Do medical specialists accept claims-based Audit and Feedback for quality improvement? A focus group study.

OBJECTIVES: Audit and Feedback (A&F) is a widely used quality improvement (QI) intervention in healthcare. However, not all feedback is accepted by professionals. While claims-based feedback has been previously used for A&F interventions, its acceptance by medical specialists is largely unknown. This study examined medical specialists' acceptance of claims-based A&F for QI. DESIGN: Qualitative design, with focus group discussions. Transcripts were analysed using discourse analysis. SETTING AND PARTICIPANTS: A total of five online focus group discussions were conducted between April 2021 and September 2022 with 21 medical specialists from varying specialties (urology; paediatric surgery; gynaecology; vascular surgery; orthopaedics and trauma surgery) working in academic or regional hospitals in the Netherlands. RESULTS: Participants described mixed views on using claims-based A&F for QI. Arguments mentioned in favour were (1) A&F stimulates reflective learning and improvement and (2) claims-based A&F is more reliable than other A&F. Arguments in opposition were that (1) A&F is insufficient to create behavioural change; (2) A&F lacks clinically meaningful interpretation; (3) claims data are invalid for feedback on QI; (4) claims-based A&F is unreliable and (5) A&F may be misused by health insurers. Furthermore, participants described several conditions for the implementation of A&F which shape their acceptance. CONCLUSIONS: Using claims-based A&F for QI is, for some clinical topics and under certain conditions, accepted by medical specialists. Acceptance of claims-based A&F can be shaped by how A&F is implemented into clinical practice. When designing A&F for QI, it should be considered whether claims data, as the most resource-efficient data source, can be used or whether it is necessary to collect more specific data.

Service Improvements and Workload Increases: Royal College of Radiologists (RCR) Re-Audit of Curative Intent Radiotherapy for Non-Small Cell Lung Cancer (NSCLC).

AIMS: The Royal College of Radiologists (RCR) audit of radical radiotherapy (RR) for patients with non-small cell lung cancer (NSCLC) in 2013 concluded that there was under-treatment compared to international comparators and marked variability between cancer networks. Elderly patients were less likely to receive guideline recommended treatments. Access to technological developments was low. Various national and local interventions have since taken place. This study aims to re-assess national practice. MATERIALS AND METHODS: Radiotherapy departments completed one questionnaire for each patient started on RR for 4 weeks in January 2023. RESULTS: Ninety-three percent of centres returned data on 295 patients. RR has increased 70% since 2013 but patients on average wait 20% longer to start treatment (p = 0.02). Staging investigations were often outside a desirable timeframe (79% of PET/CT scans). Advanced planning techniques are used more frequently: 4-dimensional planning increased from 33% to 90% (P < 0.001), cone beam imaging from 67% to 97% (p < 0.001) and colleague led peer review increased from 41% to 73% (P < 0.001). CONCLUSION: There have been significant improvements in care. There has been a considerable increase in clinical oncology workload with evidence of stress on the system that requires additional resourcing.

ASGBI trauma committee position statement: a national audit of trauma laparotomy in the UK - an unmet need.

Patients who undergo laparotomy for major trauma are amongst the most critically unwell patients, and they have high morbidity and mortality rates. Despite 20 yr of improvements in resuscitation practices, those who present with hypotension continue to have mortality rates of up to 50%. Currently there is no mechanism for capturing national audit data on these patients, leading to their exclusion from potential quality improvement initiatives. We argue that there is an unmet need for quality assurance in this patient cohort and outline possible mechanisms to address this.

Nationwide Audit of Postoperative Mortality and Complications After Digestive Cancer Surgery: Will New Legal Thresholds be Sufficient?

BACKGROUND: French policymakers recently chose to regulate high-risk digestive cancer surgery (DCS). A minimum of five cases per year should be performed for each of the following types of curative cancer surgery: esophagus/esogastric junction (ECS), stomach (GCS), liver (LCS, metastasis included), pancreas (PCS), and rectum (RCS). This study aimed to evaluate the hypothetical beneficial effects of the new legal minimal volume thresholds on the rates of 90-day postoperative mortality (90POM) for each high-risk DCS. METHODS: This nationwide observational population-based cohort study used data extracted from the French National Health Insurance Database from 1 January 2015-31 December 2017. Mixed-effects logistic regression models were performed to estimate the independent effect of hospital volume. RESULTS: During the study period, 61,169 patients (57.1 % male, age 69.7 ±12.2 years) underwent high-risk DCS including ECS (n = 4060), GCS (n = 5572), PCS (n = 8598), LCS (n = 10,988), and RCS (n = 31,951), with 90POM of 6.6 %, 6.9 %, 6.0 %, 5.2 %, and 2.9 %, respectively. For hospitals fulfilling the new criteria, 90POM was lower after adjustment only for LCS (odds ratio [OR],15.2; 95 % confidence interval [CI], 9.5-23.2) vs OR, 7.6; 95 % CI, 5.2-11.0; p < 0.0001) and PCS (OR, 3.6; 95 % CI, 1.7-7.6 vs OR, 2.1; 95 % CI, 1.0-4.4; p<0.0001). With higher thresholds, all DCSs showed a lower adjusted risk of 90POM (e.g., OR, 0.38; 95 % CI, 0.28-0.51) for PCS of 40 or higher. CONCLUSION: Based on retrospective data, thresholds higher than those promulgated would better improve the safety of high-risk DCS. New policies aiming to further centralize high-risk DCS should be considered, associated with a clear clinical pathway of care for patients to improve accessibility to complex health care in France.

A National audit of the care of patients with acute kidney injury in England and Wales in 2019 and the association with patient outcomes.

BACKGROUND: Acute kidney injury (AKI) is a common complication of hospitalisations. This national audit assessed the care received by patients with AKI in hospital Trusts in England and Wales. METHODS: Twenty four hospital Trusts across England and Wales took part. Patients with AKI stage2/3 were identified using the UK Renal Registry AKI master patient index. Data was returned through a secure portal with linkage to hospital episode statistic mortality and hospitalisation data. Completion rates of AKI care standards and regional variations in care were established. RESULTS: 989 AKI episodes were included in the analyses. In-hospital 30-day mortality was 31-33.1% (AKI 2/3). Standard AKI interventions were completed in >80% of episodes. Significant inter-hospital variation remained in attainment of AKI care standards after adjustment for age and sex. Recording of urinalysis (41.9%) and timely imaging (37.2%) were low. Information on discharge summaries relating to medication changes/re-commencement and follow-up blood tests associated with reduced mortality. No quality indicators relating to clinical management associated with mortality. Better communication on discharge summaries associated with reduced mortality. CONCLUSIONS: Outcomes for patients with AKI in hospital remain poor. Regional variation in care exists. Work is needed to assess whether improving and standardising care improves patient outcomes.

Peri-operative cardiac arrest in children as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest. An activity survey estimated UK paediatric anaesthesia annual caseload as 390,000 cases, 14% of the UK total. Paediatric peri-operative cardiac arrests accounted for 104 (12%) reports giving an incidence of 3 in 10,000 anaesthetics (95%CI 2.2-3.3 per 10,000). The incidence of peri-operative cardiac arrest was highest in neonates (27, 26%), infants (36, 35%) and children with congenital heart disease (44, 42%) and most reports were from tertiary centres (88, 85%). Frequent precipitants of cardiac arrest in non-cardiac surgery included: severe hypoxaemia (20, 22%); bradycardia (10, 11%); and major haemorrhage (9, 8%). Cardiac tamponade and isolated severe hypotension featured prominently as causes of cardiac arrest in children undergoing cardiac surgery or cardiological procedures. Themes identified at review included: inappropriate choices and doses of anaesthetic drugs for intravenous induction; bradycardias associated with high concentrations of volatile anaesthetic agent or airway manipulation; use of atropine in the place of adrenaline; and inadequate monitoring. Overall quality of care was judged by the panel to be good in 64 (62%) cases, which compares favourably with adults (371, 52%). The study provides insight into paediatric anaesthetic practice, complications and peri-operative cardiac arrest.

Can natural language processing be effectively applied for audit data analysis in gynaecological oncology at a UK cancer centre?

BACKGROUND: The British Gynaecological Cancer Society (BGCS) has highlighted the disparity of ovarian cancer outcomes in the UK compared to other European countries. Therefore, cancer quality assurance audits and subspecialty training are important in improving the UK standard of care for these patients. The current workforce crisis afflicting the NHS creates difficulty in dedicating teams of clinicians to these audits. We present a single institution study to evaluate if NLP-generated code can improve the efficiency of ovarian cancer and subspeciality reaccreditations audits. We used the chat bot Google Bard to write Visual Basic Applications algorithms that utilise Excel files from electronic health records. METHODS: Primary ovarian cancer data from 2019 to 2022 was retrospectively collected from the Cambridge University Hospital electronic health records. The surgical subspecialty reaccreditation audit analysed the 2022 surgical database. A modular coding approach with Google Bard was applied to generate audit algorithms. The time to complete these current audits was compared against the 2016 ovarian cancer and 2020 subspeciality reaccreditation audits. RESULTS: The previous ovarian cancer audit conducted in 2016 required 3 clinicians for the 135 cases and data collection required 1800 min. Data analysis was completed in 300 min. The current ovarian cancer audit allocated 2 clinicians to the 600 surgical cases. Data collection was completed in 3120 min, 3360 min for code development and 720 min for testing. The 2020 subspecialty reaccreditation audit was completed in 360 min. The 2022 subspecialty reaccreditation audit was completed in 1680 min, with 960 min for code development, 240 for debugging and 480 min for testing. CONCLUSION: We have demonstrated that NLP-generated code can significantly increase the efficiency of surgical quality assurance audits by eliminating the need for manual data analysis. With the current trajectory of NLP development, increasingly complex algorithms can be developed with minimal programming knowledge.

[Inter-radiopharmacy audit, a tool for individual and collective progress]. / L'audit croisé inter-radiopharmacies, un outil de progrès individuel et collectif.

OBJECTIVE: Radiopharmacy is a high-risk hospital pharmacy carried out in a complex regulatory environment. Adopting an audit culture is a priority issue to secure the radiopharmaceutical drug circuit. The objective of the study is to demonstrate the value of cross auditing, a hybrid between internal and third party auditing. METHOD: A 125-item evaluation tool applying to the entire radiopharmacy activity was designed. Two radiopharmacies were audited internally and then a cross-audit was organized between the two units. RESULTS: For one of the units, 12 items were rated differently during the two audits. Four of the ten non-conformities that were not observed during the internal audit were rated as critical by the radiopharmacist auditor. For the second radiopharmacy, 15 items were rated differently, two of which were rated as critical. CONCLUSION: Personal opinion may unintentionally influence a reasoning, but the independence of the auditor during cross auditing is a guarantee of objectivity. It is an alternative to internal audits which have become routine and less efficient and unlike third party audits, the auditor is familiar with the constraints and concerns of the field. The interest of this approach goes beyond the simple evaluation of non-conformities. Cross auditing encourages the sharing of experience and know-how between professionals in the same field. It creates a dynamic collaboration between establishments and contributes to the individual and collective improvement of the safety of the radiopharmaceutical drug circuit.

Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study.

BACKGROUND: The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. METHODS: Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. RESULTS: In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. CONCLUSION: Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Audit of antimicrobial stewardship in medical inpatients in Waikato, New Zealand 2021.

AIMS: Given the threat of rising antimicrobial resistance (AMR), 10 audit standards were selected to audit antimicrobial stewardship (AMS) in secondary care to assess guideline adherence and establish quality improvement initiatives in antimicrobial prescribing. METHODS: Patients were included if they received intravenous (IV) antibiotics across seven medical wards in Waikato or Thames hospitals, New Zealand, in November 2021. Audit standards were defined from the regional antimicrobial prescribing policy and adult antimicrobial guidelines. RESULTS: In total, 205 patients were audited. Microbiological sampling standards were met in 87 of 126 occasions (69.0%). Antimicrobial choices adhered to guidelines in 89 of 163 patients (54.6%), where guidelines were available. Documentation of antimicrobial indications in the medical notes and antimicrobial review at 48 to 72 hours met the standards at over 90%. Only 2 of 13 patients (15.4%) receiving piperacillin/tazobactam or a carbapenem were discussed with Infectious Diseases (ID). Documentation of indications and durations on paper-based medication charts was infrequent, around 12%. Evaluating for health equity, similar results were observed for Maori and non-Maori. CONCLUSIONS: Our audit identified specific areas for AMS quality improvement initiatives. Regular audit should become an essential element of the New Zealand AMS strategy. We believe increased AMS resources are required.

Provision of acute oncology services in the UK: data from the Society for Acute Medicine Benchmarking Audit 2022 (SAMBA22).

Acute oncology services (AOS) manage acute cancer-related presentations alongside acute medical teams. This study assessed AOS provision against national peer review measures and the burden of acute cancer-related admissions. The 2022 Society for Acute Medicine Benchmarking Audit surveyed UK hospitals, collecting hospital-level and patient-level data for all medical admissions over a 24-h period. Logistic regression models were constructed to identify differences in patient outcomes for cancer-related admissions. Most hospitals (n=120 or 91.6%) reported having an AOS. There was heterogeneity in AOS provision, with many failing to meet peer-review measures. Of the 7,116 patients, 542 (7.6%) were cancer-related admissions. Cancer-related admissions had greater clinical acuity (p<0.05), length of stay (p<0.001) and 14-day mortality (adjusted odds ratio (OR)=3.54, 95% confidence interval (CI): 2.41-5.22, p<0.001) compared with other medical admissions. Increasing availability of AOS with integration of ambulatory pathways are vital next steps to improving care for acute cancer-related admissions.