Variation in neurosurgical management of traumatic brain injury

Background: Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. Methods: A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). Results: The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. Conclusion: Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care

Evaluating quality indicators for physical therapy in primary care

Item does not contain fulltextOBJECTIVE: To evaluate measurement properties of a set of public quality indicators on physical therapy. DESIGN: An observational study with web-based collected survey data (2009 and 2010). SETTING: Dutch primary care physical therapy practices. PARTICIPANTS: In 3743 physical therapy practices, 11 274 physical therapists reporting on 30 patients each. MAIN OUTCOME MEASURES: Eight quality indicators were constructed: screening and diagnostics (n= 2), setting target aim and subsequent of intervention (n = 2), administrating results (n = 1), global outcome measures (n = 2) and patient's treatment agreement (n = 1). Measurement properties on content and construct validity, reproducibility, floor and ceiling effects and interpretability of the indicators were assessed using comparative statistics and multilevel modeling. RESULTS: Content validity was acceptable. Construct validity (using known group techniques) of two outcome indicators was acceptable; hypotheses on age, gender and chronic vs. acute care were confirmed. For the whole set of indicators reproducibility was approximated by correlation of 2009 and 2010 data and rated moderately positive (Spearman's rho between 0.3 and 0.42 at practice level) and interpretability as acceptable, as distinguishing between patient groups was possible. Ceiling effects were assessed negative as they were high to extremely high (30% for outcome indicator 6-95% for administrating results). CONCLUSION: Weaknesses in data collection should be dealt with to reduce bias and to reduce ceiling effects by randomly extracting data from electronic medical records. More specificity of the indicators seems to be needed, and can be reached by focusing on most prevalent conditions, thus increasing usability of the indicators to improve quality of care

The Reasons behind the (Non)Use of Feedback Reports for Quality Improvement in Physical Therapy: A Mixed-Method Study

OBJECTIVES: To explain the use of feedback reports for quality improvements by the reasons to participate in quality measuring projects and to identify barriers and facilitators. DESIGN: Mixed methods design. METHODS: In 2009-2011 a national audit and feedback system for physical therapy (Qualiphy) was initiated in the Netherlands. After each data collection round, an evaluation survey was held amongst its participants. The evaluation survey data was used to explain the use of feedback reports by studying the reasons to participate with Qualiphy with correlation measures and logistic regression. Semi-structured interviews with PTs served to seek confirmation and disentangle barriers and facilitators. RESULTS: Analysis of 257 surveys (response rate: 42.8%) showed that therapists with only financial reasons were less likely to use feedback reports (OR = 0.24;95%CI = 0.11-0.52) compared to therapists with a mixture of reasons. PTs in 2009 and 2010 were more likely to use the feedback reports for quality improvement than PTs in 2011 (OR = 2.41;95%CI = 1.25-4.64 respectively OR = 3.28;95%CI = 1.51-7.10). Changing circumstances in 2011, i.e. using EHRs and financial incentives, had a negative effect on the use of feedback reports (OR = 0.40, 95%CI = 0.20-0.78). Interviews with 12 physical therapists showed that feedback reports could serve as a tool to support and structure quality improvement plans. Barriers were distrust and perceived self-reporting bias on indicator scores. CONCLUSIONS: Implementing financial incentives that are not well-specified and well-targeted can have an adverse effect on using feedback reports to improve quality of care. Distrust is a major barrier to implementing quality systems

Advance Care Planning in Nursing Home Patients With Dementia: A Qualitative Interview Study Among Family and Professional Caregivers

Item does not contain fulltextOBJECTIVE: The aim of this study was to describe the process of advance care planning (ACP) and to explore factors related to the timing and content of ACP in nursing home patients with dementia, as perceived by family, physicians, and nurses. DESIGN: A qualitative descriptive study. METHODS: A total of 65 in-depth qualitative interviews were held with families, on-staff elderly care physicians, and nurses of 26 patients with dementia who died in the Dutch End Of Life in Dementia (DEOLD) study. Interviews were coded and analyzed to find themes. RESULTS: Family, nurses, and physicians of all patients indicated they had multiple contact moments during nursing home stay in which care goals and treatment decisions were discussed. Nearly all interviewees indicated that physicians took the initiative for these ACP discussions. Care goals discussed and established during nursing home stay and the terminology to describe care goals varied between facilities. Regardless of care goals and other factors, cardiopulmonary resuscitation (CPR) and hospitalization were always discussed in advance with family and commonly resulted in a do-not-resuscitate (DNR) and a do-not-hospitalize (DNH) order. The timing of care planning discussions about other specific treatments or conditions and the content of treatment decisions varied. The factors that emerged from the interviews as related to ACP were general strategies that guided physicians in initiating ACP discussions, patient's condition, wishes expressed by patient or family, family's willingness, family involvement, continuity of communication, consensus with or within family, and general nursing home policy. Two influential underlying strategies guided physicians in initiating ACP discussions: (1) wait for a reason to initiate discussions, such as a change in health condition and (2) take initiative to discuss possible treatments (actively, including describing scenarios). CONCLUSIONS: ACP is a multifactorial process, which may lean on professional caregivers' guidance. The most acute decisions are covered in advance, but a responsive as well as a proactive style is seen with other treatment decisions. Further research is needed to increase understanding of whether and how the physicians' strategies affect care processes and outcomes

Response to Wynne-Jones et al

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Symptom relief in patients with pneumonia and dementia: implementation of a practice guideline

Objective: This study aimed to assess the degree of implementation and barriers encountered in the use of a practice guideline for optimal symptom relief for patients with dementia and pneumonia in Dutch nursing homes. Methods: A process evaluation included assessment of reach, fidelity, and dose delivered using researcher's observations, and dose received was addressed in a question “use of the practice guideline,” which the physicians completed for each patient included in the study. Perceived barriers were assessed with a structured questionnaire (response 69%) and semi-structured interviews (n = 14), which were subject to qualitative content analysis. Results: Of the 55 physicians involved in the intervention phase, 87% attended an implementation meeting; 20 physicians joined the study later (reach). The intervention was implemented as planned, and all intervention components were delivered by the researchers (fidelity and dose delivered). Thirty-six physicians included 109 patients. For 81% of the patients, the treating physician stated to have used the guideline (dose received). The guideline was perceived as providing a good overview of current practice, but some physicians had expected a more directive protocol or algorithm. Further, recommended regular observations of symptoms were rarely performed. Physician's often felt that “this is not different from what we usually do,” and with the acute illness, there was not always enough time to (re)familiarize with the contents. Conclusions: The physicians used the practice guideline frequently despite important barriers. Future implementation may involve strategies such as multiple interactive meetings. Further, the greatest potential to alter usual practice should be emphasized, such as using observational instruments