Uptake and impact of synoptic reporting in a community care setting.

BACKGROUND: Breast cancer surgeries have traditionally been documented in narrative reports. Narrative reports have been shown to be incomplete. Synoptic reports utilize standardized templates to record data and have emerged as an alternative to narrative reports. This study evaluates the uptake and impact of synoptic reporting for breast cancer surgery in a community care setting. METHODS: A retrospective review of operative reports documenting breast cancer surgeries over a consecutive 3-year period. RESULTS: 772 narrative reports and 158 synoptic reports were reviewed. Synoptic reports were associated with a higher degree of overall completeness (60% vs 45%) when compared to narrative reports. 6 out of 7 surgeons that produced at least 5 synoptic and 5 narrative reports had increases in completeness with use of synoptic reporting. CONCLUSIONS: Use of synoptic reporting improves breast cancer operative report completeness and decreases superfluous content when compared to narrative reports. While synoptic report uptake during the study period was suboptimal there exists several means by which it can be improved, including investment in information technology infrastructure and emphasis on stakeholder engagement.

Completeness of breast cancer operative reports in a community care setting.

OBJECTIVES: The narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports. MATERIALS AND METHODS: A standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally. RESULTS: 772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness. CONCLUSION: The dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.

Impact of hospital volume on quality indicators for rectal cancer surgery in British Columbia, Canada.

BACKGROUND: The relationship between hospital volume and patient outcomes remains controversial for rectal cancer. METHODS: This is a population-based database study. Patients treated with surgery for a stage I to III rectal adenocarcinoma from 2003 to 2009 were identified. High-volume hospitals (HVH) were those centers performing 20 surgeries or more per year. Primary outcomes were operative and perioperative factors that have proven influence on patient outcomes. RESULTS: In all, 2,081 patients had surgery for rectal cancer. Of these, 1,690 patients had surgery in an HVH and 391 had surgery in a low-volume hospital. On multivariate analysis, patients who had surgery in an HVH were more likely to have sphincter-preserving surgery, 12 or more lymph nodes removed with the tumor, neoadjuvant radiation therapy, and receive pre-operative or postoperative chemotherapy. CONCLUSIONS: For rectal cancer patients in British Columbia, Canada, being treated at an HVH is associated with several quality indicators linked to better patient outcomes.

Non-R5-tropic HIV-1 in subtype A1 and D infections were associated with lower pretherapy CD4+ cell count but not with PI/(N)NRTI therapy outcomes in Mbarara, Uganda.

BACKGROUND: Previous studies suggest that infection with non-R5-tropic subtype B HIV-1, compared with R5, is associated with a more rapid decline in CD4 cell count, but does not affect PI/(N)NRTI therapy outcome. Here, we explored clinical correlates associated with viral tropism in subtype A1 and D infections. METHODS: HIV-1 subtype A1 (n = 196) and D (n = 143) pretherapy plasma samples and up to 7.5 years of posttherapy virologic and CD4 data were collected from a cross-sectional cohort in Mbarara, Uganda. Tropism and subtype were inferred using env V3 (geno2pheno) and gp41 (RIP) Sanger sequences. For each subtype, R5 infection was compared with non-R5 in terms of: pretherapy viral load and CD4 cell count (Mann-Whitney tests), and therapy outcomes, including time to virologic suppression, postsuppression virologic rebound, CD4 decline and CD4 recovery (log-rank tests). RESULTS: A 94% of all patients in this study achieved virologic suppression within median 3 months posttherapy. In both subtypes, non-R5 infection was associated with lower pretherapy CD4 cell count (non-R5 vs. R5; A: median 57 vs. 147 cells/µl P = 0.005; D: 80 vs. 128 cells/µl P = 0.006). Multivariable linear regression confirmed that tropism, not subtype nor the interaction between subtype and tropism, was a significant predictor of pretherapy CD4 cell count (P < 0.0001). None of pretherapy viral load, time to virologic suppression, virologic rebound, CD4 decline nor CD4 recovery was significantly different (all P > 0.09). CONCLUSION: Regardless of HIV-1 subtype or tropism, the majority of patients in this Ugandan cohort responded to therapy, even though non-R5 infection was associated with lower pretherapy CD4 cell count.

Impact of Using Audit Data to Improve the Evidence-Based Use of Single-Fraction Radiation Therapy for Bone Metastases in British Columbia.

PURPOSE: To assess the impact of a population-based intervention to increase the consistency and use of single-fraction radiation therapy (SFRT) for bone metastases. METHODS AND MATERIALS: In 2012, an audit of radiation therapy prescriptions for bone metastases in British Columbia identified significant interphysician and -center (26%-73%) variation in the use of SFRT. Anonymous physician-level and identifiable regional cancer center SFRT use data were presented to all radiation oncologists, together with published guidelines, meta-analyses, and recommendations from practice leaders. The use of SFRT for bone metastases from 2007 through 2011 was compared with use of SFRT in 2013, to assess the impact of the audit and educational intervention. Multilevel logistic regression was used to assess the relationship between the usage of SFRT and the timing of the radiation while controlling for potentially confounding variables. Physician and center were included as group effects to account for the clustered structure of the data. RESULTS: A total of 16,898 courses of RT were delivered from 2007 through 2011, and 3200 courses were delivered in 2013. The rates of SFRT use in 2007, 2008, 2009, 2010, 2011, and 2013 were 50.5%, 50.9%, 48.3%, 48.5%, 48.0%, and 59.7%, respectively (P<.001). Use of SFRT increased in each of 5 regional centers: A: 26% to 32%; B: 36% to 56%; C: 39% to 57%; D: 49% to 56%; and E: 73% to 85.0%. Use of SFRT was more consistent; 3 of 5 centers used SFRT for 56% to 57% of bone metastases RT courses. The regression analysis showed strong evidence that the usage of SFRT increased after the 2012 intervention (odds ratio 2.27, 95% confidence interval 2.06-2.50, P<.0001). CONCLUSION: Assessed on a population basis, an audit-based intervention increased utilization of SFRT for bone metastases. The intervention reversed a trend to decreasing SFRT use, reduced costs, and improved patient convenience. This suggests that dissemination of programmatic quality indicators in oncology can lead to increased utilization of evidence-based practice.

HIV drug resistance detected during low-level viraemia is associated with subsequent virologic failure.

BACKGROUND: The clinical implications of emergent HIV drug resistance on samples with low-level viraemia (LLV <1000 copies/ml) remain unclear. We undertook the present analysis to evaluate the impact of emergent HIV drug resistance at LLV on the risk of subsequent virologic failure. METHODS: One thousand, nine hundred and sixty-five patients had genotype results at LLV. Risk of virologic failure (≥1000 copies/ml) after LLV was evaluated by Kaplan-Meier analysis and Cox proportional hazards regression. Resistance was assessed using the Stanford algorithm or virtual phenotypes. Patients were grouped into four susceptibility categories ('GSS' or 'vPSS') during LLV, corresponding to the number of 'active' drugs prescribed: <1; 1-1.5; 2-2.5; and ≥3. RESULTS: A total of 1702 patients with follow-up on constant therapy were eligible for analysis. Participants excluded due to changing therapy or loss to follow-up before their next observation had mostly similar characteristics to included participants. There was a 'dose-dependent' increase in the hazard ratio for virologic failure with susceptibility categories at LLV. Compared with a GSS of at least 3, hazard ratios for virologic failure were 1.4 for GSS 2-2.5; 2.0 for GSS 1-1.5; and 3.0 for GSS less than 1 (P < 0.001). Numerous sensitivity analyses confirmed these findings. CONCLUSION: Our results demonstrate that emergent HIV drug resistance at LLV is strongly associated with subsequent virologic failure. Furthermore, we uncovered a 'dose-dependent' increase in the hazard ratio for virologic failure with decreasing GSS estimated at the time of LLV. On the basis of these findings, we propose that resistance genotyping be encouraged for HIV-infected individuals on antiretroviral therapy experiencing low-level viraemia.