Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis

Abstract Background There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries. Methods Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n < 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups. Results Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19–54.06, I2 = 0.00% and 13.92%, 95% CI = 10.19–17.65, I2 = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33–14.59, I2 = 0.00%) and was 13.58 g/dL (95% CI = 11.95–15.21, I2 = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I2 = 0.00%) in the PBT group. Conclusions The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship. Graphical abstrac

Knowledge translation of clinical practice guidelines among neurologists: A mixed-methods study.

OBJECTIVES:Clinical practice guidelines have the potential to improve care, but are often not optimally implemented. Improving guideline use in clinical practice may improve care. The objective of this study was to identify the barriers and facilitators (determinants) of guidelines use among neurologists and to propose a strategy to improve guideline implementation. METHODS:This was a mixed-methods study design. A quantitative, population-based, cross-sectional survey of Canadian neurologists was conducted. Associations between guidelines use and determinants of guidelines use were examined. Focus groups and interviews were conducted using purposeful sampling of the population. Determinants of guideline use were mapped to interventions to establish a strategy for guideline implementation among neurologists. RESULTS:38.7% (n = 311) of neurologists responded to the survey. Typically, respondents had been practicing for 16.6 years and worked in an academic institution in an urban setting. Being male and having an academic affiliation was associated with guideline use. Determinants of guideline use differed between guideline users and non-users; non-users consistently rating determinants lower than users, especially applicability. Two focus groups and one interview (n = 11) identified six main themes of determinants of guideline use: Credibility, knowledge, applicability, resources, motivation, and target audience; which was congruent with the quantitative data. The proposed knowledge translation strategy contains three pillars: guidelines development, dissemination, and interventions. CONCLUSIONS:Several determinants of guideline use not commonly discussed in the literature were identified (applicability, target audience, credibility). The proposed implementation strategy is a valuable resource for guideline developers and policy/decision-makers to improve knowledge translation of guidelines among neurologists

Knowledge translation of an online tool to determine candidacy for epilepsy surgery evaluation

BackgroundGuidelines recommend that surgery be considered in patients with drug-resistant epilepsy, yet delays to epilepsy surgery still exist. A Web-based, evidence-informed clinical decision tool (www.toolsforepilepsy.com) was developed to help physicians determine which patients are appropriate for an epilepsy surgery evaluation. We evaluated the usability and feasibility of the tool with the intended end users in order to improve implementation into practice.MethodsUsability testing was conducted with relevant end users. After the tool was modified based on usability results, another group of end users trialed the tool in their clinical practice. This latter group of end users then participated in focus groups and semi-structured interviews to address barriers and facilitators to tool implementation. Finally, a stakeholder meeting was held with domain experts and end users to discuss further changes to the tool and implementation strategies.ResultsSix overall themes were identified through usability testing, and an additional 11 themes were identified through the focus groups and interviews. The tool was modified based on these findings, which were then presented at the stakeholder meeting of experts and end users for further refinement. The findings were also used to guide discussions of potential implementation strategies at the meeting.ConclusionThis study provides guidance on how to improve the usability of clinical decision tools by engaging end users, experts, and other key stakeholders. The modifications to the tool should facilitate its implementation in clinical practice and ultimately enhance the quality of care persons with epilepsy receive

Designing and integrating a quality management program for patients undergoing head and neck resection with free-flap reconstruction

Abstract Background Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years. Methods We describe a change management approach informed by Kotter’s “8 Step Process” that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided. Results We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction. Conclusions A change management approach to design and delivery of a head and neck quality management program is practical and feasible

The impact of a quality management program for patients undergoing head and neck resection with free-flap reconstruction: longitudinal study examining sustainability

Abstract Background Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. Methods The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. Results Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. Conclusions Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients

Classification schemes for knowledge translation interventions: a practical resource for researchers

Abstract Background As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme. Methods We abstracted the following information from each of the original 51 classification scheme articles: authors’ objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not. Results Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination. Conclusions Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science

The current state of epilepsy guidelines: A systematic review

Summary Objective The International League Against Epilepsy (ILAE) Epilepsy Guidelines Task Force, composed of 14 international members, was established in 2011 to identify, using systematic review methodology, international epilepsy clinical care guidelines, assess their quality, and determine gaps in areas of need of development. Methods A systematic review of the literature (1985-2014) was performed in six electronic databases (e.g. Medline, Embase) using a broad search strategy without initial limits to language or study design. Six gray literature databases (e.g., American Academy of Neurology [AAN], ILAE) were also searched to minimize publication bias. Two independent reviewers screened abstracts, reviewed full text articles, and performed data abstraction. Descriptive statistics and a meta-analysis were generated. Results The search identified 10,926 abstracts. Of the 410 articles selected for full text review, 63 met our eligibility criteria for a guideline. Of those included, 54 were in English and 9 were in other languages (French, Spanish, and Italian). Of all guidelines, 29% did not specify the target age groups, 27% were focused on adults, 22% included only children, and 6% specifically addressed issues related to women with epilepsy. Guidelines included in the review were most often aimed at guiding clinical practice for status epilepticus (n = 7), first seizure (n = 6), drug-resistant epilepsy (n = 5), and febrile seizures (n = 4), among others. Most of the guidelines were therapeutic (n = 35) or diagnostic (n = 16) in nature. The quality of the guidelines using a 1-7 point scale (7 = highest) varied and was moderate overall (mean = 4.99 ± 1.05 [SD]). Significance We identified substantial gaps in topics (e.g., epilepsy in the elderly) and there was considerable heterogeneity in methodologic quality. The findings should offer a valuable resource for health professionals caring for people with epilepsy, since they will help guide the prioritization, development, and dissemination of future epilepsy-related guidelines