Approximation of fixed points of nonexpansive mappings and quasinonexpansive mappings in a Hilbert space

In this paper, we give a simple proof and some generalizations of results in Falset, Llorens-Fuster, Marino, and Rugiano (2016).Comment: 8 page

The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Hospital treatment of chronic obstructive pulmonary disease (COPD) frequently does not follow published evidences. This lack of adherence can contribute to the high morbidity, mortality and readmissions rates. The European Quality of Care Pathway (EQCP) study on acute exacerbations of COPD (NTC00962468) is undertaken to determine how care pathways (CP) as complex intervention for hospital treatment of COPD affects care variability, adherence to evidence based key interventions and clinical outcomes.</p> <p>Methods</p> <p>An international cluster Randomized Controlled Trial (cRCT) will be performed in Belgium, Italy, Ireland and Portugal. Based on the power analysis, a sample of 40 hospital teams and 398 patients will be included in the study. In the control arm of the study, usual care will be provided. The experimental teams will implement a CP as complex intervention which will include three active components: a formative evaluation of the quality and organization of care, a set of evidence based key interventions, and support on the development and implementation of the CP. The main outcome will be six-month readmission rate. As a secondary endpoint a set of clinical outcome and performance indicators (including care process evaluation and team functioning indicators) will be measured in both groups.</p> <p>Discussion</p> <p>The EQCP study is the first international cRCT on care pathways. The design of the EQCP project is both a research study and a quality improvement project and will include a realistic evaluation framework including process analysis to further understand why and when CP can really work.</p> <p>Trial Registration number</p> <p><b>NCT00962468</b></p

The Care Process Self-Evaluation Tool: a valid and reliable instrument for measuring care process organization of health care teams

Background: Patient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table. Methods: The psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated. Results: CFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated. Conclusions: The CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams

Management challenges in care pathways: conclusions of a qualitative study within 57 health care organizations

The objectives of this paper are to study the aim of care pathways, who has decisional power concerning pathways, the actual follow-up, challenges in cross-boundary development and the support provided by information and communication technology (ICT). The study design included a qualitative study using semi-structured interviews with 88 care pathway coordinators and members of the executive board in 57 health-care organizations enrolled in the Belgian– Dutch Clinical Pathway Network. The study revealed that the most important objectives for introducing care pathways are more standardization and quality of care. In 76% of the interviewed organizations, pathways are discussed in a committee. There is a lack of continuous follow-up when care pathways are implemented. Pathways can facilitate cross-boundary care, but are a challenge because of the fragmentation within primary care. There is a need for more ICT support for care pathways. In conclusion, the executive board members and pathway coordinators state that clearly formulated objectives, a special steering committee, a clear follow-up to keep pathways alive, cross-boundary collaboration and ICT support are among the main challenges for the management of an organization.status: publishe

Impact of a care pathway for exacerbation of chronic obstructive pulmonary disease: a cluster randomized controlled trial

Management of patients hospitalised with COPD exacerbations involves a wide range of diagnostic, pharmacological, and non-pharmacological processes. In addition, coordination of the multidisciplinary care process is complex. Implementation of care pathways has become very popular for improving care processes and optimising outcomes. However, until now it remains unclear whether care pathways actually work and which active components are responsible for their effect. In this PhD dissertation research, we examined the impact of a care pathway for COPD exacerbations on care processes and clinical outcomes by developing new methodology and analysing interim data of an international cluster Randomized Controlled Trial (cRCT).Firstly, a systematic review was conducted to explore the level of adherence of actual care to internationally acknowledged COPD guidelines. The findings showed that quality of care for these patients was very suboptimal, especially for non-pharmacological management. However, measured indicators were very discordant among previously published studies, and compliance to non-pharmacological processes was scarcely assessed, implying that further research on process adherence is needed.Secondly, a systematic literature review sought to identify all studies that had examined the development, implementation, and characteristics of existing COPD care pathways, and that had evaluated their impact on care processes, clinical outcomes, and team functioning. Only four studies with a quasi-experimental design were found. The studies described positive effects on diagnostic and non-pharmacological processes; though because of limited reporting of statistics, divergent measurements, and evaluation of a care pathway by means of a historical control group, the internal validity of the results was questionable. Therefore, confident conclusions on the impact of COPD care pathways based on these studies could not be drawn.Thirdly, in order to rate content validity of process and outcome indicators, an international Delphi study was conducted with a Delphi panel composed of 35 panelists from 15 countries. Among the panellists were 19 medical doctors, 8 nurses, and 8 physiotherapists. Consensus by at least 75% of panelists that an indicator is relevant for follow-up was reached for 26 of 72 evaluated process indicators (36.1%) and for 10 of 21 outcome indicators (47.6%).Fourthly, a new eight-step method was developed for designing the clinical content of an evidence-based care pathway. Applying this method resulted in a set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators, which were piloted and approved by nine multidisciplinary teams. These findings indicate that the sets of key interventions and indicators are appropriate for the standardisation and follow-up of in-hospital management of COPD exacerbations. Furthermore, the eight-step method can also help teams in shaping the clinical content of their future care pathways for other patient populations.Fifthly,the European Quality of Care Pathways study was launched in four countries (Belgium, Ireland, Italy, and Portugal). This is a cRCT aiming to study the impact of care pathways for COPD exacerbations on care processes and clinical outcomes. A second aim was to study why and under what circumstances care pathways work, but this research question was not included in this PhD dissertation. In total, 65 hospitals were randomised, with 33 hospitals assigned to the experimental group in which a care pathway is implemented, and 32 hospitals assigned to a control group in which usual care is provided. The experiment is a complex intervention comprising three active components: (i) feedback on actual performance based on a clinical audit before care pathway implementation, (ii) integration of a set of evidence-based key interventions, and (iii) training on care pathway development and implementation based on the PDSA cycle. The measurements, including follow-up of 24 process and 15 outcome indicators, were conducted in both groups and results were compared to see if care pathway implementation leads to better results.The EQCP study in Belgium is one year ahead of the other countries (Ireland, Italy, and Portugal) and is also considered to be a pilot test. Because of timing and feasibility of the PhD, only the results of the Belgian EQCP study are included in the results section of this dissertation. Final results based on the data of all four countries are expected to be analysed in autumn 2013, and will be disseminated by the EQCP study group via publications and conference proceedings in 2013 and 2014. The preliminary results of the Belgian EQCP study strongly suggest that care pathways lead to improved care processes, as an increase in performance levels of 10 to 50% were found. These results also show that care pathways have the potential to improve clinical outcomes. However, the Belgian sample size is small, and consequently statistical power is limited. Not surprisingly, then, only scarce significant results were found, leading to provisional conclusions at this time. Significant conclusions on the effectiveness of care pathways can only be drawn based on the results of the total sample of the four involved countries. However, according to clinical practice guidelines, the criterion is that all process indicators must meet 100% performance, regardless of patient characteristics. Consequently, the results on the process indicators, in this case better performance levels of up to 50% in the care pathway group, may not be may not be considered to be coincidental results arising from chance variation in small samples. Finally, a process evaluation on the implementation level of the set of evidence-based key interventions was conducted in the seven experimental hospitals in the Belgium EQCP study. Although study coordinators and team members reported that the care activities were highly implemented, these implementation levels did not correspond with the results on process indicators after implementation, as a considerable number of indicators were still suboptimally performed. These findings suggest that the teams may have overestimated their own implementation level, and consequently additional measures like interviews and direct observation may be needed to provide more objective information on the implementation process. However, this implementation analyses give teams insight into discrepancies between highly reported implementation levels and subtoptimal performance of the implemented processes. Consequently, these analyses may sensitise the teams that further actions for improvement are necessary. Secondly, these analyses will provide important insights for other teams planning to implement the care pathway intervention, especially with regard to possible improvement actions and potential barriers for implementation. The EQCP study will be continued in Ireland, Italy, and Portugal, and the same protocol will be used, including the same intervention and the same measurements. Preliminary results from these countries show that adherence to guidelines is comparable with the Belgian data, implying that considerable room for improvement exists also in these countries. Although performance levels improved in the care pathway group, half of the indicators remained suboptimally performed, indicating that the complex intervention was adopted but not integrated into daily practice. As a consequence, a Belgian clinical working group on in-hospital management of COPD exacerbations will be initiated. The aims of this group will be (i) to further improve in-hospital care for COPD patients experiencing exacerbations, and (ii) to assess and enhance sustainability of results. Therefore, a Continous Quality Improvement (CQI) approach will be used. Important additional focus will be put on team training, patient involvement, and organisational context. Future research on care pathways should focus on reorganisation of chronic care in order to deal with the current challenges of rising chronic disease, ageing population, and the inevitable shift from hospital-centred medicine to home care and self-management. An integrated care pathway that bridges primary care and hospitals, and allows multidisciplinary teams to interact with active patients and communities, facilitated by information technology (IT), can encounter the current defragmented implementation of the Chronic Care Model and has an enormous potential for optimising chronic patient care and improving outcomes like hospital admissions and quality of life. In conclusion, the results of this dissertation strongly suggest that care pathways lead to improved care processes and have potential to optimise clinical outcomes. Nevertheless, to further improve the care process and to enhance sustainability, continuous quality improvement will be needed.status: publishe

Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines

Rationale Chronic obstructive pulmonary disease (COPD) exacerbations are a leading cause of hospitalization. Suboptimal inhospital management is expected to lead to more frequent exacerbations and recurrent hospital admission, and is associated with increased mortality. Aims To explore inhospital management of COPD and to compare the results with recommendations from international guidelines. Methods A literature search was carried out for relevant articles published 2000-2009 in the databases Medline, Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and Invert. In addition, the reference lists of the selected articles were examined. Main inclusion criteria were as follows: COPD, exacerbation, hospitalization, description of inpatient management, and clinical trials. Assessment and treatment strategies in different studies were analysed and compared with American Thoracic Society-European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease guidelines. Outcomes were analysed. Results Seven eligible studies were selected. Non-pharmacological treatment was infrequently explored. When compared with international guidelines, diagnostic assessment and therapy were suboptimal, especially non-pharmacological treatment. Respiratory physicians were more likely to perform recommended interventions than non-respiratory physicians. Conclusions Adherence to international guidelines is low for inhospital management of COPD exacerbations, especially in terms of non-pharmacological treatment. Further investigation is recommended to explore strategies like care pathways that improve performance of recommended interventions.status: publishe

Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD Exacerbation

This study aimed to increase our understanding of processes that underlie the effect of care pathway implementation on reduced 30-day readmission rate. Adherence to evidence-based recommendations, teamwork and burnout have previously been identified as potential mechanisms in this association. We conducted a secondary data analysis of 257 patients admitted with chronic obstructive pulmonary disease exacerbation and 284 team members caring for these patients in 19 Belgian, Italian and Portuguese hospitals. Clinical measures included 30-day readmission and adherence to a specific set of five care activities. Teamwork measures included team climate for innovation, level of organized care and burnout (emotional exhaustion, level of competence and mental detachment). Care pathway implementation was significantly associated with better adherence and reduced 30-day readmission. Better adherence and higher level of competence were also related to reduced 30-day readmission. Only better adherence fully mediated the association between care pathway implementation and reduced 30-day readmission. Better team climate for innovation and level of organized care, although both improved after care pathway implementation, did not show any explanatory mechanisms in the association between care pathway implementation and reduced 30-day readmission. Implementation of a care pathway had an impact on clinical and team indicators. To reduce 30-day readmission rates, in the development and implementation of a care pathway, hospitals should measure adherence to evidence-based recommendations during the whole process, as this can give information regarding the success of implementation