End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice.

BACKGROUND: Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia. METHODS AND FINDINGS: Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia. CONCLUSIONS: The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention.

Surgical team composition has a major impact on effectiveness and costs in laparoscopic donor nephrectomy.

PURPOSE: Limited evidence exists that optimization of surgical team composition may improve effectiveness of laparoscopic donor nephrectomy (LDN). METHODS: A retrospective cohort study with 541 consecutive LDNs. From 2003 to 2012, surgical team composition was gradually optimized with regard to the surgeons' experience, proficient assistance and the use of fixed teams. RESULTS: Multivariable analysis showed that a surgical team with an experienced surgeon had a significantly shorter operation time (OT) (-18 min, 95% CI -28 to -9), less estimated blood loss (EBL) (-64 mL, 95% CI -108 to -19) and shorter length of stay (LOS) (-1 day, 95% CI -1.6 to 0). Proficient assistance was also independently associated with a shorter OT (-43 min, 95% CI -53 to -33) and reduced EBL (-58 mL, 95% CI -109 to -6), whereas those procedures performed by fixed teams were related to a shorter operation (-50 min, 95% CI -59 to -43) and warm ischemia time (-1.8, 95% CI -2.1 to -1.5), a reduced mean complication grade (-0.14 per patient, 95% CI -0.3 to -0.02) and a shorter LOS (-1.1 day, 95% CI -1.7 to -05). Health care costs for LDN by one staff surgeon with unproficient assistance were 7.707 Euro, whereas costs for LDN by two staff surgeons in fixed teams were 5.614 Euro. CONCLUSIONS: Surgical team composition has a major impact on variables that reflect the effectiveness of LDN from the donors' perspective. Health care costs are lower for LDNs performed by two experienced surgeons in fixed team composition. We advocate the use of two experienced surgeons in fixed team composition for LDN.

Finding a BETTER way: a qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice.

BACKGROUND: Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention. METHODS: We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding. RESULTS: A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings. CONCLUSIONS: The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

High-definition with i-Scan gives comparable accuracy for detecting colonic lesions by non-expert and expert endoscopists.

BACKGROUND: Lesion detection rate during colonoscopy may be influenced by the endoscopist's experience. EPK-i system colonoscopy (i-Scan) can improve mucosal and vascular visualization for detecting lesions. AIM: To compare mucosal lesions detection rate and the withdrawal time of the instrument among non-expert and expert endoscopists. METHODS: Colonoscopy records of all consecutive patients undergoing first HD+ with i-Scan- or SWL-equipped colonoscopy for colorectal cancer screening over a twelve-month period were evaluated, in a "post hoc" analysis. RESULTS: 542 colonoscopies (389 HD+ with i-Scan; 153 SWL): expert and non-expert endoscopists did respectively 272 and 117 HD+ with i-Scan and 83 and 70 SWL colonoscopies. Expert endoscopists did more i-Scan colonoscopies than non-experts (p=0.006). In the SWL procedures, the experts detected mucosal lesions in more colonoscopies than non-experts (61/22 vs. 23/47, p=0.0001) and found a significantly higher mean number of lesions (1.34 vs. 0.47; p=0.0001). Experts detected more or less the same mean number of lesions with both imaging techniques, while among non-experts detection with HD+ with i-Scan was significantly better than with SWL imaging (1.39 vs. 0.47; p=0.0001). CONCLUSIONS: HD+ with i-Scan imaging enables less skilled endoscopists to achieve results comparable to those of experienced ones in detecting mucosal lesions.

Going the distance for certified cancer registrars.

Cancer registry departments are using electronic technology to solve the local and national Certified Tumor Registrar (CTR) shortages. As demand for CTRs continues to increase without an accompanied increase in the supply of qualified personnel, cancer registry departments are looking for new solutions to this growing local and national trend. In order to solve this problem, some cancer registries have started using telecommunication to fill the empty positions within their departments. This is the case at Roper St. Francis Healthcare (RSFH) in Charleston, SC, where Cancer Registry Manager, Ellen Kolender, RHIA, CTR, used telecommuting to fill one full-time and one part-time CTR position.

Associations between structural capabilities of primary care practices and performance on selected quality measures.

BACKGROUND: Recent proposals to reform primary care have encouraged physician practices to adopt such structural capabilities as performance feedback and electronic health records. Whether practices with these capabilities have higher performance on measures of primary care quality is unknown. OBJECTIVE: To measure associations between structural capabilities of primary care practices and performance on commonly used quality measures. DESIGN: Cross-sectional analysis. SETTING: Massachusetts. PARTICIPANTS: 412 primary care practices. MEASUREMENTS: During 2007, 1 physician from each participating primary care practice (median size, 4 physicians) was surveyed about structural capabilities of the practice (responses representing 308 practices were obtained). Data on practice structural capabilities were linked to multipayer performance data on 13 Healthcare Effectiveness Data and Information Set (HEDIS) process measures in 4 clinical areas: screening, diabetes, depression, and overuse. RESULTS: Frequently used multifunctional electronic health records were associated with higher performance on 5 HEDIS measures (3 in screening and 2 in diabetes), with statistically significant differences in performance ranging from 3.1 to 7.6 percentage points. Frequent meetings to discuss quality were associated with higher performance on 3 measures of diabetes care (differences ranging from 2.3 to 3.1 percentage points). Physician awareness of patient experience ratings was associated with higher performance on screening for breast cancer and cervical cancer (1.9 and 2.2 percentage points, respectively). No other structural capabilities were associated with performance on more than 1 measure. No capabilities were associated with performance on depression care or overuse. LIMITATION: Structural capabilities of primary care practices were assessed by physician survey. CONCLUSION: Among the investigated structural capabilities of primary care practices, electronic health records were associated with higher performance across multiple HEDIS measures. Overall, the modest magnitude and limited number of associations between structural capabilities and clinical performance suggest the importance of continuing to measure the processes and outcomes of care for patients. PRIMARY FUNDING SOURCE: The Commonwealth Fund.

The quality of reporting of orthopaedic randomized trials with use of a checklist for nonpharmacological therapies.

BACKGROUND: The Consolidated Standards of Reporting Trials statement for the reporting of randomized controlled trials has been limited by its applicability to surgical trials. In response, a Checklist to Evaluate a Report of a Nonpharmacological Trial was recently developed by the Consolidated Standards of Reporting Trials group to address reporting issues in surgical trials. We aimed (1) to apply the checklist for nonpharmacological therapies to orthopaedic randomized controlled trials across multiple journals from 2004 through 2005, and (2) to survey authors when methodological safeguards itemized in the checklist were not reported to determine whether they actually had been performed. We hypothesized that lack of reporting of a methodological safeguard did not necessarily mean it had not been conducted. METHODS: We searched for relevant orthopaedic randomized controlled trials across eight journals in the period from January 2004 through December 2005. We applied the Checklist to Evaluate a Report of a Nonpharmacological Trial to all eligible studies. We contacted authors to determine what methodological safeguards were actually used, especially when details remained unclear from the publication. RESULTS: We included eighty-seven randomized controlled trials from eighty-five scientific reports. In assessing the randomized controlled trials with the checklist for nonpharmacological therapies, seventy-three studies (84%) had unclear reporting of treatment allocation concealment. Only seventeen studies (20%) mentioned surgeon skill or experience. The blinding of patients, ward staff, rehabilitation staff, clinical outcome assessors, and nonclinical outcome assessors was unclear in forty-eight (55%), sixty-three (72%), sixty-four (74%), forty (46%), and thirty-three studies (38%), respectively. Authors from forty-three randomized controlled trials responded to our survey. The results of the survey showed that 41% (95% confidence interval, 25% to 58%) of the trials had adequate allocation concealment when this had been unclear from the report. Although the surgical experience of the investigators was rarely reported, most authors (70%) acknowledged that they had defined "surgical expertise criteria" such as minimum case criteria, specialized training, and clinical performance. The survey also showed that 28% to 40% of the trials had blinding of relevant groups despite the fact that the reporting of such blinding had been unclear in the publications. CONCLUSIONS: The quality of reporting in the orthopaedic literature was highly variable. Readers should not assume that bias-reducing safeguards that were not reported in a randomized controlled trial did not occur. Our study reinforces the need for the consistent use of a tool like the Checklist to Evaluate a Report of a Nonpharmacological Trial to assess the methodology of surgical trials.

The management of poor performance.

Identification of poor performance is in an integral part of government policy. The suggested approach for the identification of such problems, advocated by the General Medical Council, is that of appraisal. However, traditionally, there has been a reluctance to deal with poor performers, as all doctors have made mistakes and are usually only too ready to forgive and be non-critical of colleagues. The problems are widespread, and 6% of the senior hospital workforce in any 5-year period may have problems.

Nurses screening for skin cancer: an observation study.

Skin cancer rates in Australia are the highest in the world and it is an important cause of mortality and morbidity. Screening is a method of control for skin cancer/melanoma through early diagnosis and prompt referral and treatment. To date, there have been no controlled trials evaluating the impact of screening on morbidity and mortality, and hence insufficient evidence to recommend for or against routine screening for skin cancer/melanoma by primary care providers. Australian health authorities have called for studies that investigate the viability of using trained observers apart from medical practitioners--such as nurses, pharmacists and physiotherapists--in opportunistic screening for skin cancer in populations that have a high prevalence of these skin cancers, largely on the basis of cost arguments. We conducted a double blind observation screening study comparing the performance of nurses to those plastic surgeons participating in a skin cancer screening program. The role of the nurse in this program was not to diagnose skin cancer, but to not miss lesions that required further specialist examination. Measurements were recorded for 256 screenees. Plastic surgeons issued 77 (30%) individual referrals for lesions suspicious of being skin cancer. Nurse observations noted 73 (95%) of these 77 cases. The case for the pre-screening of large populations for skin/cancer by trained nurses warrants further attention.

The quality of Pap test specimens collected by nurses in a breast and cervical cancer screening clinic.

BACKGROUND: It is possible that nurses can help close the gap between the Healthy People 2000 clinical preventive services goals and current cancer screening rates by collecting Pap test specimens in clinical practices. The purpose of this analysis was to determine whether nurses can collect high-quality Pap tests. DESIGN: Retrospective cohort analysis of all Pap tests submitted to a commercial pathology laboratory between January 1, 1996 and July 31, 1996. Pap tests collected by the nurses at Rosebud Hospital (N = 404) were compared to the Pap tests collected by other providers at the Rosebud Hospital (N = 118) and the Pap tests collected by providers from all other sites (N = 22,696). SETTING: The Indian Health Service Hospital, Rosebud, South Dakota. SUBJECTS: Eight nurses who had been trained to collect Pap test specimens. MAIN OUTCOME MEASURES: The proportion of Pap test specimens that were wholly satisfactory and the proportion of Pap test specimens collected from nonpregnant patients that lacked endocervical cells. RESULTS: The proportion of specimens that were wholly satisfactory was 79.8% (95% CI = 75.9-83.7) for the nurses, 65.3% (95% CI = 56.7-73.9) for other Rosebud providers, and 81.7% (95% CI = 81.2-82.2) for non-Rosebud providers. The proportion of specimens that lacked endocervical cells and were from nonpregnant patients was 6.4% (95% CI = 4.0-8.8) for Rosebud nurses, 8.5% for other Rosebud providers (95% CI = 3.5-13.5), and 7.9% for non-Rosebud providers (95% CI = 7.6-8.2). CONCLUSIONS: After one week of training, nurses can collect Pap test specimens that are of the same quality as the specimens collected by physicians, nurse practitioners, and physician assistants. The widespread availability of female nurses and the high quality of their work suggest that they can contribute to the Healthy People 2000 goals by collecting Pap test specimens.

Es la superintendencia de salud la moderna inquisición de hospitales y médicos?

La Superintendencia Nacional de Salud, reestructurada a partir del decreto 1266 de 1994, posee poderes casi omnímodos sobre las instituciones de salud. Lamentablemente los fallos de dicha entidad no han sido los más acertados y ello nos obliga, como médicos, a conocer a fondo los aspectos jurídicos y sociales que rigen dicha entidad.

Frequência de perfuraçöes das luvas protetoras durante diferentes procedimentos cirúrgicos / Perforation frequency of the protective gloves during differents surgical procedures

Para avaliar a freqüência das perfuraçoes nas luvas protetoras, durante o ato cirúrgico, os autores apresentam um estudo prospectivo testando 2576 luvas, utilizando o método de pressao de água, para constatar a existência de perfuraçoes. Para refletir o perfil do trabalho diferente de cirurgioes e instrumentadora, foram criados grupos diferentes e anotados os locais das perfuraçoes. Entre os cirurgioes, 1821 luvas, 23,2 por cento deles foram perfuradas e entre as instrumentadoras, 764 luvas foram testadas, constatando-se um percentual de 21 por cento, que estavam perfuradas no mínimo uma vez. Os índices mais altos de perfuraçoes foram encontradas nos procedimentos ortopédicos (37,5 por cento), os menores índices nos procedimentos cistoscópicos (3 por cento) e laparoscópicos (9,5 por cento). Na equipe dos cirurgioes, o polegar (48,2 por cento) e o indicador (22,7 por cento) sao as regioes mais afetadas, o mesmo no grupo das instrumentadoras (polegar 34,8 por cento; indicador 38,5 por cento). Os autores sugerem a adoçao de estratégias para a diminuiçao do risco da infecçao cruzada, como aprimoramento da técnica cirúrgica, efetuar as suturas teciduais com maior cuidado, habituar-se ao uso de duas luvas e outras.

The limits of medical quality assurance systems.

Quality Assurance (QA) via the process of review systems is a retrospective look at what was. It is a picture of the past. Any such system is bound to have limitations, because the past cannot be changed. In QA, the ultimate aim should be to educate physicians as to where they made mistakes so that they can learn how to prevent them in the future. The distribution of what mistakes can be avoided, so that all physicians can learn from others' mistakes, takes the whole team closer to the aim of real QA--preventing mistakes. The first part of this article looks at QA in general terms; the second part looks at inherent biases that should be removed so that the team reaches the goal of bona fide quality.