Delayed administration of dopaminergic drugs is not associated with prolonged length of stay of hospitalized patients with Parkinson's disease

Background: Punctual delivery of dopaminergic medication to Parkinson's disease (PD) patients may be important in optimizing disease control. We tested the hypothesis that prompt delivery of l-dopa medications to emergency hospital inpatients was associated with a decreased length of stay in hospital. Methods: The study population consisted of all urgent hospitalizations for patients with a diagnosis of PD to the Royal Derby Hospital over a two-year period. Data were extracted on timing of delivery of drugs, number of co-morbidities and length of stay. Statistical analysis used linear regression adjusting for within admission clustering. Results: 431 individuals provided data from a total of 737 admissions. 39% of scheduled l-dopa doses were either not given or administered over 30 min later than the scheduled time. There was no association between the omission or timing of a dose of PD medication and length of stay in hospital. The number of coded diagnoses was strongly associated with length of stay with a dose-response association (pTREND<0.001). Those with 10 concurrent diagnoses had a 11 day longer stay (95% confidence intervals: +2 to +21) than those with no comorbidities. Conclusions Delayed administration of dopaminergic drugs is not associated with prolonged length of stay of in patients with PD who were admitted to hospital as an emergency. However, the number of co-existing medical diagnoses was associated with length of stay, and early attention to these has the potential to improve patient care and decrease length of stay in hospital

The potential to quantify polypharmacy in older adult hospital inpatients using electronic prescribing software: A feasibility study

Polypharmacy in older adults is a growing problem, as some drugs may be either unnecessary or even harmful. Admission to hospital under a Medicine for the Elderly specialist physicians represents an opportunity to review patients’ medication. The recent introduction of electronic prescribing to some hospitals in the United Kingdom allows the development of tools to measure polypharmacy in in-patients, and subsequently to assess the efficacy of interventions that aim to optimize medication prescribing. We tested the feasibility of developing an Excel-based software code that measured the number of medications a group of patients were taking at admission and how many of these were still prescribed on discharge. Electronic prescribing data was obtained from the Royal Derby Hospital, over a period of 52 weeks from April 2017 to March 2018 for all patients over the age of 65 years who were admitted onto the medicine for the elderly wards and subsequently discharged. On admission, the median number of eligible medications was 11 (interquartile range IQR 8 to 15). At the time of discharge, the median number of eligible medications retained since admission was 9 (IQR 6 to 12). This represents a median number of medications that have been removed from the current medication regimen of 2 (IQR 1 to 3, p [less than] 0.001). Electronic prescribing software in hospitals allows the development of tools to measure the burden of medications, and to examine the efficacy of future interventions that are developed to optimize drug prescribing in older adults

Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study

ObjectivesThere is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors.Study designSingle-centre qualitative study.MethodsThe financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach.ResultsThree focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure.ConclusionThe findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care

Hospital doctors’ attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study

Background: Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests. Methods: We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention. Results: Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests. Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors’ confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message. Conclusion: The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment

Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study

© 2020 The Authors Objectives: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. Study design: Single-centre qualitative study. Methods: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. Results: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. Conclusion: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care

An evaluation of a price transparency intervention for two commonly prescribed medications on total institutional expenditure: a prospective study

Importance: Providing cost feedback has been demonstrated to decrease demand from clinicians. Objective: We tested the hypothesis that providing the cost of drugs to clinicians would modify total expenditure. Design: A prospective study design with a step-wise intervention. Setting/Participants: Individuals who were admitted to the XXX from November 2013 to November 2015 under the physicians. Intervention: The cost of all antibiotics and inhaled corticosteroids was added to the electronic prescribing system. Main outcomes: The weekly cost for antibiotics and inhaled corticosteroids in the intervention period compared to baseline. Results: Mean weekly expenditure on antibiotics per patient decreased by £3.75 (95% confidence intervals CI: -6.52 to -0.98) after the intervention from a pre-intervention mean of £26.44, and then slowly increased subsequently by £0.10/week (95%CI: +0.02 to +0.18). Mean weekly expenditure on inhaled corticosteroids per patient did not substantially change after the intervention (-£0.03, 95%CI: -0.06 to -0.01 after the intervention from a pre-intervention mean of £5.29 per person). New clinical guidelines for inhaled corticosteroids were associated with a decrease in weekly expenditure. Conclusions and relevance: Provision of cost feedback resulted in no sustained change in institutional expenditure. However, clinical guidelines have potential for modifying clinical prescribing behaviour

Frequency of stepping down antibiotics and nebuliser treatment is lower at weekends compared to weekdays: an observational study

We hypothesised that delays in providing non-urgent medication step-downs at weekends to medical management may be associated with increased length of stay.In a novel use of electronic prescribing data, we analysed emergency admissions from a busy acute medical hospital over 52 weeks from November 2014 to October 2015. The main outcomes of interest were switching from intravenous antibiotics to oral antibiotics and stopping nebulised bronchodilators. The rate of switching from intravenous to oral antibiotics was lower on Saturdays and Sundays compared with weekdays, and the rate of stopping nebulised bronchodilators was similarly lower at weekends (p<0.001). Median length of stay was shorter in those whose antibiotic treatment was stepped down at weekends compared with weekdays (4 days versus 5 days, p<0.001). Reduced medication step-downs at weekends may represent a bottleneck in patient flow. Electronic prescribing data are a valuable resource for future health services research

Development and evaluation of a brief educational cartoon on trainee clinicians’ awareness of risks of ionising-radiation exposure: a feasibility pre-post intervention study of a novel educational tool to promote patient safety

Background: Over recent decades, CT scans have become routinely available and are used in both acute medical and outpatient environments. However, there is a small increase in the risk of adverse consequences, including an increase in the risk of both malignancy and cataracts. Clinicians are often unaware of these facts, and this represents a challenge for medical educators in England, where almost 5 million CT scans are done annually. New whiteboard methodologies permit development of innovative educational tools that are efficient and scalable in communicating simple educational messages that promote patient safety. Methods: A short educational whiteboard cartoon was developed to explore the prior observation that adolescents under the care of paediatricians had a much lower risk of receiving a CT scan than those under the care of clinicians who care for adults. This explored the risks after receiving a CT scan and strategies that can be used to avoid them. The educational cartoon was piloted on new doctors who were attending induction training at a busy teaching hospital. Results: The main output was the educational whiteboard cartoon itself. Before the new medical trainees’ induction, 56% (25/45) had received no formal training in radiation awareness, and this decreased to 26% (6/23) after the exposure to the educational cartoon (p=0.02). At baseline, 60% (27/45) of respondents considered that young females were at highest risk from exposure to ionising radiation, and this increased to 87% (20/23) after exposure to the educational cartoon (p=0.06). Conclusions: This proof-of-concept feasibility study demonstrates that whiteboard cartoons provide a novel and feasible approach to efficiently promote patient safety issues, where a short succinct message is often appropriate

Evaluation of the impact of a brief educational message on clinicians’ awareness of risks of ionising-radiation exposure in imaging investigations:a pilot pre-post intervention study

Background:In the context of increasing availability of computed tomography (CT) scans, judicious use of ionising radiation is a priority to minimise the risk of future health problems. Hence, education of clinicians on the risks and benefits of CT scans in the management of patients is important. Methods:An educational message about the associated lifetime cancer risk of a CT scan was added to all CT scan reports at a busy acute teaching hospital in the UK. An online multiple choice survey was completed by doctors before and after the intervention, assessing education and knowledge of the risks involved with exposure to ionising radiation.Results:Of 546 doctors contacted at baseline, 170 (31%) responded. Over a third (35%) of respondents had received no formal education on the risks of exposure to ionising radiation. Over a quarter (27%) underestimated (selected 1 in 30 000 or negligible lifetime cancer risk) the risk associated with a chest, abdomen and pelvis CT scan for a 20 year old female. Following exposure to the intervention for one year there was a statistically significant improvement in plausibleestimates of risk from 68.3% to 82.2% of respondents (p < 0.001). There was no change in the proportion of doctors correctly identifying imaging modalities that do or do not involve ionising radiation.Conclusions:Training on the longterm risks associated with diagnostic radiation exposure is inadequate among hospital doctors.Exposure to a simple non-directional educational message for one year improved doctors’ awareness of risks associated with CT scans. This demonstrates the potential of the approach to improve knowledge that could improve clinical practice. This approach is easily deliverable and may have applications in other areas of clinical medicine. The wider and longer term impact on radiation awareness is unknown, however, and there may be a need for regular mandatory training in the risks of radiation exposure