigators will ensure the trial is conducted in accordance with the principles of the Declaration of Helsinki and with the ICH Guidelines for Good Clinical Practice. Individual participant consent will be obtained. Results will be disseminated via peer-reviewed publication. The trial is registered with Clinicaltrials.gov (NCT02941107) and important modifications to this protocol will be updated.
TRIAL REGISTRATION NUMBER
NCT02941107; Pre-results.
Topics: Administration, Oral; Antibodies, Viral; Australia; Bayes Theorem; Clinical Trials, Phase IV as Topic; Diarrhea; Double-Blind Method; Gastroenteritis; Humans; Immunization Programs; Immunoglobulin A; Infant; Native Hawaiian or Other Pacific Islander; Randomized Controlled Trials as Topic; Rotavirus Infections; Rotavirus Vaccines; Vaccines, Attenuated
PubMed: 31727664
DOI: 10.1136/bmjopen-2019-032549 -
Journal For Healthcare Quality :... 2020Patients discharged against medical advice (AMA) have disproportionately high health care costs and increased morbidity, mortality, and hospital readmissions. Although...
BACKGROUND
Patients discharged against medical advice (AMA) have disproportionately high health care costs and increased morbidity, mortality, and hospital readmissions. Although patient risk factors for discharge AMA are known, there are little data regarding physician discharge practices surrounding AMA discharges.
METHODS
We performed a cross-sectional analysis of patients discharged AMA from a large, urban, academic medical center. Our study predictors included patient demographics and admission characteristics: primary service team, time of discharge, documentation of anticipated AMA discharge, and length of stay. The primary outcomes were physician discharge practices including a scheduled follow-up appointment, documentation of informed consent, documentation of a risk/benefit discussion, and notification of the attending physician. Our coprimary outcome was the incidence of 30-day hospital readmission.
RESULTS
Among AMA discharges, 33% had follow-up appointments scheduled upon discharge. There was documentation of a risk/benefit discussion (69%), informed consent (63%), and notification of the attending physician (72%) in most discharges. Physician discharge practices were not associated with 30-day hospital readmission.
CONCLUSIONS
Adherence to discharge best practices in AMA discharges was inconsistent and suboptimal, particularly for scheduling follow-up appointments, but was not associated with hospital readmission. Our results highlight the difficulty in facilitating safe transitions of care for patients discharged AMA.
Topics: Academic Medical Centers; Adult; Aged; Attitude of Health Personnel; Cross-Sectional Studies; Female; Guideline Adherence; Humans; Male; Middle Aged; New York City; Patient Discharge; Patient Readmission; Physicians; Retrospective Studies; Risk Factors; Treatment Refusal
PubMed: 31688424
DOI: 10.1097/JHQ.0000000000000227