The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics

Objectives To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis

OBJECTIVE: To evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care (ie, patient-centredness, effectiveness, efficiency, timeliness, equity and safety). DESIGN: Systematic review and meta-analysis. DATA SOURCES: CINAHL, Cochrane, Embase, HMIC, Medline/PubMed and PsycINFO, from 1997 to 2017. ELIGIBILITY CRITERIA: Randomised trials focusing on adult subjects, testing an intervention consisting of sharing EHRs with patients, and with an outcome in one of the six domains of quality of care. DATA ANALYSIS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Title and abstract screening were performed by two pairs of investigators and assessed using the Cochrane Risk of Bias Tool. For each domain, a narrative synthesis of the results was performed, and significant differences in results between low risk and high/unclear risk of bias studies were tested (t-test, p<0.05). Continuous outcomes evaluated in four studies or more (glycated haemoglobin (HbA1c), systolic blood pressure (SBP) and diastolic blood pressure (DBP)) were pooled as weighted mean difference (WMD) using random effects meta-analysis. Sensitivity analyses were performed for low risk of bias studies, and long-term interventions only (lasting more than 12 months). RESULTS: Twenty studies were included (17 387 participants). The domain most frequently assessed was effectiveness (n=14), and the least were timeliness and equity (n=0). Inconsistent results were found for patient-centredness outcomes (ie, satisfaction, activation, self-efficacy, empowerment or health literacy), with 54.5% of the studies (n=6) demonstrating a beneficial effect. Meta-analyses showed a beneficial effect in effectiveness by reducing absolute values of HbA1c (unit: %; WMD=-0.316; 95% CI -0.540 to -0.093, p=0.005, I 2=0%), which remained significant in the sensitivity analyses for low risk of bias studies (WMD= -0.405; 95% CI -0.711 to -0.099), and long-term interventions only (WMD=-0.272; 95% CI -0.482 to -0.062). A significant reduction of absolute values of SBP (unit: mm Hg) was found but lost in sensitivity analysis for studies with low risk of bias (WMD= -1.375; 95% CI -2.791 to 0.041). No significant effect was found for DBP (unit: mm Hg; WMD=-0.918; 95% CI -2.078 to 0.242, p=0.121, I 2=0%). Concerning efficiency, most studies (80%, n=4) found either a reduction of healthcare usage or no change. A beneficial effect was observed in a range of safety outcomes (ie, general adherence, medication safety), but not in medication adherence. The proportion of studies reporting a beneficial effect did not differ between low risk and high/unclear risk studies, for the domains evaluated. DISCUSSION: Our analysis supports that sharing EHRs with patients is effective in reducing HbA1c levels, a major predictor of mortality in type 2 diabetes (mean decrease of -0.405, unit: %) and could improve patient safety. More studies are necessary to enhance meta-analytical power and assess the impact in other domains of care. PROTOCOL REGISTRATION: http://www.crd.york.ac.uk/PROSPERO (CRD42017070092)

Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study

Background. A range of public inquiries in the English National Health Service have indicated repeating failings in complaint handling, and patients are often left dissatisfied. The complex, bureaucratic nature of complaints systems is often cited as an obstacle to meaningful investigation and learning, but a detailed examination of how such bureaucratic rules, regulations, and infrastructure shape complaint handling, and where change is most needed, remains relatively unexplored. Methods. Through staff interviews and documentary analysis, we examined how complaints are handled, investigated, and monitored within an acute NHS trust rated as well-performing in complaint handling. We sought to examine how national policies structure local practices of complaint handling, how are they understood by those responsible for enacting them within local practice, and if there are any discrepancies between policies-as-intended and their reality in local practice. Results. Findings illustrate four areas of practice where national policies and regulations result in adverse consequences in local practices, and partly function to undermine an improvement-focused approach to complaints. These include muddled routes for raising formal complaints, investigative procedures structured to scrutinize the ‘validity’ of complaints, irreliable data collection systems, and adverse incentives and workarounds resulting from bureaucratic performance targets. Conclusion. This study demonstrates how national policies and regulations for complaint handling can impede, rather than promote, quality improvement in local settings. Accordingly, we propose a number of necessary reforms, including patient involvement in complaints investigations, the establishment of independent investigation bodies, and more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights

Introduction: A global rise in patient complaints has been accompanied by growing research to effectively analyse complaints for safer, more patient-centric care. Most patients and families complain to improve the quality of healthcare, yet progress has been complicated by a system primarily designed for case-by-case complaint handling. Aim: To understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Method: Literature screening and patient codesign shaped the review's aim in the first stage of this three-stage review. Ten sources were searched including academic databases and policy archives. In the second stage, 13 front-line experts were interviewed to develop initial practice-based programme theory. In the third stage, evidence identified in the first stage was appraised based on rigour and relevance, and selected to refine programme theory focusing on what works, why and under what circumstances. Results: A total of 74 academic and 10 policy sources were included. The review identified 12 mechanisms to achieve: patient-centric complaint handling and system-wide quality improvement. The complaint handling pathway includes (1) access of information; (2) collaboration with support and advocacy services; (3) staff attitude and signposting; (4) bespoke responding; and (5) public accountability. The improvement pathway includes (6) a reliable coding taxonomy; (7) standardised training and guidelines; (8) a centralised informatics system; (9) appropriate data sampling; (10) mixed-methods spotlight analysis; (11) board priorities and leadership; and (12) just culture. Discussion: If healthcare settings are better supported to report, analyse and use complaints data in a standardised manner, complaints could impact on care quality in important ways. This review has established a range of evidence-based, short-term recommendations to achieve this

The anatomy of clinical decision-making in multidisciplinary cancer meetings:A cross-sectional observational study of teams in a natural context

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled "Holistic and Clinical inputs" (patient views, psychosocial aspects, patient history, comorbidities, oncologists', nurses', and surgeons' inputs), "Radiology" (radiology results, radiologists' inputs), "Pathology" (pathology results, pathologists' inputs), and "Meeting Management" (meeting chairs' and coordinators' inputs). A negative cross-loading was observed from surgeons' input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P &lt; 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P &lt; 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs' input and their corresponding surgical input into case reviews.</p

Dreading the pain of others? Altruistic responses to others' pain underestimate dread

A dislike of waiting for pain, aptly termed ‘dread’, is so great that people will increase pain to avoid delaying it. However, despite many accounts of altruistic responses to pain in others, no previous studies have tested whether people take delay into account when attempting to ameliorate others' pain. We examined the impact of delay in 2 experiments where participants (total N = 130) specified the intensity and delay of pain either for themselves or another person. Participants were willing to increase the experimental pain of another participant to avoid delaying it, indicative of dread, though did so to a lesser extent than was the case for their own pain. We observed a similar attenuation in dread when participants chose the timing of a hypothetical painful medical treatment for a close friend or relative, but no such attenuation when participants chose for a more distant acquaintance. A model in which altruism is biased to privilege pain intensity over the dread of pain parsimoniously accounts for these findings. We refer to this underestimation of others' dread as a ‘Dread Empathy Gap’

Gaps and Overlaps in Cancer Multidisciplinary Team Communication: Analysis of Speech

Funder: Health Services and Delivery Research Programme; FundRef: https://doi.org/10.13039/501100002001 Guided by the principles of conversation analysis, we examined the communication practices used to negotiate levels of participation in cancer multidisciplinary team meetings and their implications for patient safety. Three cancer teams participated. Thirty-six weekly meetings were video recorded, encompassing 822 case reviews. A cross-section was transcribed using Jefferson notation. We found a low frequency of gaps between speakers (3%), high frequency of overlaps (24%), and no-gaps-no-overlaps (73%), suggesting fast turn transitions. Securing a turn to speak is challenging due to a systematic reduction in turn-taking opportunities. We contribute to group research with the development of a microlevel methodology for studying multidisciplinary teams. </jats:p

Experimental Bariatric Surgery in Rats Generates a Cytotoxic Chemical Environment in the Gut Contents

Bariatric surgery, also known as metabolic surgery, is an effective treatment for morbid obesity, which also offers pronounced metabolic effects including the resolution of type 2 diabetes and a decrease in cardiovascular disease and long-term cancer risk. However, the mechanisms of surgical weight loss and the long-term consequences of bariatric surgery remain unclear. Bariatric surgery has been demonstrated to alter the composition of both the microbiome and the metabolic phenotype. We observed a marked shift toward Gammaproteobacteria, particularly Enterobacter hormaechei, following Roux-en-Y gastric bypass (RYGB) surgery in a rat model compared with sham-operated controls. Fecal water from RYGB surgery rats was highly cytotoxic to rodent cells (mouse lymphoma cell line). In contrast, fecal water from sham-operated animals showed no/very low cytotoxicity. This shift in the gross structure of the microbiome correlated with greatly increased cytotoxicity. Urinary phenylacetylglycine and indoxyl sulfate and fecal gamma-aminobutyric acid, putrescine, tyramine, and uracil were found to be inversely correlated with cell survival rate. This profound co-dependent response of mammalian and microbial metabolism to RYGB surgery and the impact on the cytotoxicity of the gut luminal environment suggests that RYGB exerts local and global metabolic effects which may have an influence on long-term cancer risk and cytotoxic load

Handheld computers and the 21(st )century surgical team: a pilot study

BACKGROUND: The commercial development and expansion of mobile phone networks has led to the creation of devices combining mobile phones and personal digital assistants, which could prove invaluable in a clinical setting. This pilot study aimed to look at how one such device compared with the current pager system in facilitating inter-professional communication in a hospital clinical team. METHODS: The study looked at a heterogeneous team of doctors (n = 9) working in a busy surgical setting at St. Mary's Hospital in London and compared the use of a personal digital assistant with mobile phone and web-browsing facilities to the existing pager system. The primary feature of this device being compared to the conventional pager was its use as a mobile phone, but other features evaluated included the ability to access the internet, and reference data on the device. A crossover study was carried out for 6 weeks in 2004, with the team having access to the personal digital assistant every alternate week. The primary outcome measure for assessing efficiency of communication was the length of time it took for clinicians to respond to a call. We also sought to assess the ease of adoption of new technology by evaluating the perceptions of the team (n = 9) to personal digital assistants, by administering a questionnaire. RESULTS: Doctors equipped with a personal digital assistant rather than a pager, responded more quickly to a call and had a lower of failure to respond rate (RR: 0.44; 95%CI 0.20–0.93). Clinicians also found this technology easy to adopt as seen by a significant reduction in perceptions of nervousness to the technology over the six-week study period (mean (SD) week 1: 4.10 (SD 1.69) vs. mean (SD) week 6: 2.20 (1.99); p = 0.04). CONCLUSION: The results of this pilot study show the possible effects of replacing the current hospital pager with a newer, more technologically advanced device, and suggest that a combined personal digital assistant and mobile phone device may improve communication between doctors. In the light of these encouraging preliminary findings, we propose a large-scale clinical trial of the use of these devices in facilitating inter-professional communication in a hospital setting