Benchmarked performance charts using principal components analysis to improve the effectiveness of feedback for audit data in HIV care

Abstract Background Feedback tools for clinical audit data that compare site-specific results to average performance over all sites can be useful for quality improvement. Proposed tools should be simple and clearly benchmark the site’s performance, so that a relevant action plan can be directly implemented to improve patient care services. We aimed to develop such a tool in order to feedback data to UK HIV clinics participating in the 2015 British HIV Association (BHIVA) audit assessing compliance with the 2011 guidelines for routine investigation and monitoring of adult HIV-1- infected individuals. Methods HIV clinic sites were asked to provide data on a random sample of 50–100 adult patients attending for HIV care during 2014 and/or 2015 by completing a self-audit spreadsheet. Outcomes audited included the proportion of patients with recorded resistance testing, viral load monitoring, adherence assessment, medications, hepatitis testing, vaccination management, risk assessments, and sexual health screening. For each outcome we benchmarked the proportion for a specific site against the average performance. We produced performance charts for each site using boxplots for the outcomes. We also used the mean and differences from the mean performance to produce a dashboard for each site. We used principal components analysis to group correlated outcomes and simplify the dashboard. Results The 106 sites included in the study provided information on a total of 7768 patients. Outcomes capturing monitoring of treatment of HIV-infection showed high performance across the sites, whereas testing for hepatitis, and risk assessment for cardiovascular disease and smoking, management of flu vaccination, sexual health screening, and cervical cytology for women were very variable across sites. The principal components analysis reduced the original 12 outcomes to four factors that represented HIV care, hepatitis testing, other screening tests, and resistance testing. These provided simplified measures of adherence to guidelines which were presented as a 4 bar dashboard of performance. Conclusion Our dashboard performance charts provide easily digestible visual summaries of locally relevant audit data that are benchmarked against the overall mean and can be used to improve feedback to HIV services. Feedback from clinicians indicated that they found these charts acceptable and useful

The Pediatric Choroidal and Ciliary Body Melanoma Study A Survey by the European Ophthalmic Oncology Group

Purpose: To collect comprehensive data on choroidal and ciliary body melanoma (CCBM) in children and to validate hypotheses regarding pediatric CCBM: children younger than 18 years, males, and those without ciliary body involvement (CBI) have more favorable survival prognosis than young adults 18 to 24 years of age, females, and those with CBI. Design: Retrospective, multicenter observational study. Participants: Two hundred ninety-nine patients from 24 ocular oncology centers, of whom 114 were children (median age, 15.1 years; range, 2.7-17.9 years) and 185 were young adults. Methods: Data were entered through a secure website and were reviewed centrally. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards regression. Main Outcome Measures: Proportion of females, tumor-node-metastasis (TNM) stage, cell type, and melanoma-related mortality. Results: Cumulative frequency of having CCBM diagnosed increased steadily by 0.8% per year of age between 5 and 10 years of age and, after a 6-year transition period, by 8.8% per year from age 17 years onward. Of children and young adults, 57% and 63% were female, respectively, which exceeded the expected 51% among young adults. Cell type, known for 35% of tumors, and TNM stage (I in 22% and 21%, II in 49% and 52%, III in 30% and 28%, respectively) were comparable for children and young adults. Melanoma-related survival was 97% and 90% at 5 years and 92% and 80% at 10 years for children compared with young adults, respectively (P = 0.013). Males tended to have a more favorable survival than females among children (100% vs. 85% at 10 years; P = 0.058). Increasing TNM stage was associated with poorer survival (stages I, II, and III: 100% vs. 86% vs. 76%, respectively; P = 0.0011). By multivariate analysis, being a young adult (adjusted hazard rate [HR], 2.57), a higher TNM stage (HR, 2.88 and 8.38 for stages II and III, respectively), and female gender (HR, 2.38) independently predicted less favorable survival. Ciliary body involvement and cell type were not associated with survival. Conclusions: This study confirms that children with CCBM have a more favorable survival than young adults 18 to 25 years of age, adjusting for TNM stage and gender. The association between gender and survival varies between age groups. (C) 2016 by the American Academy of Ophthalmology.Peer reviewe

Inflammatory Cytokines in Eyes with Uveal Melanoma and Relation with Macrophage Infiltration

Eyes with uveal melanoma have been shown to have multiple cytokines and chemokines in the aqueous humor. This study was conducted to determine whether a relation exists between the presence of these cytokines and the prognostic factors and survival of uveal melanoma

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P =.003; effect = 0.506 (.172–.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P =.003; OR =.509 (.326–.792)), patients in the No-Trial group endured fewer infections (P =.006; proportion difference =.43 (.007–.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. Perspective: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted

Correlation between <i>HLA-</i> gene expression and the expression of the genes encoding the HLA transcriptional regulators and peptide-loading machinery.

<p>Correlation between <i>HLA-</i> gene expression and the expression of the genes encoding the HLA transcriptional regulators and peptide-loading machinery.</p

Schematic illustration of tumor characteristics and infiltrate.

<p>UM with monosomy 3 attract an infiltrate, producing different cytokines, including Interferon-gamma. The tumor cell (UM cell) responds by increasing HLA class I and II levels, as well as rendering the infiltrating immune cells ineffective (immune suppression) and creating a tumor-favorable environment, with amongst others, stimulation of angiogenesis.</p

Chromosomal aberrations and HLA expression.

<p>Comparison between chromosomal aberrations and the expression of HLA class I and II antigens in a set of 27 primary UM. Tumors are divided according to their chromosome 3 and 6 status (disomy or monosomy of chromosome 3, and disomy of chromosome 6 or gain of 6p). HLA gene expression was determined using an Illumina microarray (A) and protein expression by immunohistochemistry (B) in UM. Additionally, HLA gene expression was determined using qPCR, which served to validate the Illumina findings (C). Four data points of the qPCR that are outside the axis limits (> 11 and < 24) are not shown (HLA-A, D3D6p: 17; HLA-B, D3D6p: 24, and M3D6p: 12; B2M, D3D6p: 13). Only significant p-values are shown, all other comparisons between the groups were not significant (p-values not shown). Error-bars represent the interquartile range. Results were obtained using the Mann-Whitney U tests.</p

Tumor infiltrating immune cells.

<p>Association between a low or high density of tumor-infiltrating CD3+ (A), and CD68+ (B)cells and several HLA and HLA-related genes (Illumina array) in primary UM. CD3 (cells/mm²) and CD68 (pixels x 10³/mm²) scores were dichotomized at the median.</p

Effect of the absence of human leukocytes.

<p>Gene-expression (log 2 intensity values) of HLA-B, HLA-DRA, CD3D (as marker for T-cells), and CD163 (as marker for macrophages), of the original tumors (patient) compared to the xenografts (xeno). MP’s are primary tumors; MM’s are metasisis.</p