Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient-physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts - diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories. © 2010 Elsevier Inc.

Provision of pharmaceutical care by community pharmacists:a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

What are tests for? The implications of stuttering steps along the patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense. © 2014 Elsevier Ltd.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.

Improving the description of the retinal vasculature and patient history taking for monitoring systemic hypertension

Systemic hypertension is an important public health concern. If optometrists are to perform a more active role in the detection and monitoring of high blood pressure (BP), there is a need to improve the consistency of describing the retinal vasculature and to assess patient's ability to correctly report the diagnosis of hypertension, its control and medication. One hundred and one patients aged >40 years were dilated and had fundus photography performed. BP was measured and a self-reported history of general health and current medication was compared with the records of their general practitioner (GP). The status of the retinal vasculature was quantified using a numeric scale by five clinicians and this was compared to the same evaluation performed with the aid of a basic pictorial grading scale. Image analysis was used to objectively measure the artery-to-vein (A/V) ratio and arterial reflex. Arteriolar tortuosity and calibre changes were found to be the most sensitive retinal signs of high BP. Using the grading scale to describe the retinal vasculature significantly improved inter- and intra-observer repeatability. Almost half the patients examined were on medication for high BP or cardiovascular disease. Patients' ability to give their complete medical history was poor, as was their ability to recall what medication they had been prescribed. GPs indicated it was useful to receive details of their patient's BP when it was >140/90 mmHg. The use of improved description of the retinal vasculature and stronger links between optometrists and GPs may enhance future patient care. © 2001 The College of Optometrists. Published by Elsevier Science Ltd. All rights reserved.

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

Giving whistleblowers greater protection:improving quality of care

This year, an independent review of whisleblowing in the NHS made recommendations as to how whistleblowers could be given greater protection. The review, chaired by Sir Robert Francis, intended to improve the quality of patient care and safety in the health service. But with many practitioners remaining unregulated, there are unanswered questions as to how reports of mistakes can be properly investigated and the necessary action taken against incompetent or negligent practitioners. Amanda Casey, Chair of the Registration Council for Clinical Physiologists, makes the case for regulation of professionals whose work poses potential risks to patients and can place healthcare managers in an invidious position.

Diabetes management in care homes:steps in the right direction?

Aims: Previous research has identified several inadequacies in management of diabetes within care homes many of which were highlighted in Diabetes UK’s report Diabetes in care homes:awareness, screening, training. The aim of this study was to see if this was still the case and to identify specific areas for improvement. Methods: Thirty care homes in Birmingham were invited to participate in the study. Data were collected using a standard questionnaire based on the Diabetes UK national survey of care homes comprising questions relating to screening, self-management, care planning and local authority support. All returned responses were analysed. Results: Responses were received from 20 of the 30 care homes approached. The mean percentage of residents with diabetes in the care homes sampled was 13.7%. None of the homes screened for diabetes on admission and only 5% screened residents annually.80% of homes acknowledged providing diabetes-specific training to staff. Residents in 95% of homes had a medical review in the last 12 months: 70% with a GP, 20% with a diabetes specialist nurse/nurse. 65% of homes provided support for self-management.45% of care homes did not have individualised care plans for residents with diabetes. 35% of managers reported poor support and guidance from their local authority.Conclusions: Improvements were noted in the care provided to individuals with diabetes living in care homes in Birmingham. Aspects relating to screening, individualised care plans and support to care home staff still need attention.

Formal professional relationships between general practitioners and specialists: possible associations with patient health and pharmacy costs

This article investigates whether the strength of formal professional relationships between general practitioners (GPs) and specialists (SPs) affects either the health status of patients or their pharmacy costs. To this end, it measures the strength of formal professional relationships between GPs and SPs through the number of shared patients and proxies the patient health status by the number of comorbidities diagnosed and treated. In strong GP–SP relationships, the patient health status is expected to be high, due to efficient care coordination, and the pharmacy costs low, due to effective use of resources. To test these hypotheses and compare the characteristics of the strongest GP–SP connections with those of the weakest, this article concentrates on diabetes—a chronic condition where patient care coordination is likely important. Diabetes generates the largest shared patient cohort in Hungary, with the highest traffic of specialist medication prescriptions. This article finds that stronger ties result in lower pharmacy costs, but not in higher patient health statuses. Key points for decision makers • The number of shared patients may be used to measure the strength of formal professional relationships between general practitioners and specialists. • A large number of shared patients indicates a strong, collaborative tie between general practitioners and specialists, whereas a low number indicates a weak, fragmented tie. • Tie strength does not affect patient health—strong, collaborative ties between general practitioners and specialists do not involve better patient health than weak, fragmented ties. • Tie strength does affect pharmacy costs—strong, collaborative ties between general practitioners and specialists involve significantly lower pharmacy costs than weak, fragmented ties. • Pharmacy costs may be reduced by lowering patient care fragmentation through channelling a general practitioner’s patients to a small number of specialists and increasing collaboration between general practitioner and specialists. • Limited patient choice is financially more beneficial than complete freedom of choice, and no more detrimental to patient health.

A gyógyszerkiadás és a betegek egészségi állapota a háziorvosi és szakorvosi kapcsolatok függvényében = Formal professional relations between general practitioners and specialists. Possible links with patient health and pharmacy cost

Arra a kérdésre keressük a választ, hogy a szoros háziorvosi-szakorvosi szakmai kapcsolatoknak van-e hatásuk a betegek gyógyszerkiadására, illetve egészségi állapotára. Az orvosok közötti szakmai kapcsolatok szorosságát a közösen gondozott betegek száma alapján határoztuk meg, míg a betegek egészségügyi állapotát a diagnosztizált és kezelt társbetegségek számával mértük. Hipotézisünk egyrészt az volt, hogy a hatékonyabb koordinációnak köszönhetően a szoros kapcsolatban kezelt betegek jobb egészségi állapotúak, másrészt kezelésük az erőforrások hatékonyabb felhasználása miatt kisebb gyógyszerköltséggel jár. E két hipotézist a cukorbetegekre teszteltük. Azért esett erre a krónikus betegségre a választásunk, mert itt a háziorvosok és a szakorvosok együttműködése elsődleges fontosságú. Magyarországon a cukorbetegek esetében a legnagyobb a közösen kezelt betegek populációja, valamint itt a legmagasabb a szakorvosi javaslatra felírt háziorvosi receptek száma. Azt az eredményt kaptuk, hogy a szoros kapcsolatban kezelt betegek nem rendelkeznek sem jobb, sem rosszabb egészségi állapottal, miközben a kapcsolódó gyógyszerkiadásuk szignifikánsan alacsonyabb. ____ The article considers whether strong formal professional relations between GPs and specialists in shared care affect either the health of patients or the pharmacy costs they incur. The strength of such relations is measured by the number of shared patients; patient health is proxied by number of co-morbidities diagnosed and treated. The first hypothesis is that patients treated amid strong GP-specialist relations have better health status than those treated amid weak ones, due to enhanced efficiency of care coordination. The second is that patients treated in such strong relations incur lower pharmacy costs high numbers of shared patients are assumed to promote appropriate, effective use of resources. The article tests these hypotheses and compares the outcomes of the strongest and weakest GP-specialist relations through the example of diabetes, a chronic condition where patient-care coordination is important. Diabetes generates the largest shared patient cohort in Hungary, with the highest number of specialist medication prescriptions. This article finds that stronger ties result in significantly lower pharmacy costs, but not a higher patient health status.

Subject -centered and problem -based approaches to teaching clinical competence in physical therapy

Physical therapy students must apply the relevant information learned in their academic and clinical experience to problem solve in treating patients. I compared the clinical cognitive competence in patient care of second-year masters students enrolled in two different curricular programs: modified problem-based (M P-B; n = 27) and subject-centered (S-C; n = 41). Main features of S-C learning include lecture and demonstration as the major teaching strategies and no exposure to patients or problem solving learning until the sciences (knowledge) have been taught. Comparatively, main features of M P-B learning include case study in small student groups as the main teaching strategy, early and frequent exposure to patients, and knowledge and problem solving skills learned together for each specific case. Basic and clinical orthopedic knowledge was measured with a written test with open-ended items. Problem solving skills were measured with a written case study patient problem test yielding three subscores: assessment, problem identification, and treatment planning. ^ Results indicated that among the demographic and educational characteristics analyzed, there was a significant difference between groups on ethnicity, bachelor degree type, admission GPA, and current GPA, but there was no significant difference on gender, age, possession of a physical therapy assistant license, and GRE score. In addition, the M P-B group achieved a significantly higher adjusted mean score on the orthopedic knowledge test after controlling for GRE scores. The S-C group achieved a significantly higher adjusted mean total score and treatment management subscore on the case study test after controlling for orthopedic knowledge test scores. These findings did not support their respective research hypotheses. There was no significant difference between groups on the assessment and problem identification subscores of the case study test. The integrated M P-B approach promoted superior retention of basic and clinical science knowledge. The results on problem solving skills were mixed. The S-C approach facilitated superior treatment planning skills, but equivalent patient assessment and problem identification skills by emphasizing all equally and exposing the students to more patients with a wider variety of orthopedic physical therapy needs than in the M P-B approach. ^

Cost-effectiveness of natriuretic peptide-based screening and collaborative care: a report from the STOP-HF (St Vincent's Screening TO Prevent Heart Failure) study

AIMS: Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention.

METHODS AND RESULTS: This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels >50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38-0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49-0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range -€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range -€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000.

CONCLUSION: Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective.

TRIAL REGISTRATION: NCT00921960.

Natriuretic peptide-based screening and collaborative care for heart failure:the STOP-HF randomized trial

IMPORTANCE: Prevention strategies for heart failure are needed.

OBJECTIVE: To determine the efficacy of a screening program using brain-type natriuretic peptide (BNP) and collaborative care in an at-risk population in reducing newly diagnosed heart failure and prevalence of significant left ventricular (LV) systolic and/or diastolic dysfunction.

DESIGN, SETTING, AND PARTICIPANTS: The St Vincent's Screening to Prevent Heart Failure Study, a parallel-group randomized trial involving 1374 participants with cardiovascular risk factors (mean age, 64.8 [SD, 10.2] years) recruited from 39 primary care practices in Ireland between January 2005 and December 2009 and followed up until December 2011 (mean follow-up, 4.2 [SD, 1.2] years).

INTERVENTION: Patients were randomly assigned to receive usual primary care (control condition; n=677) or screening with BNP testing (n=697). Intervention-group participants with BNP levels of 50 pg/mL or higher underwent echocardiography and collaborative care between their primary care physician and specialist cardiovascular service.

MAIN OUTCOMES AND MEASURES: The primary end point was prevalence of asymptomatic LV dysfunction with or without newly diagnosed heart failure. Secondary end points included emergency hospitalization for arrhythmia, transient ischemic attack, stroke, myocardial infarction, peripheral or pulmonary thrombosis/embolus, or heart failure.

RESULTS: A total of 263 patients (41.6%) in the intervention group had at least 1 BNP reading of 50 pg/mL or higher. The intervention group underwent more cardiovascular investigations (control, 496 per 1000 patient-years vs intervention, 850 per 1000 patient-years; incidence rate ratio, 1.71; 95% CI, 1.61-1.83; P<.001) and received more renin-angiotensin-aldosterone system-based therapy at follow-up (control, 49.6%; intervention, 56.5%; P=.01). The primary end point of LV dysfunction with or without heart failure was met in 59 (8.7%) of 677 in the control group and 37 (5.3%) of 697 in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37-0.82; P = .003). Asymptomatic LV dysfunction was found in 45 (6.6%) of 677 control-group patients and 30 (4.3%) of 697 intervention-group patients (OR, 0.57; 95% CI, 0.37-0.88; P = .01). Heart failure occurred in 14 (2.1%) of 677 control-group patients and 7 (1.0%) of 697 intervention-group patients (OR, 0.48; 95% CI, 0.20-1.20; P = .12). The incidence rates of emergency hospitalization for major cardiovascular events were 40.4 per 1000 patient-years in the control group vs 22.3 per 1000 patient-years in the intervention group (incidence rate ratio, 0.60; 95% CI, 0.45-0.81; P = .002).

CONCLUSION AND RELEVANCE: Among patients at risk of heart failure, BNP-based screening and collaborative care reduced the combined rates of LV systolic dysfunction, diastolic dysfunction, and heart failure.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00921960.

Predictors of caregiver burden across the home-based palliative care trajectory in Ontario, Canada

Family caregivers of patients enrolled in home-based palliative care programmes provide unpaid care and assistance with daily activities to terminally ill family members. Caregivers often experience caregiver burden, which is an important predictor of anxiety and depression that can extend into bereavement. We conducted a longitudinal, prospective cohort study to comprehensively assess modifiable and non-modifiable patient and caregiver factors that account for caregiver burden over the palliative care trajectory. Caregivers (n = 327) of patients with malignant neoplasm were recruited from two dedicated home-based palliative care programmes in Southern Ontario, Canada from 1 July 2010 to 31 August 2012. Data were obtained from bi-weekly telephone interviews with caregivers from study admission until death, and from palliative care programme and home-care agency databases. Information collected comprised patient and caregiver demographics, utilisation of privately and publicly financed resources, patient clinical status and caregiver burden. The average age of the caregivers was 59.0 years (SD: 13.2), and almost 70% were female. Caregiver burden increased over time in a non-linear fashion from study admission to patient death. Increased monthly unpaid care-giving time costs, monthly public personal support worker costs, emergency department visits and low patient functional status were associated with higher caregiver burden. Greater use of hospice care was associated with lower burden. Female caregivers tended to report more burden compared to men as death approached, and burden was higher when patients were male. Low patient functional status was the strongest predictor of burden. Understanding the influence of modifiable and non-modifiable factors on the experience of burden over the palliative trajectory is essential for the development and targeting of programmes and policies to support family caregivers and reduce burden. Supporting caregivers can have benefits such as improved caregiver health outcomes, and enhancing their ability to meet care-giving demands, thereby potentially allowing for longer patient care in the home setting.

Providing a ‘whole-of-family’ approach to care: family-focused practices in mental health services

Introduction: Family members including children are all impacted by a family member’s mental illness. Although mental health services are increasingly encouraged to engage in family-focused practice, this is not a well-understood concept or practice in mental health care. Methods: An integrative review using systematic methods was conducted with international literature, with the aim of identifying concepts and practices of family-focused practice in child and youth and adult mental health services. Results: Findings from 40 peer-reviewed literature identified a range of understandings and applications of family-focused practice, including who comprises the ‘family’, whether the focus is family of origin or family of procreation or choice, and whether the context of practice is child and youth or adult. ‘Family’ as defined by its members forms the foundation for practice that aims to provide a whole-of-family approach to care. Six core practices comprise a family focus to care: assessment; psychoeducation; family care planning and goal-setting; liaison between families and services; instrumental, emotional and social support; and a coordinated system of care between families and services. Conclusion: By incorporating key principles and the core family-focused practices into their care delivery, clinicians can facilitate a whole-of-family approach to care and strengthen family members’ wellbeing and resilience, and their individual and collective health outcomes.