Although healthcare quality and patient safety have longstanding international attention, the target of reducing diagnostic errors has only recently gained prominence, even though numerous patients, ...families and professional caregivers have suffered from diagnostic mishaps for a long time. Similarly, patients have always been involved in their own care to some extent, but only recently have patients sought more opportunities for engagement and participation in healthcare improvements. This paper brings these two promising trends together, analysing strategies for patient involvement in reducing diagnostic errors in an individual's own care, in improving the healthcare delivery system's diagnostic safety, and in contributing to research and policy development on diagnosis-related issues.
Summary Background Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been ...compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics. Methods We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat. Findings Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5·9 years (IQR 5·0–10·0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio HR 0·91, 95% CI 0·82–1·02; p=0·12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0·70, 0·56–0·87); however, mortality was similar between groups in patients without diabetes (HR 0·98, 0·86–1·12; p=0·014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1·25 (0·94–1·66) in patients younger than 55 years, 0·90 (0·75–1·09) in patients aged 55–64 years, and 0·82 (0·70–0·97) in patients 65 years and older (p=0·002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics. Interpretation Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups. Funding Agency for Healthcare Research and Quality.
There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions.
To systematically ...review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.
Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016.
Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included.
Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses.
Postoperative pain and consumption of opioids and analgesics.
Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).
In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.
Objectives
In the context of validating a measure of patient report specific to diagnostic accuracy in emergency department or urgent care, this study investigates patients’ and care partners’ ...perceptions of diagnoses as accurate and explores variations in how they reason while they assess accuracy.
Methods
In February 2022, we surveyed a national panel of adults who had an emergency department or urgent care visit in the past month to test a patient-reported measure. As part of the survey validation, we asked for free-text responses about why the respondents indicated their (dis)agreement with 2 statements comprising patient-reported diagnostic accuracy: 1) the explanation they received of the health problem was true and 2) the explanation described what to expect of the health problem. Those paired free-text responses were qualitatively analyzed according to themes created inductively.
Results
A total of 1,116 patients and care partners provided 982 responses coded into 10 themes, which were further grouped into 3 reasoning types. Almost one-third (32%) of respondents used only corroborative reasoning in assessing the accuracy of the health problem explanation (alignment of the explanation with either test results, patients’ subsequent health trajectory, their medical knowledge, symptoms, or another doctor’s opinion), 26% used only perception-based reasoning (perceptions of diagnostic process, uncertainty around the explanation received, or clinical team’s attitudes), and 27% used both types of reasoning. The remaining 15% used general beliefs or nonexplicated logic (used only about accurate diagnoses) and combinations of general reasoning with perception-based and corroborative.
Conclusions
Patients and care partners used multifaceted reasoning in their assessment of diagnostic accuracy.
Implications
As health care shifts toward meaningful diagnostic co-production and shared decision making, in-depth understanding of variations in patient reasoning and mental models informs use in clinical practice.
Highlights
An analysis of 982 responses examined how patients and care partners reason about the accuracy of diagnoses they received in emergency or urgent care.
In reasoning, people used their perception of the process and whether the diagnosis matched other factual information they have.
We introduce “patient reasoning” in the diagnostic measurement context as an area of further research to inform diagnostic shared decision making and co-production of health.
"Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore ...the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains.PURPOSE"Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains.We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples.METHODSWe conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples.We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges.RESULTSWe identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges.The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.CONCLUSIONThe multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.
Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.
To evaluate the benefits and harms of rFVIIa use for 5 off-label, ...in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.
Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.
Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.
Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.
16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference RD, 0.03 95% CI, 0.01 to 0.06) and high-dose rFVIIa use (RD, 0.06 CI, 0.01 to 0.11). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 CI, 0.01 to 0.10) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 CI, -0.02 to -0.08). Mortality was higher in observational studies than in RCTs.
The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.
Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
Abstract Growing consensus within the health care field suggests that context matters and needs more concerted study for helping those who implement and conduct research on quality improvement ...interventions. Health care delivery system decision makers require information about whether an intervention tested in one context will work in another with some differences from the original site. We aimed to define key terms, enumerate candidate domains for the study of context, provide examples from the pediatric quality improvement literature, and identify potential measures for selected contexts. Key sources include the organizational literature, broad evaluation frameworks, and a recent project in the patient safety area on context sensitivity. The article concludes with limitations and next steps for developments in this area.
Care coordination has increasingly been recognized as an important aspect of high-quality health care delivery. Robust measures of coordination processes will be essential tools to evaluate, guide ...and support efforts to understand and improve coordination, yet little agreement exists among stakeholders about how to best measure care coordination. We aimed to review and characterize existing measures of care coordination processes and identify areas of high and low density to guide future measure development.
We conducted a systematic review of measures published in MEDLINE through April 2012 and identified from additional key sources and informants. We characterized included measures with respect to the aspects of coordination measured (domain), measurement perspective (patient/family, health care professional, system representative), applicable settings and patient populations (by age and condition), and data used (survey, chart review, administrative claims).
Among the 96 included measure instruments, most relied on survey methods (88%) and measured aspects of communication (93%), in particular the transfer of information (81%). Few measured changing coordination needs (11%). Nearly half (49%) of instruments mapped to the patient/family perspective; 29% to the system representative and 27% to the health care professionals perspective. Few instruments were applicable to settings other than primary care (58%), inpatient facilities (25%), and outpatient specialty care (22%).
New measures are needed that evaluate changing coordination needs, coordination as perceived by health care professionals, coordination in the home health setting, and for patients at the end of life.
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