Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines.

Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

Higher vedolizumab serum levels do not increase the risk of adverse events in patients with inflammatory bowel disease.

Background: Although its mechanism of action may confer a safety benefit, vedolizumab has still been associated with adverse events (AE). We investigated whether inflammatory bowel disease (IBD) patients with higher trough vedolizumab serum levels experienced an increased risk of AEs.Methods: This was a retrospective study of 76 IBD patients with at least one measurement of serum vedolizumab available. Vedolizumab levels ranged from <3.5 mcg/mL to 87.2 mcg/mL (median = 15.8 mcg/mL). The primary outcome was the rate of overall AEs. Secondary outcomes included the rates of infections, dermatologic reactions, infusion reactions, and other AEs. Multivariate logistic regression analysis was performed to evaluate the relationship between serum vedolizumab levels and AEs.Results: 19 patients out of 76 reported AEs. In patients with higher vedolizumab levels, there were 10 AEs reported out of 38 patients, which was not significantly different from the 9 AEs reported in 38 patients with lower vedolizumab levels (26.3% vs. 23.7%, p = .79). After adjustment for potential covariates, IBD patients with higher vedolizumab levels did not have higher odds of an AE than patients with lower levels (OR 0.92, 95% CI 0.30-2.81). Longer duration of therapy had higher odds of AEs, (OR of 1.04 at 95% CI 1.00-1.09, p = .0494 per additional month). None of the other variables were associated with a greater risk of AEs.Conclusions: There does not appear to be an increased risk of adverse events in IBD patients with higher vedolizumab levels, but duration of therapy may increase the risk of AEs.

Canadian expert consensus: management of hypersensitivity reactions to intravenous iron in adults.

BACKGROUND AND OBJECTIVES: Rare but potentially life-threatening hypersensitivity reactions can occur during the administration of intravenous iron. To provide guidance to healthcare professionals caring for adults receiving intravenous iron, a panel of 10 Canadian clinical experts developed a practical algorithm for the identification and management of hypersensitivity reactions to intravenous iron. MATERIALS AND METHODS: A systematic search of PubMed to February 2018 was performed. Articles related to hypersensitivity reactions were selected for review. The algorithm was developed during a 1-day live meeting based on the literature review and clinical expertise where evidence was lacking. The algorithm was then refined through an iterative process involving a web-based platform and virtual meetings. RESULTS: The algorithm provides guidance to healthcare professionals in preparing for and administering IV iron, as well as recognizing and managing hypersensitivity reactions to intravenous iron. Considerations for re-challenging patients who have experienced prior reactions are provided. CONCLUSION: Healthcare professionals who are involved in the care of patients receiving intravenous iron should be trained to anticipate, recognize and manage hypersensitivity reactions to intravenous iron to optimize patient care.

Application of Next Generation Quality/Statistical Process Control and Expert-Led Case Review to Increase the Consistency of Diagnostic Rates in Precancerous Colorectal Polyps.

BACKGROUND: Prior work suggests high interrater variability in the pathologist diagnostic rate (PDR) of the precancerous polyp sessile serrated adenoma (SSA). OBJECTIVES: To improve the diagnostic consistency in the pathological evaluation of colorectal polyp specimens with diagnostic rate awareness, using funnel plots (FPs)/control charts (CCs), and a focused group case review. METHODS: All colorectal polyp specimen (CRPS) reports September 2015 to August 2017 were analyzed at one institution. PDRs were extracted using a hierarchical free-text string matching algorithm and visualized using FPs, showing pathologist specimen volume versus PDR, and CCs, showing pathologist versus normed PDR. The FPs/CCs were centered on the group median diagnostic rate (GMDR). Pathologists were shown their baseline SSA diagnostic rate in relation to the practice, and in January 2017, there was a focused group case review/open discussion of approximately 40 sequential cases signed as SSA with a gastrointestinal pathology expert. RESULTS: Nine pathologists interpreted more than 250 CRPSs per year. FPs/CCs for the first and second years showed 6/4 and 3/1 P < .05/P < .001 pathologist outliers, respectively, in relation to the GMDR for SSA and 0/0 and 0/0 P < .05/P < .001 pathologist outliers, respectively, in relation to the GMDR for tubular adenoma (TA). An in silico kappa (ISK) for SSA improved from 0.52 to 0.62. CONCLUSION: Diagnostic rate awareness facilitated by FPs/CCs coupled with focused expert-led reviews may help calibrate PDR. Variation in SSA PDRs still remains high in relation to TA. ISK represents an intuitive, useful metric and Next Generation Quality/Statistical Process Control a promising approach for objectively increasing diagnostic consistency.

Stability of diagnostic rate in a cohort of 38,813 colorectal polyp specimens and implications for histomorphology and statistical process control.

This work sought to quantify pathologists' diagnostic bias over time in their evaluation of colorectal polyps to assess how this may impact the utility of statistical process control (SPC). All colorectal polyp specimens(CRPS) for 2011-2017 in a region were categorized using a validated free text string matching algorithm. Pathologist diagnostic rates (PDRs) for high grade dysplasia (HGD), tubular adenoma (TA_ad), villous morphology (TVA + VA), sessile serrated adenoma (SSA) and hyperplastic polyp (HP), were assessed (1) for each pathologist in yearly intervals with control charts (CCs), and (2) with a generalized linear model (GLM). The study included 64,115 CRPS. Fifteen pathologists each interpreted > 150 CRPS/year in all years and together diagnosed 38,813. The number of pathologists (of 15) with zero or one (p < 0.05) outlier in seven years, compared to their overall PDR, was 13, 9, 9, 5 and 9 for HGD, TVA + VA, TA_ad, HP and SSA respectively. The GLM confirmed, for the subset where pathologists/endoscopists saw > 600 CRPS each(total 52,760 CRPS), that pathologist, endoscopist, anatomical location and year were all strongly correlated (all p < 0.0001) with the diagnosis. The moderate PDR stability over time supports the hypothesis that diagnostic rates are amendable to calibration via SPC and outcome data.

Management of antithrombotic therapy after gastrointestinal bleeding: A mixed methods study of health-care providers.

Essentials The factors influencing anticoagulation management after gastrointestinal bleeding are unclear. Focus groups and a discrete choice experiments survey of health-care providers were conducted. Re-bleeding risk and thrombosis risk were the most important factors influencing decision making. Preference variability exists with a minority most sensitive to the anticoagulation indication. ABSTRACT: Background Oral anticoagulants (OACs) are permanently discontinued in up to 50% of patients after gastrointestinal (GI) bleeding despite evidence of benefit to restarting. Objectives We aimed to identify factors influencing health-care provider decision making regarding resuming OAC after GI bleeding and to identify preference groups. Patients/Methods We conducted focus group discussions (FGDs) with health-care providers. Themes identified and ranked through a dot voting exercise became the attributes for a discrete choice experiment survey of health-care providers developed using Sawtooth (Sawtooth Software, Provo, UT, USA). Hierarchical Bayes analysis was used to estimate preference coefficients (utilities) for each attribute. Preference groups were identified using latent class analysis. Results We conducted four FGDs involving 29 participants. The five most important factors identified in the FGDs were included in the survey. There were 250 survey respondents (mean age 45 years, 53% male). The most important factor was re-bleeding risk followed by thrombosis risk, index bleed severity, indication for OAC, and patient characteristics. Two preference groups were identified, a majority group (87% of respondents) placed the highest utility on re-bleeding risk followed by thrombosis risk, while a minority group (13% of respondents) placed the highest utility on OAC indication. Conclusions Overall, the most important factor influencing provider decision making was re-bleeding risk followed closely by thrombosis risk, although the indication for OAC was most important for a minority of respondents. This highlights variability among providers in an area lacking high-quality data to guide practice. Further research is needed to determine absolute rates of outcomes and patient values and preferences.

An Electronic Clinical Decision-Making Tool for Patients with Suspected Colorectal Cancer-Preliminary Evaluation in Patients Presenting with Rectal Bleeding.

BACKGROUND AND OBJECTIVES: The CarePath-CRC electronic clinical decision-making application was designed to assist physicians with evaluation of patients with suspected colorectal cancer (CRC). The physician completes an interactive checklist of evidence-based clinical parameters, and a recommended referral urgency is generated based on the post-test probability of CRC. This study aimed toward validation of the tool in symptomatic patients presenting with rectal bleeding. METHODS: The medical records of a sample of patients with histologically confirmed CRC from 2010 to 2014 were reviewed. The CarePath-CRC tool was applied retrospectively to all patients who initially presented with rectal bleeding, to determine its sensitivity for detecting CRC in this population. A generated recommendation of 'immediate referral' (referral ≤24 hours, expected endoscopy ≤2 weeks) or 'urgent referral' (expected consultation and endoscopy ≤4 and ≤8 weeks) was considered a positive test result. An a priori sensitivity of 90% was deemed adequate, based on test characteristics of the tool's individual clinical criteria. RESULTS: The tool was applied to 281 patients. A total of 69 (24.6%) and 211 (75.1%) patients met criteria for immediate and urgent referral, respectively. The remaining patient (0.4%) met criteria for 'possible priority referral', while none met criteria for 'no specific action recommended'. This resulted in a calculated sensitivity of 99.6% (95% confidence interval 98.0 to 99.9%). CONCLUSIONS: The CarePath-CRC tool is sensitive in the prediction of CRC in patients presenting with rectal bleeding. A prospective cohort study is being designed to allow for acquisition of comprehensive test performance characteristics and full validation of the instrument.

Resident Practice Audit in Gastroenterology (RPAGE): an innovative approach to trainee evaluation and professional development in medicine.

BACKGROUND: The Resident Practice Audit in Gastroenterology (RPAGE) captures assessments of knowledge, professionalism, and technical skills, in real time. This brief report describes this innovative instrument and aspects of its utility. METHODS: Assessment data on colonoscopy, endoscopy, and sigmoidoscopy procedures in 2016 were submitted to a repeated measures ANOVA with six within subjects' assessments and one between subjects' factor of year of specialization to evaluate construct validity. The validity hypothesis tested was that more experienced residents would be rated higher than less experienced residents. Reliability was assessed using Cronbach's alpha. RESULTS: The proportion of completed assessments was relatively low (9 to 22%). Overall reliability was high (α >0.8). There was evidence of validity as global ratings indicated higher competence for senior residents at colonoscopy (1.6) and upper endoscopy (1.4) than for more junior residents (1.9 and 2.1 respectively). These differences were significant for both colonoscopy, (F (1, 282) = 14.8, p <0.001) and endoscopy, F (1, 136) = 56.9, p <0.001. CONCLUSION: These findings suggest RPAGE is an acceptable electronic log of practice data, but may not be acceptable for workplace based assessment. A key next step will be to evaluate how information collected through RPAGE can help inform resident competency committees.

Domperidone Prescribing Practices Exposed Patients to Cardiac Risk despite a "Black Box" Warning: A Canadian Tertiary Care Center Study.

Background. In 2012, Health Canada released a warning regarding domperidone use, based on associations with life-threatening arrhythmias and death. Objective. This study aimed to compare the appropriateness of domperidone prescribing patterns before the advisory to those afterward. Methods. Two retrospective reviews were conducted for patients prescribed domperidone during quarters in 2005 and 2012. Outcomes included appropriateness of indication, dosing regimens, monitoring of electrolytes, baseline electrocardiogram performance and characteristics, presence of left ventricular dysfunction, and coprescription of QT-prolonging medications. Univariable and multivariable logistic regression analyses were performed. p values < 0.05 were considered significant. Results. 290 and 287 patients were analyzed in 2005 and 2012, respectively. Domperidone initiation in hospital decreased from 2005 to 2012 (71.4% versus 39.4%, p < 0.0001) as did prescriptions for nonapproved indications (84.8% versus 58.2%, p < 0.0001). In-hospital initiation predicted prescription for nonapproved indications (OR = 7.01, 95% CI 4.52-10.87, p < 0.0001). Use of domperidone as the sole GI drug predicted nonapproved indications (OR = 2.51, 95% CI 1.38-4.55, p = 0.002). Conclusions. The advisory was associated with more appropriate domperidone initiation and compliance with recommended dosages. Our study suggests the need for increased awareness of the dosing and monitoring of domperidone to ensure patient safety.

Effectiveness of test-enhanced learning in continuing health sciences education: a randomized controlled trial.

BACKGROUND: Increasing concerns over the effectiveness and quality of continuing medical education (CME) programs has encouraged educators to use theoretically driven empirical research to improve the educational value of these activities. Within cognitive psychology, theories of learning and knowledge acquisition, such as test-enhanced learning (TEL), may be used to enhance the effectiveness of CME protocols and delivery. The present study examined whether the pedagogical benefits of testing can be observed in practicing physicians. METHODS: A total of 83 physicians were recruited following an education session on constipation management and were randomized to either (a) the test condition (n = 43), where learners wrote a short test consisting of 10 short-answer questions (SAQs), or (b) the study condition (n = 40), where learners studied the same information. Four weeks later, 56 (68%) physicians completed a final test with 10 new SAQs, with 27 being from the initial test condition and 29 belonging to the initial study condition. RESULTS: Performance on the final SAQ test was equivalent for both test (42.5%) and study-only (41.2%) conditions (p = .71). DISCUSSION: The null findings in the present study are inconsistent with previous research showing the pedagogical benefits of testing relative to studying. Given that most TEL research focuses on novice learners, who lack strong associative memory networks, it is possible that TEL is specific to novices and not generalizable to experts. Alternative explanations focus on the importance of repeated, distributed testing with feedback.

The impact of fragility fracture on health-related quality of life : the importance of antifracture therapy.

Both general and specific health status instruments can be utilised in evaluating health-related quality of life (HR-QOL) deficits resulting from osteoporotic fractures. Osteoporotic hip, vertebral and wrist fractures significantly decrease HR-QOL in most HR-QOL domains investigated. The presence of multiple vertebral fractures leads to larger decrements in HR-QOL. More research needs to be completed with these HR-QOL tools to better assess the true burden of osteoporotic fractures, particularly in the case of hip fractures, as the burden is surely being underestimated without recognition of HR-QOL. Only when the burden of fragility fractures is understood, inclusive of HR-QOL, will the value of proven antifracture prevention and treatment therapies be appreciated. Information collected by HR-QOL instruments may provide new insight as to how to improve quality of life for patients with fractures and how to properly allocate healthcare spending.