Incorporating the patient-centered approach into clinical practice helps improve quality of care in cases of hypertension: a retrospective cohort study.

BACKGROUND: Treating hypertensive patients by integrating the patient-centered approach would influence the practice and outcome of treatment. Our purpose was to determine whether the implementation of a patient-centered approach in health care delivery can improve adhering to guidelines and the quality-of-care. METHODS: A retrospective study was conducted using secondary data from the electronic medical records of the patients treated in the two primary care outpatient settings at the Family Medicine (FM) and Social Security (SS) clinics. A key feature of the FM clinic is the incorporation of a patient-centered approach in its service delivery. Individual information regarding initial assessment and treatment at the follow-up visits was reviewed for 1 year. Comparison of adherence to treatment guidelines between the two primary care clinics was performed by using chi-square, Fisher's exact test or a t-test. To explore the difference in blood pressure and BP control between the two clinics, linear and logistic regression analysis respectively were performed with an adjustment for CV risk score in 2016 as a key confounder. RESULTS: The evidence included 100 records from each clinic, showed variation between the two primary care sites. The FM clinic had more complete records regarding family history of hypertension, assessment for secondary causes, prescription for lifestyle modification and appropriate adjustment of medication. Higher levels of blood pressure control were recorded in the FM clinic, specifically systolic pressure 2.92 mmHg (p = 0.073) and diastolic pressure 5.38 mmHg (p <  0.001) lower than those recorded in the SS clinic. There was a 2.96 times higher chance for BP goals to be achieved in patients in receipt of hypertensive care at the FM clinic (p = 0.004). CONCLUSIONS: Adopting a patient-centered approach in service delivery could improve the quality of care for hypertension patients in primary care in Thailand.

Impact of chronic kidney disease on mortality and cardiovascular outcomes after acute coronary syndrome: A nationwide data linkage study (ANZACS-QI 44).

AIMS: Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD). We examined the characteristics, management and outcomes of patients with CKD in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) national registry. METHODS: The cohort comprised New Zealand (NZ) patients with an acute coronary syndrome undergoing coronary angiography between January 2013 and December 2016. Patients were categorized according to their stage of CKD. Outcomes included all-cause and cause-specific mortality and hospitalization with myocardial infarction (MI), stroke and major bleeding. RESULTS: Of the 20 604 patients, 20.3% had normal renal function, with 53.3%, 23.3%, 1.7% and 1.4% having CKD stages 2, 3, 4 and 5 CKD, respectively. Patients with severe CKD were more likely to be Maori or Pacific and live in an area with greater socioeconomic deprivation. Death, recurrent MI or stroke, and major bleeding all increased incrementally with each worsening stage of CKD severity. Compared with those with normal renal function, patients with stage 5 CKD had a much higher all-cause (hazard ratio [HR] 16.41, 95% CI 13.06-20.61), cardiovascular (HR 16.38, 95% CI 12.17-22.04) and non-cardiovascular mortality (HR 13.66 9, 95% CI.56-19.51). In addition, patients with stage 5 CKD were at a higher risk of recurrent MI or stroke (HR 4.73, 95% CI 3.86-5.80) and bleeding (HR 5.84, 95% CI 4.39-7.76). CONCLUSION: CKD was associated with increased mortality and a high incidence of morbidity in patients undergoing coronary angiography in New Zealand. Initiatives to understand and improve outcomes in this group of patients are urgently needed.

Development of an electronic health record-based chronic kidney disease registry to promote population health management.

BACKGROUND: Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care. METHODS: Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m2 separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m2; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations. RESULTS: The CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact. CONCLUSIONS: A CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.

Temporal analysis of thyroid cancer management in a Melbourne tertiary centre.

BACKGROUND: The American Thyroid Association (ATA) management guidelines for thyroid cancer were revised in 2009. The aim of this study was to determine if management of thyroid cancer in our institution has changed in accordance with the introduction of the revised ATA guidelines (ATA2009 ), and to compare the characteristics and management of thyroid cancer in a Melbourne endocrine surgery unit over a 7-year period. METHODS: All patients treated by the Monash University Endocrine Surgery Unit for thyroid cancer between 2007 and 2013 were divided into two groups - the pre-ATA2009 group (2007-2010) and the post-ATA2009 group (2011-2013). Comparisons were made of the demographics, cytology, pathology, surgical outcome and adjuvant therapy using t-test and chi-squared tests. RESULTS: There were 333 patients in the pre-ATA2009 group and 342 patients in the post-ATA2009 group. Fewer non-diagnostic fine-needle aspiration cytology results were identified in the post-ATA2009 group (4% versus 0.9%; P = 0.01), while the rates of other fine-needle aspiration cytology categories were similar. There was a reduction in the use of radioactive iodine ablation in the post-ATA2009 group, both in the proportion of patients being treated (66% versus 48%; P < 0.001) and the dosages used (mean 96 mCi versus 80 mCi; P < 0.01), despite similar tumour size in both groups. CONCLUSION: The key changes in practice thought to be attributable to the 2009 revised ATA guidelines were the reduction in the use and dosage of radioactive iodine in the management of differentiated thyroid cancer.

Organ damage mitigation with the Baskent Sickle Cell Medical Care Development Program (BASCARE).

The Eastern Mediterranean is among the regions where sickle cell disease (SCD) is common. The morbidity and mortality of this disease can be postponed to adulthood through therapies implemented in childhood. The present study focuses on the organ damage-reducing effects of the Baskent Sickle Cell Medical Care Development Program (BASCARE), which was developed by a team who lives in this region and has approximately 25 years of experience. The deliverables of the program included the development of an electronic health recording system (PRANA) and electronic vaccination system; the use of low citrate infusion in routine prophylactic automatic erythrocyte exchange (ARCE) programs including pregnant women; the use of leukocyte-filtered and irradiated blood for transfusion; the use of magnetic resonance imaging methods (T2) for the management of transfusion-related hemosiderosis; and the implementation of an allogeneic hematopoietic stem cell transplantation protocol for adult patients. The sample was composed of 376 study subjects and 249 control subjects. The hospital's Data Management System and the central population operating system were used for data collection. BASCARE enabled better analysis and interpretation of complication and mortality data. Vaccination rates against influenza and pneumococcal disease improved (21.5% vs 50.8% and 21.5% vs 49.2%, respectively). Effective and safe ARCE with low citrate infusion were maintained in 352 subjects (1003 procedures). Maternal and fetal mortality was prevented in 35 consecutive pregnant patients with ARCE. Chelating therapy rates reduced from 6.7% to 5%. Successful outcomes could be obtained in all 13 adult patients who underwent allogeneic peripheral stem cell transplantation from a fully matched, related donor. No patients died by day 100 or after the first year. Cure could be achieved without graft loss, grades III to IV acute graft versus host disease, extensive chronic graft versus host disease, or other major complications. The BASCARE program significantly improved patient care and thereby prolonged the life span of SCD patients (42 ± 13 years vs 29 ±â€Š7 years, P < .001). We may recommend using such individualized programs in centers that provide health care for patients with SCD, in accordance with holistic approach due to the benign nature but malignant course of the disease.

Rural Health Clinic efficiency and effectiveness: insight from a nationwide survey.

This study reports the results of a nationwide survey of Rural Health Clinics (RHCs). The purpose was to identify factors that contribute to efficiency and effectiveness in RHCs. Factors related to cost efficiency were analyzed using multiple regression; factors related to the likelihood of providing preventive diabetic care, an effectiveness indicator, were analyzed using logistic regression. The study found: (1) technical efficiency to be positively related to cost efficiency; (2) non-profit control to be inversely related to cost efficiency in independent RHCs; and (3) provider-based RHCs and technology use to be related to the likelihood of providing preventive diabetic care. Implications for RHCs are: (1) improvement in technical efficiency could enhance cost efficiency; (2) visits to PAs and NPs, an indicator of process efficiency, may not guarantee the provision of preventive diabetic care; and (3) strategies for improving RHC efficiency and effectiveness may be different for provider-based and independent clinics.

Clinical process redesign for unplanned arrivals in hospitals.

*Emergency department performance had been deteriorating in NSW Health facilities and at Flinders Medical Centre before a fundamentally new approach involving a redesign method, additional bed capacity and more rigorous hospital performance management was applied. *Redesign was undertaken in over 60 hospitals in New South Wales. *Numerous disconnections and misalignments in the process of care delivery have been uncovered during the diagnostic phase of this redesign. *Solutions addressed the entire patient journey through the hospital, to produce smoother patient flow along the continuum of care. *To achieve a sustained improvement in performance, numerous solutions must be simultaneously implemented in each hospital. *With this multipronged approach, a turnaround in NSW emergency access performance has been achieved in the face of rising demand for services; the improvement has continued over 3 years. *This article reports on our findings from system-wide redesign for unplanned hospital attendances.

Primary care after psychiatric crisis: a qualitative analysis.

PURPOSE: Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients' experiences with health care after a psychiatric crisis. METHODS: A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients' responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA). RESULTS: At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group. CONCLUSIONS: This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.

Pediatric hematology and oncology in Iran.

UNLABELLED: Pediatric hematology and oncology (PHO) is a rapidly expandingfield. It has been our goal to meet the needs and increasing demands for comprehensive medical care of children suffering from chronic blood diseases and malignancies. In the past decade we have been able expand and optimize the PHO services throughout Iran, in general and in respect to their prevalence and clinical importance, by trained pediatric hematologist-oncologists, pediatric surgeons and improved para clinical facilities. Major beta-thalassemics receive blood transfusion and chelation therapy according to the current standards mostly at regional blood banks centers. To curb major beta-thalassemia a premarital screening program has been enacted and abortion has been legitimized if major thalassemia is diagnosed by CVS. Hemophiliacs are supervised and treated as indicated by Iranian Hemophilia Comprehensive Care Centers (IHCCC). Screening for transfusion related complications and transmitted viral diseases (HBV, HCV and HIV) in both cohorts are carried out in regular intervals and necessary management will be then carried out as indicated at respective specialized units. Childhood malignancies are treated according to protocols adopted from accredited institutions in the USA and Europe, with almost comparable results. BMT is available for selected patients with beta-thalassemia or malignancies. By going to public we have been able to rise general awareness about chronic blood diseases and childhood malignancies and have initiated establishment of parents groups and formation of NGOs to support these children and their families. Foundation of Iranian Society of Pediatric Hamatology and Oncology (ISPHO) in the year 2000 has been another step forward to consolidate and coordinate the available manpower and facilities. CONCLUSION: By evaluation of the country's main problems and shortcomings and conduction of collaborative studies and operation planning one will succeed to get the expected feedback and scientifically based approach to provide medical services to far reaching underdeveloped regions.

Identifying nurse and health visitor priorities in a PCT using the Delphi technique.

A three-stage Delphi investigation was undertaken over a 4-month period in a primary care trust to identify the perceived clinical needs of nurses. Practice nurses, district nurses, health visitors and community hospital nurses all participated. In round 1, there were 28 replies from these groups of nurses, in round 2 there were 31, and in round 3 there were 25 replies. In round 1, 77 issues (excluding duplications) were identified. These were separated into three themes according to the most appropriate method for addressing the issue: education (29 issues), research (16 issues) and management (32). In round 2, the issues were redistributed in the three areas and staff were asked to choose the ten most important issues from education, research and management. Finally, in round 3 the ten issues in education, research and management were prioritized in terms of the "most pressing". The most pressing education need was recognizing accountability; the most pressing research need was caseload/dependency scoring--matching staff levels to workload, and the most pressing management need was risk management, e.g. staff safety. The results have identified locally that there is a gap between the modernization agenda and what nursing staff consider to be the issues that need addressing locally. If measures are not put in place to address these local issues, there is a danger that nurses will not take a full and active role in the modernization of the NHS.