Emergency Manuals: How Quality Improvement and Implementation Science Can Enable Better Perioperative Management During Crises

© 2017 Sara N. Goldhaber-Fiebert, Carl Macrae How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care

Committing to Exercise: Contract Design for Virtuous Habit Formation

Sedentary lifestyles, obesity, and obesity-related chronic diseases have become increasingly common among U.S. adults, posing a major health policy challenge. While individuals may be interested in exercising more to reduce these health risks, they often have difficultly forming long-term exercise habits. Behavioral economic devices like commitment contracts aid individuals make repeated actions in situations where there are upfront costs and the benefits, though substantial, are delayed. It is not known whether such contracts can help individuals to sustain increased exercise. We conducted a randomized controlled trial to test whether nudges and anchoring could be used to shift the types of exercise commitment contracts people entered into using a web-based contract creation tool. At the time of contract creation, users selected a contract length (duration); number of times a week to exercise (frequency); and a financial penalty for failing to live up to the contract in a given week (stake). We randomly set the default duration shown to users (8 weeks, 12 weeks, or 16 weeks). Outcomes include: contract acceptance; chosen duration, frequency, total exercise sessions; and chosen financial stake. We analyzed the data using multivariable regressions and also developed a theoretical model of active choice in the context of nudges, fitting the model to the data using non-linear optimization. 619 users, age 18-69, were included in the study, of whom 61% accepted/signed an exercise commitment contract. Users who were shown a longer default contract durations were significantly more likely to choose a contract of longer duration. There was no difference in the likelihood of accepting contracts or in the chosen exercise frequency or financial stakes. Our model of active choice suggested that almost 50% of users were highly susceptible to default values for contract duration, with the greatest effect for users interested in exercise contracts with durations nearer to the nudged defaults. This implication of the model was confirmed by quantile regressions (greatest effect of nudges for contract durations between the 40th and 80th percentiles). With changes in default values, individuals can be nudged into longer exercise commitment contracts that obligate them to greater numbers of exercise sessions.

Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes:Evidence from rural Bihar, India

BACKGROUND: Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges. METHODS: We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics. FINDINGS: 80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively). INTERPRETATION: Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care

Cost Effectiveness of Fibrosis Assessment Prior to Treatment for Chronic Hepatitis C Patients

Chronic hepatitis C (HCV) is a liver disease affecting over 3 million Americans. Liver biopsy is the gold standard for assessing liver fibrosis and is used as a benchmark for initiating treatment, though it is expensive and carries risks of complications. FibroTest is a non-invasive biomarker assay for fibrosis, proposed as a screening alternative to biopsy.We assessed the cost-effectiveness of FibroTest and liver biopsy used alone or sequentially for six strategies followed by treatment of eligible U.S. patients: FibroTest only; FibroTest with liver biopsy for ambiguous results; FibroTest followed by biopsy to rule in; or to rule out significant fibrosis; biopsy only (recommended practice); and treatment without screening. We developed a Markov model of chronic HCV that tracks fibrosis progression. Outcomes were expressed as expected lifetime costs (2009 USD), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER).Treatment of chronic HCV without fibrosis screening is preferred for both men and women. For genotype 1 patients treated with pegylated interferon and ribavirin, the ICERs are $5,400/QALY (men) and$6,300/QALY (women) compared to FibroTest only; the ICERs increase to $27,200/QALY (men) and$30,000/QALY (women) with the addition of telaprevir. For genotypes 2 and 3, treatment is more effective and less costly than all alternatives. In clinical settings where testing is required prior to treatment, FibroTest only is more effective and less costly than liver biopsy. These results are robust to multi-way and probabilistic sensitivity analyses.Early treatment of chronic HCV is superior to the other fibrosis screening strategies. In clinical settings where testing is required, FibroTest screening is a cost-effective alternative to liver biopsy

Multi-Country analysis of palm oil consumption and cardiovascular disease mortality for countries at different stages of economic development: 1980-1997

<p>Abstract</p> <p>Background</p> <p>Cardiovascular diseases represent an increasing share of the global disease burden. There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat.</p> <p>Methods</p> <p>The study analyzed country-level data from 1980-1997 derived from the World Health Organization's Mortality Database, U.S. Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries). Outcomes included mortality from IHD and stroke for adults aged 50 and older. Predictors included per-capita consumption of palm oil and cigarettes and per-capita Gross Domestic Product as well as time trends and an interaction between palm oil consumption and country economic development level. Analyses examined changes in country-level outcomes over time employing linear panel regressions with country-level fixed effects, population weighting, and robust standard errors clustered by country. Sensitivity analyses included further adjustment for other major dietary sources of saturated fat.</p> <p>Results</p> <p>In developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000 (95% CI [21-115]), whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 (95% CI [-12-49]) but were not significant. For historically high-income countries, changes in IHD and stroke mortality rates from palm oil consumption were smaller (IHD: 17 deaths per 100,000 (95% CI [5.3-29]); stroke: 5.1 deaths per 100,000 (95% CI [-1.2-11.0])). Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries.</p> <p>Conclusions</p> <p>Increased palm oil consumption is related to higher IHD mortality rates in developing countries. Palm oil consumption represents a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens.</p

Calculating the Expected Value of Sample Information in Practice: Considerations from Three Case Studies

Investing efficiently in future research to improve policy decisions is an important goal. Expected Value of Sample Information (EVSI) can be used to select the specific design and sample size of a proposed study by assessing the benefit of a range of different studies. Estimating EVSI with the standard nested Monte Carlo algorithm has a notoriously high computational burden, especially when using a complex decision model or when optimizing over study sample sizes and designs. Therefore, a number of more efficient EVSI approximation methods have been developed. However, these approximation methods have not been compared and therefore their relative advantages and disadvantages are not clear. A consortium of EVSI researchers, including the developers of several approximation methods, compared four EVSI methods using three previously published health economic models. The examples were chosen to represent a range of real-world contexts, including situations with multiple study outcomes, missing data, and data from an observational rather than a randomized study. The computational speed and accuracy of each method were compared, and the relative advantages and implementation challenges of the methods were highlighted. In each example, the approximation methods took minutes or hours to achieve reasonably accurate EVSI estimates, whereas the traditional Monte Carlo method took weeks. Specific methods are particularly suited to problems where we wish to compare multiple proposed sample sizes, when the proposed sample size is large, or when the health economic model is computationally expensive. All the evaluated methods gave estimates similar to those given by traditional Monte Carlo, suggesting that EVSI can now be efficiently computed with confidence in realistic examples.Comment: 11 pages, 3 figure

Modeling human papillomavirus and cervical cancer in the United States for analyses of screening and vaccination

Background: To provide quantitative insight into current U.S. policy choices for cervical cancer prevention, we developed a model of human papillomavirus (HPV) and cervical cancer, explicitly incorporating uncertainty about the natural history of disease. Methods: We developed a stochastic microsimulation of cervical cancer that distinguishes different HPV types by their incidence, clearance, persistence, and progression. Input parameter sets were sampled randomly from uniform distributions, and simulations undertaken with each set. Through systematic reviews and formal data synthesis, we established multiple epidemiologic targets for model calibration, including age-specific prevalence of HPV by type, age-specific prevalence of cervical intraepithelial neoplasia (CIN), HPV type distribution within CIN and cancer, and age-specific cancer incidence. For each set of sampled input parameters, likelihood-based goodness-of-fit (GOF) scores were computed based on comparisons between model-predicted outcomes and calibration targets. Using 50 randomly resampled, good-fitting parameter sets, we assessed the external consistency and face validity of the model, comparing predicted screening outcomes to independent data. To illustrate the advantage of this approach in reflecting parameter uncertainty, we used the 50 sets to project the distribution of health outcomes in U.S. women under different cervical cancer prevention strategies. Results: Approximately 200 good-fitting parameter sets were identified from 1,000,000 simulated sets. Modeled screening outcomes were externally consistent with results from multiple independent data sources. Based on 50 good-fitting parameter sets, the expected reductions in lifetime risk of cancer with annual or biennial screening were 76% (range across 50 sets: 69–82%) and 69% (60–77%), respectively. The reduction from vaccination alone was 75%, although it ranged from 60% to 88%, reflecting considerable parameter uncertainty about the natural history of type-specific HPV infection. The uncertainty surrounding the model-predicted reduction in cervical cancer incidence narrowed substantially when vaccination was combined with every-5-year screening, with a mean reduction of 89% and range of 83% to 95%. Conclusion: We demonstrate an approach to parameterization, calibration and performance evaluation for a U.S. cervical cancer microsimulation model intended to provide qualitative and quantitative inputs into decisions that must be taken before long-term data on vaccination outcomes become available. This approach allows for a rigorous and comprehensive description of policy-relevant uncertainty about health outcomes under alternative cancer prevention strategies. The model provides a tool that can accommodate new information, and can be modified as needed, to iteratively assess the expected benefits, costs, and cost-effectiveness of different policies in the U.S

Effect Of A Large-Scale Social Franchising And Telemedicine Program On Childhood Diarrhea And Pneumonia Outcomes In India

Despite its rapid growth, there is little evidence on the population impact of social franchising in the health sector. This paper evaluates a large-scale social franchising and telemedicine program in Bihar, India: the World Health Partners (WHP) Sky Program. Studying appropriate treatment for childhood diarrhea and pneumonia – and associated health outcomes, we analyze data collected from 67,950 children (ages 5 and under) in 2011 and 2014 using multivariate difference-in-difference models. We find that the WHP-Sky program did not improve rates of appropriate treatment or disease prevalence. Both provider participation and service use among target populations were low. Our results do not imply that social franchising cannot succeed, but rather underscore the importance of understanding factors that explain variation in performance of social franchises. Our findings also highlight, for donors and governments in particular, the importance of conducting rigorous impact evaluations of new, potentially innovative healthcare delivery programs before investing in their scale-up