Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Front-Line Physicians' Satisfaction with Information Systems in Hospitals

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.Peer reviewe

Development and use of methods to estimate chronic disease prevalence in small populations

Introduction National data on the prevalence of chronic diseases on general practice registers is now available. The aim of this PhD was to develop and validate epidemiological models for the expected prevalence of chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), stroke, hypertension, overall cardiovascular disease (CVD) and high CVD risk at general practice and small area level, and to explore the extent of undiagnosed disease, factors associated with it, and its impact on population health. Methods Multinomial logistic regression models were fitted to pooled Health Survey for England data to derive odds ratios for disease risk factors. These were applied to general practice and small area level population data, split by age, sex, ethnicity, deprivation, rurality and smoking status, to estimate expected disease prevalence at these levels. Validation was carried out using external data, including population-based epidemiological research and case-finding initiatives. Practice-level undiagnosed disease prevalence i.e. expected minus registered disease prevalence, and hospital admission rates for these conditions, were evaluated as outcome indicators of the quality and supply of primary health care services, using ordinary least squares (OLS) regression, geographically-weighted regression (GWR), and other spatial analytic methods. Results Risk factors, odds of disease and expected prevalence were consistent with external data sources. Spatial analysis showed strong evidence of spatial non-stationarity of undiagnosed disease prevalence, with high levels of undiagnosed disease in London and other conurbations, and associations with low supply of primary health care services. Higher hospital admission rates were associated with population deprivation, poorer quality and supply of primary health care services and poorer access to them, and for COPD, with higher levels of undiagnosed disease. Conclusion The epidemiologic prevalence models have been implemented in national data sources such as NHS Comparators, the Association of Public Health Observatories website, and a number of national reports. Early experience suggests that they are useful for guiding case-finding at practice level and improving and regulating the quality of primary health care. Comparisons with external data, in particular prevalence of disease detected by general practices, suggest that model predictions are valid. Practice-level spatial analyses of undiagnosed disease prevalence and hospital admission rates failed to demonstrate superiority of GWR over OLS methods. Disease modellers should be encouraged to collaborate more effectively, and to validate and compare modelling methods using an agreed framework. National leadership is needed to further develop and implement disease models. It is likely that prevalence models will prove to be most useful for identifying undiagnosed diseases with a slow and insidious onset, such as COPD, diabetes and hypertension

Too much, too late? Drug prescribing for older people near the end of life

Background. The burden of drugs prescribed to older persons at the end of life has recently drawn increasing scrutiny. Growing evidence suggests that patients with lifelimiting diseases and poor prognosis are prescribed drugs that may do more harm than good or treatments that have little chance of achieving their benefit during the patients’ short remaining lifespan. The overall aim of this thesis was to evaluate the quality of drug prescribing in older adults near the end of life. Except for Study III, all studies are based on routinely collected administrative and healthcare data with national coverage in Sweden. Study I. We found that, throughout their last year of life, older adults (n=511 843) used an increasing number of prescription drugs. The proportion of older adults exposed to ≥10 drugs increased from 30.3% one year before death to 47.2% during the last month of life. Polypharmacy was fuelled not only by the initiation of symptomatic drugs to ensure comfort but also by the frequent continuation of long-term preventive treatments and medicines prescribed for the management of chronic diseases that may otherwise lead to short-term complications. Study II. Older adults who died with solid cancer (n=151 201) often continued to receive preventive drugs until the very end of life. Over the course of the last 12 months of life, there was little change in the receipt of antihypertensive agents (absolute change -0.3%, 95% CI -0.6 to 0.0), vitamin K antagonists (+1.5%, 95% CI 1.1 to 1.9), antiplatelet agents (- 1.5%, 95% CI -1.8 to -1.2), statins (-4.7%, 95% CI -5.0 to -4.4), bisphosphonates (-0.3%, 95% CI -0.4 to -0.2), or vitamins (+1.0, 95% CI 0.8 to 1.2). During the last year before death, median drug costs amounted to $1482 (interquartile range [IQR],$700-$2896]) per person, including$213 (IQR, $77-$490) for preventive therapies. We found important differences between cancer types with regard to the use and costs of preventive drugs, which can be explained only in part by age and chronic multimorbidity. Study III. Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries participated in a Delphi consensus panel to identify drugs deemed “often adequate”, “questionable”, or “often inadequate” for use in older patients aged ≥75 years with an estimated life expectancy of 3 months or less. Drug classes rated as “often adequate” are predominantly indicated for symptom management and comfort care. Among the drugs and drug classes considered “questionable” for use near the end of life, a vast majority are prescribed for the longterm management of non-life-threatening chronic conditions or for the secondary prevention of chronic diseases that may otherwise quickly lead to serious clinical complications. Finally, drugs defined as “often inadequate” encompasses mostly drugs and supplements prescribed for primary prevention or as part of a long-term strategy of secondary or tertiary prevention. Study IV. By applying the list mentioned above to a cohort of 58 415 older persons who died from conditions potentially amenable to palliative care in 2015, we found that 32% continued and 14% initiated at least one drug considered “often inadequate” during their last three months of life. Excluding older adults who died from acute and potentially unpredictable fatal events had little if any influence on the results. Conclusion. Older people are prescribed an increasing number of drugs as they approach the end of life. A sizeable fraction of these drugs is not directed towards the relief of distressing symptoms but instead aims at prolonging survival and managing chronic comorbidities. We have developed a consensus-based set of explicit criteria for delineating drugs that are “often adequate” from those deemed “questionable” or “often inadequate” for use in older persons at the end of life. In the absence of high-quality data from randomised clinical trials and sufficiently robust observational studies, these criteria can be used not only to provide guidance at the bedside but also to generate comparable epidemiological evidence across patient groups, care settings, regions, and countries

Managing healthcare transformation towards P5 medicine (Published in Frontiers in Medicine)

Health and social care systems around the world are facing radical organizational, methodological and technological paradigm changes to meet the requirements for improving quality and safety of care as well as efficiency and efficacy of care processes. In this they’re trying to manage the challenges of ongoing demographic changes towards aging, multi-diseased societies, development of human resources, a health and social services consumerism, medical and biomedical progress, and exploding costs for health-related R&D as well as health services delivery. Furthermore, they intend to achieve sustainability of global health systems by transforming them towards intelligent, adaptive and proactive systems focusing on health and wellness with optimized quality and safety outcomes. The outcome is a transformed health and wellness ecosystem combining the approaches of translational medicine, 5P medicine (personalized, preventive, predictive, participative precision medicine) and digital health towards ubiquitous personalized health services realized independent of time and location. It considers individual health status, conditions, genetic and genomic dispositions in personal social, occupational, environmental and behavioural context, thus turning health and social care from reactive to proactive. This requires the advancement communication and cooperation among the business actors from different domains (disciplines) with different methodologies, terminologies/ontologies, education, skills and experiences from data level (data sharing) to concept/knowledge level (knowledge sharing). The challenge here is the understanding and the formal as well as consistent representation of the world of sciences and practices, i.e. of multidisciplinary and dynamic systems in variable context, for enabling mapping between the different disciplines, methodologies, perspectives, intentions, languages, etc. Based on a framework for dynamically, use-case-specifically and context aware representing multi-domain ecosystems including their development process, systems, models and artefacts can be consistently represented, harmonized and integrated. The response to that problem is the formal representation of health and social care ecosystems through an system-oriented, architecture-centric, ontology-based and policy-driven model and framework, addressing all domains and development process views contributing to the system and context in question. Accordingly, this Research Topic would like to address this change towards 5P medicine. Specifically, areas of interest include, but are not limited: • A multidisciplinary approach to the transformation of health and social systems • Success factors for sustainable P5 ecosystems • AI and robotics in transformed health ecosystems • Transformed health ecosystems challenges for security, privacy and trust • Modelling digital health systems • Ethical challenges of personalized digital health • Knowledge representation and management of transformed health ecosystems Table of Contents: 04 Editorial: Managing healthcare transformation towards P5 medicine Bernd Blobel and Dipak Kalra 06 Transformation of Health and Social Care Systems—An Interdisciplinary Approach Toward a Foundational Architecture Bernd Blobel, Frank Oemig, Pekka Ruotsalainen and Diego M. Lopez 26 Transformed Health Ecosystems—Challenges for Security, Privacy, and Trust Pekka Ruotsalainen and Bernd Blobel 36 Success Factors for Scaling Up the Adoption of Digital Therapeutics Towards the Realization of P5 Medicine Alexandra Prodan, Lucas Deimel, Johannes Ahlqvist, Strahil Birov, Rainer Thiel, Meeri Toivanen, Zoi Kolitsi and Dipak Kalra 49 EU-Funded Telemedicine Projects – Assessment of, and Lessons Learned From, in the Light of the SARS-CoV-2 Pandemic Laura Paleari, Virginia Malini, Gabriella Paoli, Stefano Scillieri, Claudia Bighin, Bernd Blobel and Mauro Giacomini 60 A Review of Artificial Intelligence and Robotics in Transformed Health Ecosystems Kerstin Denecke and Claude R. Baudoin 73 Modeling digital health systems to foster interoperability Frank Oemig and Bernd Blobel 89 Challenges and solutions for transforming health ecosystems in low- and middle-income countries through artificial intelligence Diego M. López, Carolina Rico-Olarte, Bernd Blobel and Carol Hullin 111 Linguistic and ontological challenges of multiple domains contributing to transformed health ecosystems Markus Kreuzthaler, Mathias Brochhausen, Cilia Zayas, Bernd Blobel and Stefan Schulz 126 The ethical challenges of personalized digital health Els Maeckelberghe, Kinga Zdunek, Sara Marceglia, Bobbie Farsides and Michael Rigb

Acute oncology service = Acute palliative service? Early palliative care assessment results from a pilot project in South Wales

Background: The National Chemotherapy Advisory Group report 2009 recommends an acute oncology service (AOS) in every UK hospital with an emergency department. Patients discussed in Acute Oncology Service settings are often very unwell, at the start of their cancer journey, and may have multiple challenging symptoms. Aims: Will earlier palliative care intervention in AOS meetings result in an increase in palliative care involvement? As a comparative baseline we used data from Royal Sussex County Hospital, where an acute admission AOS data collection was carried out: in 53 patients with cancer, palliative care were involved in four cases (7.5%). Methods: As part of this project, our palliative care team started to attend AOS meetings at Velindre Cancer Hospital on a daily basis. After initial embedding, a strategy to collect data was designed and an audit cycle was carried out. Results: Through integration of the palliative care team into Acute Oncology Service meetings, key areas of advance care planning were addressed and discussions with patients were planned. Of 100 patients assessed during the AOS reporting period, 80% were not known to a palliative care team/provider. Of all patients analysed, 28% required no palliative input, 29% were signposted to another palliative care team, 27% received same day face to face palliative care review and 16% required verbal advice only to a generalist team member. Advance care planning discussions in the sample of patients who needed some palliative care input were held within a two week time frame in 61% of cases. Discussion: Significant findings included large population (80%) unknown to palliative care services at AOS entry point, but with high level of unmet need. 72% had palliative care needs. 29% had received their cancer diagnosis within the last month. Conclusion: AOS meetings appear to be a valid entry point for referral to palliative services, despite many AOS patients being at the start of their cancer diagnosis