Development and internal validation of prediction models for future hospital care utilization by patients with multimorbidity using electronic health record data

OBJECTIVE: To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. DESIGN: Retrospective cohort study. SETTING: A teaching hospital in the Netherlands (542 beds) PARTICIPANTS: All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). OUTCOMES: ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. STATISTICAL ANALYSIS: Multivariable logistic regression with forward selection. RESULTS: Evaluation of the models’ performance showed c-statistics of 0.70 (95% CI 0.69–0.72) for the hospitalization model, 0.72 (95% CI 0.70–0.74) for the ED visits model and 0.76 (95% 0.74–0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. CONCLUSIONS: These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach

Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines

Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity.We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines.Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions

Adaptation of clinical guidelines: literature review and proposition for a framework and procedure

Purpose. The development and updating of high-quality clinical practice guidelines require substantial resources. Many guideline programmes throughout the world are using similar strategies to achieve similar goals, resulting in many guidelines on the same topic. One method of using resources more efficiently and avoiding unnecessary duplication of effort would be to adapt existing guidelines. The aim was to review the literature on adaptation of guidelines and to propose a systematic approach for adaptation of guidelines. Data sources. We selected and reviewed reports describing the methods and results of adaptation of guidelines from those found by searching Medline, Internet, and reference lists of relevant papers. On the basis of this review and our experience in guideline development, we proposed a conceptual framework and procedure for adaptation of guidelines. Results. Adaptation of guidelines is performed either as an alternative to de novo guideline development or to improve guideline implementation through local tailoring of an international or national guideline. However, no validated process for the adaptation of guidelines produced in one cultural and organizational setting for use in another (i.e. trans-contextual adaptation) was found in the literature. The proposed procedure is a stepwise approach to trans-contextual adaptation, including searching for existing guidelines, quality appraisal, detailed analysis of the coherence between the evidence and the recommendations, and adaptation of the recommendations to the target context of use, taking into account the organization of the health care system and cultural context. Conclusions. Trans-contextual adaptation of guidelines is increasingly being considered as an alternative to de novo guideline development. The proposed approach should be validated and evaluated to determine if it can reduce duplication of effort and inefficient use of resources, although guaranteeing a high-quality product, compared with de novo developmen

Coordinating and tailoring hospital care for patients with multimorbidity:who will take the lead?

OBJECTIVE: To gain insight in medical specialists' and nurse practitioners' opinions on multimorbidity and coordination and tailoring of hospital care.DESIGN: Exploratory mixed-method design.METHOD: From August 2018 until January 2019, 35 Dutch medical associations were asked to forward a digital survey with open- and close-ended questions to their members. We used qualitative and quantitative methods to analyze the data. The main themes were identified with inductive, thematic analysis.RESULTS: There were 554 respondents from 22 associations, 43% of the medical specialist respondents were internist (n=221). The qualitative analysis of the answers regarding what is required in hospital care for patients with multimorbidity resulted in eight themes at the patient's, professional's and hospital organization's level. To the open question about who should take the lead, respondents most often answered the geriatrician or internist, followed by the general practitioner, 'the care professional who is treating the main problem', a nurse practitioner/physician assistant and the 'attending physician of the primary team'. All geriatricians and almost all internists felt they possessed the competencies to take the lead in hospital care for patients with multimorbidity.CONCLUSION: Medical specialists' and nurse practitioners' diverse ideas about who should take the lead in hospital care for patients with multimorbidity were a noteworthy finding. It is important to start local conversations about how to divide roles and responsibilities regarding the coordination and tailoring of hospital care for patients with multimorbidity.</p

Learning through assessment

This book aims to contribute to the discourse of learning through assessment within a self-directed learning environment. It adds to the scholarship of assessment and self-directed learning within a face-to-face and online learning environment. As part of the NWU Self-Directed Learning Book Series, this book is devoted to scholarship in the field of self-directed learning, focusing on ongoing and envisaged assessment practices for self-directed learning through which learning within the 21st century can take place. This book acknowledges and emphasises the role of assessment as a pedagogical tool to foster self-directed learning during face-to-face and online learning situations. The way in which higher education conceptualises teaching, learning and assessment has been inevitably changed due to the COVID- 19 pandemic, and now more than ever we need learners to be self-directed in their learning. Assessment plays a key role in learning and, therefore, we have to identify innovative ways in which learning can be assessed, and which are likely to become the new norm even after the pandemic has been brought under control. The goal of this book, consisting of original research, is to assist with the paradigm shift regarding the purpose of assessment, as well as providing new ideas on assessment strategies, methods and tools appropriate to foster self-directed learning in all modes of delivery

Self-Directed Learning

This book on self-directed learning (SDL) is devoted to original academic scholarship within the field of education, and is the 6th volume in the North-West University (NWU) SDL book series. In this book the authors explore how self-directed learning can be considered an imperative for education in a complex modern society. Although each chapter represents independent research in the field of self-directed learning, the chapters form a coherent contribution concerning the scholarship of self-directed learning, and specifically the effect of environmental and praxis contexts on the enhancement of self-directed learning in a complex society. The publication as a whole provides diverse perspectives on the importance of self-directed learning in varied contexts. Scholars working in a wide range of fields are drawn together in this scholarly work to present a comprehensive dialogue regarding self-directed learning and how this concept functions in a complex and dynamic higher education context. This book presents a combination of theory and practice, which reflects selected conceptual dimensions of self-directed learning in society, as well as research-based findings pertaining to current topical issues relating to implementing self-directed learning in the modern world. The varied methodologies provide the reader with different and balanced perspectives, as well as varied and innovative ideas on how to conduct research in the field of self-directed learning

Learning through assessment

This book aims to contribute to the discourse of learning through assessment within a self-directed learning environment. It adds to the scholarship of assessment and self-directed learning within a face-to-face and online learning environment. As part of the NWU Self-Directed Learning Book Series, this book is devoted to scholarship in the field of self-directed learning, focusing on ongoing and envisaged assessment practices for self-directed learning through which learning within the 21st century can take place. This book acknowledges and emphasises the role of assessment as a pedagogical tool to foster self-directed learning during face-to-face and online learning situations. The way in which higher education conceptualises teaching, learning and assessment has been inevitably changed due to the COVID- 19 pandemic, and now more than ever we need learners to be self-directed in their learning. Assessment plays a key role in learning and, therefore, we have to identify innovative ways in which learning can be assessed, and which are likely to become the new norm even after the pandemic has been brought under control. The goal of this book, consisting of original research, is to assist with the paradigm shift regarding the purpose of assessment, as well as providing new ideas on assessment strategies, methods and tools appropriate to foster self-directed learning in all modes of delivery

Self-Directed Learning

This book on self-directed learning (SDL) is devoted to original academic scholarship within the field of education, and is the 6th volume in the North-West University (NWU) SDL book series. In this book the authors explore how self-directed learning can be considered an imperative for education in a complex modern society. Although each chapter represents independent research in the field of self-directed learning, the chapters form a coherent contribution concerning the scholarship of self-directed learning, and specifically the effect of environmental and praxis contexts on the enhancement of self-directed learning in a complex society. The publication as a whole provides diverse perspectives on the importance of self-directed learning in varied contexts. Scholars working in a wide range of fields are drawn together in this scholarly work to present a comprehensive dialogue regarding self-directed learning and how this concept functions in a complex and dynamic higher education context. This book presents a combination of theory and practice, which reflects selected conceptual dimensions of self-directed learning in society, as well as research-based findings pertaining to current topical issues relating to implementing self-directed learning in the modern world. The varied methodologies provide the reader with different and balanced perspectives, as well as varied and innovative ideas on how to conduct research in the field of self-directed learning

Subacromial decompression surgery for adults with shoulder pain : a clinical practice guideline

Clinical question Do adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery. Current practice SAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations. Recommendation The guideline panel makes a strong recommendation against surgery. How this guideline was created A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation. The evidence Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery. Understanding the recommendation The panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.Peer reviewe