Objective To explore evidence on the links between patient experience and clinical safety and effectiveness outcomes. Design Systematic review. Setting A wide range of settings within primary and ...secondary care including hospitals and primary care centres. Participants A wide range of demographic groups and age groups. Primary and secondary outcome measures A broad range of patient safety and clinical effectiveness outcomes including mortality, physical symptoms, length of stay and adherence to treatment. Results This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations. Conclusions The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. It supports the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective or mood-oriented, divorced from the ‘real’ clinical work of measuring safety and effectiveness.
Plan-do-study-act (PDSA) cycles provide a structure for iterative testing of changes to improve quality of systems. The method is widely accepted in healthcare improvement; however there is little ...overarching evaluation of how the method is applied. This paper proposes a theoretical framework for assessing the quality of application of PDSA cycles and explores the consistency with which the method has been applied in peer-reviewed literature against this framework.
NHS Evidence and Cochrane databases were searched by three independent reviewers. Empirical studies were included that reported application of the PDSA method in healthcare. Application of PDSA cycles was assessed against key features of the method, including documentation characteristics, use of iterative cycles, prediction-based testing of change, initial small-scale testing and use of data over time.
73 of 409 individual articles identified met the inclusion criteria. Of the 73 articles, 47 documented PDSA cycles in sufficient detail for full analysis against the whole framework. Many of these studies reported application of the PDSA method that failed to accord with primary features of the method. Less than 20% (14/73) fully documented the application of a sequence of iterative cycles. Furthermore, a lack of adherence to the notion of small-scale change is apparent and only 15% (7/47) reported the use of quantitative data at monthly or more frequent data intervals to inform progression of cycles.
To progress the development of the science of improvement, a greater understanding of the use of improvement methods, including PDSA, is essential to draw reliable conclusions about their effectiveness. This would be supported by the development of systematic and rigorous standards for the application and reporting of PDSAs.
This letter presents a distributive environmental justice analysis of unconventional gas development in the area of Pennsylvania lying over the Marcellus Shale, the largest shale gas formation in ...play in the United States. The extraction of shale gas using unconventional wells, which are hydraulically fractured (fracking), has increased dramatically since 2005. As the number of wells has grown, so have concerns about the potential public health effects on nearby communities. These concerns make shale gas development an environmental justice issue. This letter examines whether the hazards associated with proximity to wells and the economic benefits of shale gas production are fairly distributed. We distinguish two types of distributive environmental justice: traditional and benefit sharing. We ask the traditional question: are there a disproportionate number of minority or low-income residents in areas near to unconventional wells in Pennsylvania? However, we extend this analysis in two ways: we examine income distribution and level of education; and we compare before and after shale gas development. This contributes to discussions of benefit sharing by showing how the income distribution of the population has changed. We use a binary dasymetric technique to remap the data from the 2000 US Census and the 2009-2013 American Communities Survey and combine that data with a buffer containment analysis of unconventional wells to compare the characteristics of the population living nearer to unconventional wells with those further away before and after shale gas development. Our analysis indicates that there is no evidence of traditional distributive environmental injustice: there is not a disproportionate number of minority or low-income residents in areas near to unconventional wells. However, our analysis is consistent with the claim that there is benefit sharing distributive environmental injustice: the income distribution of the population nearer to shale gas wells has not been transformed since shale gas development.
Ensuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving ...inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems.
Using analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and 'simple rules' were identified reflecting the practical strategies that enhanced project progress.
The framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) 'act scientifically and pragmatically' - knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) 'embrace complexity' - evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) 'engage and empower' - evidence translation and system navigation requires commitment and insights from staff and patients with experience of the local system, and changes need to align with their motivations and concerns. Twelve associated 'simple rules' are presented to provide actionable guidance to support evidence translation and improvement in complex systems.
By recognising how agency, interconnectedness and unpredictability influences evidence translation in complex systems, SHIFT-Evidence provides a tool to guide practice and research. The 'simple rules' have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.
Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and ...uncertainty about its effectiveness remains.
We conducted a pragmatic randomized trial with an integrated cost-effectiveness analysis in 56 hospitals in England. Patients were randomly assigned to receive either EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was all-cause mortality at 90 days.
We enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90 days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients (29.2%) in the usual-care group had died (relative risk in the EGDT group, 1.01; 95% confidence interval CI, 0.85 to 1.20; P=0.90), for an absolute risk reduction in the EGDT group of -0.3 percentage points (95% CI, -5.4 to 4.7). Increased treatment intensity in the EGDT group was indicated by increased use of intravenous fluids, vasoactive drugs, and red-cell transfusions and reflected by significantly worse organ-failure scores, more days receiving advanced cardiovascular support, and longer stays in the intensive care unit. There were no significant differences in any other secondary outcomes, including health-related quality of life, or in rates of serious adverse events. On average, EGDT increased costs, and the probability that it was cost-effective was below 20%.
In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment Programme; ProMISe Current Controlled Trials number, ISRCTN36307479.).
The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based ...training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings.
Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison.
The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery.
The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.
Traditional measures of scholarly impact (ie, impact factor, citation rate) do not account for the role of social media in knowledge dissemination. The Altmetric Attention Score (AAS) tracks the ...online sharing activity of articles on platforms such as Twitter and Facebook. All 285 original scientific articles published in Journal of Burn Care & Research and Burns from January to December 2017 were obtained from official journal websites. Article characteristics extracted include AAS; number of Twitter, Facebook, and news outlet mentions; subject of study and study design; number of citations; number of authors and academic institutions; and others. The average AAS for all articles was 6.1 (SD: 48; range: 0 to 611) in which 156 (55%) of those had Twitter mentions. The mean AAS for Journal of Burn Care & Research and Burns were 7.7 (SD: 54; range: 0 to 536) and 5.3 (SD: 45; range: 0 to 611), respectively. There was a weak, positive correlation between AAS and citation count for all articles (ρ = 0.12; P = .049), and this finding was consistent for Journal of Burn Care & Research (ρ = 0.21; P = .039) and Burns (ρ = 0.15; P = .038) individually. The weak correlation between the two metrics supports that AAS and citation count capture the attention of different audiences. In addition, studies discussing skin grafting were associated with higher average AAS (β: 29 95% CI: 4.2 to 54; P = .022). Overall, our findings support using both AAS and traditional bibliometrics to assess article impact.
If approximately 80% of the public in the UK support wind energy, why is only a quarter of contracted wind power capacity actually commissioned? One common answer is that this is an example of the ...'not in my backyard' (Nimby) syndrome: yes, wind power is a good idea as long as it is not in my backyard. However, the Nimby claim that there is an attitude-behaviour gap has been rightly criticised. This article distinguishes between two kinds of gap that might be confused, namely the 'social gap' - between the high public support for wind energy expressed in opinion surveys and the low success rate achieved in planning applications for wind power developments - and the 'individual gap', which exists when an individual person has a positive attitude to wind power in general but actively opposes a particular wind power development. Three different explanations of the social gap are distinguished, only one of which depends upon the individual gap. In the second section of the article the relevance of our three explanations for policy is considered. It is argued that the different explanations suggest different policy responses and that the success of efforts to increase wind energy capacity may depend on developing a better understanding of the relative significance of the three explanations.
Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI). This is a ...retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality. Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration. Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.
•Clinical use criteria may identify appropriate candidates for hydroxocobalamin treatment.•Criteria applied: hypotension, cardiac or respiratory arrest, seizure, or elevated lactate.•Respiratory arrest alone may not be an indicator for hydroxocobalamin treatment.•Time to treatment should be optimized at institutions using hydroxocobalamin.•Emerging associations of hydroxocobalamin with kidney injury require further study.
There is a commonly held assumption that early August is an unsafe period to be admitted to hospital in England, as newly qualified doctors start work in NHS hospitals on the first Wednesday of ...August. We investigate whether in-hospital mortality is higher in the week following the first Wednesday in August than in the previous week.
A retrospective study in England using administrative hospital admissions data. Two retrospective cohorts of all emergency patients admitted on the last Wednesday in July and the first Wednesday in August for 2000 to 2008, each followed up for one week.
The odds of death for patients admitted on the first Wednesday in August was 6% higher (OR 1.06, 95% CI 1.00 to 1.15, p=0.05) after controlling for year, gender, age, socio-economic deprivation and co-morbidity. When subdivided into medical, surgical and neoplasm admissions, medical admissions admitted on the first Wednesday in August had an 8% (OR 1.08, 95% CI 1.01 to 1.16, p=0.03) higher odds of death. In 2007 and 2008, when the system for junior doctors' job applications changed, patients admitted on Wednesday August 1(st) had 8% higher adjusted odds of death than those admitted the previous Wednesday, but this was not statistically significant (OR 1.08, 95% CI 0.95 to 1.23, p=0.24).
We found evidence that patients admitted on the first Wednesday in August have a higher early death rate in English hospitals compared with patients admitted on the previous Wednesday. This was higher for patients admitted with a medical primary diagnosis.
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