Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records.

IMPORTANCE: Hypertension poses a significant public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal. OBJECTIVE: This study aims to develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence. DESIGN: We conducted a qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System who had at least two consecutive visits between January 1, 2013, and October 31, 2018. SETTING: This was a thematic analysis of EHR data to generate a real-world taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension. PARTICIPANTS: We identified patients with markedly elevated blood pressure ([BP]; defined as at least 2 consecutive readings of BP ≥160/100 mmHg) and no prescription for antihypertensive medication within a 90-day of the 2nd BP elevation (n=4,828). We randomly selected 100 records from the group of all eligible patients for qualitative analysis. MAIN OUTCOMES AND MEASURES: The scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management. RESULTS: Thematic saturation was reached after analyzing 100 patient records. Three content domains emerged: clinician-related scenarios (neglect and diffusion of responsibility), patient-related scenarios (patient non-adherence and patient preference), and clinical complexity-related scenarios (diagnostic uncertainty, maintenance of current intervention and competing medical priorities). Through a metareview of literature, we identified several plausible influencing factors, including a lack of protocols and processes that clearly define the roles within the institution to implement guidelines, infrastructure limitations, and clinicians' lack of autonomy and authority, excessive workload, time constraints, clinician belief that intervention was not part of their role, or perception that guidelines restrict clinical judgment. CONCLUSIONS AND RELEVANCE: This study illuminates reasons for suboptimal adherence to guidelines for managing markedly elevated BP. The taxonomy of suboptimal adherence scenarios, derived from real-world EHR data, is pragmatic and provides a basis for developing targeted interventions to improve clinician guideline adherence and patient outcomes.

Totally implantable venous access ports and associated complications in sub-Saharan Africa: a single-centre retrospective analysis.

Purpose: Although totally implantable venous access ports (TIVAPs) have been safe and valuable in the management of cancer and other chronically ill patients who require long-term intermittent venous access, a few complications have been reported with their use. Data on the use of TIVAPs in sub-Saharan Africa and other low- and middle-income regions is limited. In this study, we determine the complications that arise from TIVAP use at a cancer centre in Nigeria. Patients and Methods: Between 4 January 2018 and 15 September 2020, 100 patients received TIVAPs at our centre, primarily for the administration of chemotherapy for the treatment of solid tumours. Data were retrospectively extracted from the institutional electronic medical records and descriptive analysis of patient and disease characteristics, port-specific data and data on complications and outcomes was conducted. Results: The 100 patients who were implanted with TIVAPs at our cancer centre had their devices in situ for a total of 27,183 days, with a mean duration of use of 272 catheter-days (SD: 267 days; range: 2-952). TIVAP-related complications were identified in 13 patients (13%), i.e., an incidence of 0.478 complications/1,000 catheter-days. The mean time to onset of complications was 61 days (SD: 105 days; median: 23 days; range: 0-389). The complications observed include port-site bleeding, pocket infection, cutaneous site infection, arterial puncture, wound dehiscence, difficult access (due to port malpositioning and port site fibrosis) and others. No deaths, pneumothorax, haemothorax, catheter occlusions, or catheter-associated venous thromboses were recorded. Conclusion: Our study shows that TIVAPs can be used successfully in our environment and presents a case for more widespread use to improve both the patient experience and the ability of healthcare providers to deliver optimal treatment.

Cancer presentation patterns in Lagos, Nigeria: Experience from a private cancer center.

BACKGROUND: Cancer incidence and mortality is increasing worldwide. In 2018, there were an estimated 18.1 million new cancer cases and 9.6 million cancer deaths. In Nigeria, it is estimated that 100,000 new cases occur annually, with a high case fatality ratio. The burden of cancer in Nigeria is significant, as the country still grapples with infectious diseases and has limited data on cancer epidemiology. Our study is descriptive using data from a hospital-based registry. OBJECTIVES: This retrospective study assesses the characteristics of patients that presented to a private cancer center in Lagos, Nigeria. We aimed to update knowledge on the current trends of cancer in Nigeria as exemplified by the experience of this cancer center and set a foundation for guiding future research and policy efforts in cancer screening, prevention, and control. METHODS: The records of all the 548 oncology patients registered at the Lakeshore Cancer Center (LCC) cancer registry from January 2015 to June 2018 were reviewed for this study. RESULTS: Most common cancer types were breast cancer for females (46%) and prostate cancer for males (32%). 92% of the tumors were malignant and 97% of the patients were symptomatic. Among patients diagnosed with cancer, 49% were ≤ 50 years old, 90% paid for their healthcare out of pocket, and 67% did not complete treatment. CONCLUSIONS: This study highlights the state of cancer care in Nigeria and should guide future research, with a focus on public awareness, screening programs and implementation of novel cancer control policies and infrastructure that supports early detection.

Time to return to school in child and adolescent burn patients from a sub-Saharan tertiary hospital.

BACKGROUND: Africa, with the largest number of paediatric burns needs to focus more attention on paediatric burn survivors. Burn injury truncates schooling in child and adolescent burn patients. The aim of this study was to determine the time to return to school and factors influencing this in child and adolescent burn patients. METHODOLOGY: A cross-sectional study of child and adolescent patients aged one to nineteen years that had been managed for bun injuries. Demographic variables were obtained from archived computerized data. Phone interviews were conducted to obtain time to return to school variables using a questionnaire. Descriptive statistics, students t test, fishers exact test and Chi square test were uses as appropriate for analysis on data on SPSS version 23. A p value <0.05 was considered statistically significant. RESULTS: Thirty-one patients were recruited for the study. There was a female preponderance, 19 (61.3%). The mean age of the patients was 7.2 (±5.3) years. Scald injuries were the commonest [N = 14 (45.2%)] cause of burn. The mean Total Burn Surface Area (TBSA) was 14.1 (±12.0)%. The mean length of hospital stay was 30 (±59) days. The mean time to return to school after discharge from the hospital was 8.4 (±8.7) weeks. The occurrence of burns on the trunk was significantly (p = 0.048) associated with an earlier time to return to school. CONCLUSION: Time to return to school from burn injury and from discharge in child and adolescent burn survivors in this study are at least three times longer than previous studies. The burn care team needs to consider school re-entry programs for these children.