Description of Post-discharge Outcomes of Patients with COVID-19 in a Tertiary Referral Center in the Philippines.

Background and Objectives: The immediate post-discharge period of COVID-19 patients is a vulnerable state due to several complications that may arise during this time. Some patients get readmitted shortly after being discharged while others report persistence of symptoms, develop specialized needs, or observe a decline from their baseline functional capacity. Information on the outcomes of post-COVID discharge patients in our institution is currently lacking. This study described the outcomes of patients with COVID-19 after their discharge from the service areas of Philippine General Hospital. Methods: This study is a retrospective chart review involving charts of all adult patients discharged from the PGH COVID service areas last August 2021 to October 2021. Data from their follow up consults at 1 week, 1 month, and 3 months post-discharge were reviewed. Baseline characteristics and post-discharge outcomes including post-COVID symptoms, special care needs, mortality, rehospitalization, emergency consult, level of dependence, and ability to return to work were assessed. Results: A total of 171 patient charts were included. The mean age of patients was 53.7 years. Most were male (60.2%), unemployed (59.7%), non-smoker (55%), hypertensive (57.9%), diabetic (50.2%), and obese (50.2%). Most of them were oxygen requiring (80%) and with severe to critical COVID infection (72.5%) during admission. At 3 months post-discharge, 113 (66%) were stable and able to complete the follow up, 8 (4.6%) died, 9 (5.2%) got readmitted, and 41 (23.9%) were lost to follow up. Among those who were able to follow up after 3 months, 84 (74%) were asymptomatic. Among those who remained symptomatic, the most common symptoms were dyspnea, fatigue, and cough. After 3 months, 100 (88%) did not require special care needs, 100 (88%) were fully independent, and 45 (39.8%) were able to return to baseline work. Conclusions: Despite the majority of patients having severe to critical COVID infection during admission, most were asymptomatic within 3 months post-discharge. In those who developed persistent symptoms, dyspnea, cough, and fatigue were the most common symptoms identified regardless of COVID severity. Majority did not require special care needs.

Description of Core Performance Measures and Indicators of Patient Safety Used by Select Government and Private Hospitals in the Philippines.

Background: In 2008, the Department of Health (DOH) issued Administrative Order 2008-0023 that called for an "effective and efficient monitoring system that will link all patient safety initiatives". However, there are still no explicit and harmonized targets to measure effectiveness and to provide benchmarks that assess whether previous efforts were helpful. Objective: The study aimed to describe the status of patient safety performance measures and indicators on the international patient safety goals (IPSGs) in select hospitals in the Philippines. Methods: Descriptive, cross-sectional design was used to investigate currently used performance measures and indicators. Data collection included administration of a Hospital Patient Safety Indicators Questionnaire (HPSIQ) that summarized the currently used patient safety measures and indicators in the sampled Level 2 and level 3 hospitals and triangulation by review of documents such as hospital databases, protocols on reporting, and manuals for information gathering regarding patient safety. Performance measures were categorized using the Donabedian framework. Core indicators were identified through review of standards that cut across the six IPSGs and evaluation of overarching processes and concepts in patient safety. Results: Forty-one level 2 and 3 hospitals participated in the study. Most performance indicators were process measures (52%), while structure (31%) and outcome measures (17%) accounted for the rest. There is an obvious lack of structural requirements for patient safety in the hospitals included in this study. Less than half the hospitals surveyed implement risk assessment and management consistently. Reporting of events, near-misses, and patient safety data are widely varied among hospitals. Data utilization for quality improvement is not fully established in many of the hospitals. Patient engagement is not integrated in service delivery and performance measurement but is crucial in promoting patient safety. Conclusion: Mechanisms to improve hospitals' capacity to monitor, anticipate, and reduce risk of patient harm during the provision of healthcare should be provided. Having a unified set of definitions and protocols for measurement will facilitate reliable monitoring and improvement. Leadership and governance, both internal (e.g., hospital administrators) and external (e.g., DOH) that recognize a data-driven approach to policymaking and improvement of service delivery are crucial in promoting patient safety.

A comparison of the characteristics of adult medicine patients seeking telemedicine consultations versus in-person consultations in a Philippine public hospital.

Background: Telemedicine employs the use of technology to increase access to health care. This is especially relevant in developing countries where accessibility is an important issue. In developed countries, studies have shown that despite greater availability and accessibility, there are still disparities in telemedicine use. In the Philippines, however, it is unknown what factors are related to telemedicine use since its underutilization precludes proper characterization of telemedicine patients. We sought to compare the characteristics of telemedicine patients and patients consulting in-person in the internal medicine outpatient department of a Philippine public hospital. Methods: This is a retrospective descriptive study. Chart reviews were done for patients who consulted from May 2021 to July 2021. They were classified as either having telemedicine consults only or having in-person consults only. Each group was characterized and compared according to demographics, socioeconomic characteristics, health behaviors, and reasons for consultation. Results: Unadjusted analyses showed that younger, single, or employed individuals were more likely to use telemedicine. However, in adjusted analyses, no demographic factors were associated with telemedicine use. Only the patient type and medical concern were significantly different between patient groups in this public hospital setting. New patients and those consulting for clearance/referral purposes or endocrine-related symptoms were more likely to seek teleconsults. Conclusions: The findings showed which patients are more likely to use telemedicine in the Philippines. Continued telemedicine use for these patients should be explored to complement in-person medical care.

Predictors of readmission in a medical department of a tertiary university hospital in the Philippines.

BACKGROUND: Identifying factors that increase the risk for hospital readmission helps in determining potential targets for quality improvement efforts. The main objective of this study was to examine factors that predict increased risk of hospital readmission within 30 days of hospital discharge of patients under the General Medicine service of a tertiary government hospital in Manila, Philippines. METHODS: We performed a retrospective cohort study which included service patients 19 years old and above readmitted within 30 days following discharge. A total of 324 hospital readmissions within 30 days of discharge from January 1 to December 31, 2019 were reviewed. We estimated the rate of 30-day readmission and identified factors associated with preventable readmissions using multivariable logistic regression. RESULTS: Of the 4,010 hospitalizations under General Medicine service in 2019, 602 (18%) were readmissions within 30 days of discharge, majority of which were related to the index admission (90%) and unplanned (68%). Predictors of preventable readmission were emergency readmission (OR 3.37, 95% CI 1.72 to 6.60), having five to ten medications at discharge (OR 1.78, 95% CI 1.10 to 2.87), and presence of nosocomial infection (OR 1.86, 95% CI 1.09 to 3.17). The most frequent reason for readmission among preventable ones is health-care related infection (42.9%). CONCLUSIONS: We identified factors which increased the likelihood of preventable readmissions such as type of readmission, number of medications per day, and presence of nosocomial infections. We propose that these issues be addressed to improve healthcare delivery and reduce readmission-related expenditures. Further studies should be pursued to identify impactful evidence-based practices.

GOLD 2023 Update: Implications for Clinical Practice.

In 2022, over 3 million people died of chronic obstructive pulmonary disease (COPD) and the global burden of the disease is expected to increase over the coming decades. Recommendations for the treatment and management of patients with COPD are published by the Global Initiative for Chronic Obstructive Lung Disease, and updated annually with scientific evidence-based recommendations. The 2023 updates, published in November 2022, contain key changes to recommendations for diagnosis and treatment of COPD that are anticipated to have a significant impact on clinical practice for patients with COPD. Updates to how COPD is defined and diagnosed, including the expansion of contributing factors beyond tobacco use, have the potential to lead to the diagnosis of more patients and to allow for the implementation of early interventions for patients during early stages of the disease. Simplification of the treatment algorithms, and placement of triple therapy within these algorithms, will support clinicians in providing appropriate, timely treatment for patients with COPD with a focus on reducing the risk of future exacerbations. Finally, recognition of mortality reduction as a treatment goal in COPD supports an increase in the use of triple therapy, the only pharmacological intervention that has been demonstrated to improve survival for patients with COPD. Although further guidance and clarification are needed in some areas, such as use of blood eosinophil counts in guiding treatment decisions and implementation of treatment protocols following hospitalizations, recent updates to the GOLD recommendations will support clinicians in addressing current gaps in patient care. Clinicians should utilize these recommendations to drive the early diagnosis of patients with COPD, the identification of exacerbations, and the selection of appropriate, timely treatments for patients.

Prevalence and predictors of prolonged length of stay among patients admitted under general internal medicine in a tertiary government hospital in Manila, Philippines: a retrospective cross-sectional study.

BACKGROUND: Prolonged hospitalization leads to poorer health outcomes and consumes limited hospital resources. This study identified factors associated with prolonged length of stay (PLOS) among internal medicine patients admitted in a tertiary government hospital. METHODS: We reviewed the medical records of 386 adult patients admitted under the primary service of General Internal Medicine at the Philippine General Hospital from January 1 to December 31, 2019. PLOS was defined as at least 14 days for emergency admissions or 3 days for elective admissions. Sociodemographics, clinical characteristics, admission- and hospital system-related factors, disease-specific factors, outcome on the last day of hospitalization, and hospitalization costs were obtained. We determined the proportion with PLOS and reviewed reasons for discharge delays. We conducted multiple logistic regression analyses to assess associations between various factors and PLOS. RESULTS: The prevalence of PLOS is 19.17% (95% CI 15.54, 23.42). Positive predictors include being partially dependent on admission (aOR 2.61, 95% CI 0.99, 6.86), more co-managing services (aOR 1.26, 95% CI 1.06, 1.50), and longer duration of intravenous antibiotics (aOR 1.36, 95% CI 1.22, 1.51). The only negative predictor is the need for intravenous antibiotics (aOR 0.14, 95% CI 0.04, 0.54). The most common reason for discharge delays was prolonged treatment. The median hospitalization cost of patients with PLOS was PHP 77,427.20 (IQR 102,596). CONCLUSIONS: Almost a fifth of emergency admissions and a quarter of elective admissions had PLOS. Addressing factors related to predictors such as functional status on admission, number of co-managing services, and use of intravenous antibiotics can guide clinical and administrative decisions, including careful attention to vulnerable patients and judicious use of resources.

Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial.

BACKGROUND: Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. OBJECTIVE: In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). METHODS: We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians "cared" for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. RESULTS: We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. CONCLUSIONS: Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. TRIAL REGISTRATION: ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901.

Initiative to Improve Evidence-Based Chronic Obstructive Pulmonary Disease Hospitalist Care Using a Novel On-Line Gamification Patient Simulation Tool: A Prospective Study.

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality. Much of the disease burden comes from exacerbations requiring hospitalization. Unwarranted care variation and divergence from evidence-based COPD management guidelines among hospitalists is a leading driver of the poor outcomes and excess costs associated with COPD-related hospitalizations. We engaged with Novant Health hospitalists to determine if measurement and feedback using fixed-choice simulated patients improves evidence-based care delivery and reduces costs. We created a series of gamified acute-care COPD case simulations with real-time feedback over 16 weeks then performed a year-over-year analytic comparison of the cost, length of stay (LOS), and revisits over the six months prior to the introduction of the simulated patients, the four months while caring for the simulated patients, and the six months after. In total, 245 hospitalists from 15 facilities at Novant Health participated. At baseline, the overall quality-of-care was measured as 58.4% + 12.3%, with providers correctly identifying COPD exacerbation in 92.4% of cases but only identifying the grade and group in 61.9% and 49.5% of cases, respectively. By the study end, the quality-of-care had improved 10.5% (p < 0.001), including improvements in identifying the grade (+9.7%, p = 0.044) and group (+8.4%, p = 0.098). These improvements correlated with changes in real-world performance data, including a 19% reduction in COPD-related pharmacy costs. Overall, the annualized impact of COPD improvements led to 233 fewer inpatient days, 371 fewer revisit days, and inpatient savings totaling nearly $1 million. Engaging practicing providers with patient simulation-based serial measurements and gamified evidence-based feedback potentially reduces inpatient costs while simultaneously reducing patient LOS and revisit rates.

Randomized Trial to Improve Primary Care Patient Management and Patient Outcomes Using a Drug-Drug Interaction Test: Confirmation of the DECART Simulated Patient Clinical Utility Trial Results.

Drug-drug interactions (DDIs) are a serious problem in the healthcare system, leading to excess healthcare utilization and costs. We conducted a second prospective randomized, controlled trial to further establish the real-world clinical utility of a novel assay that objectively identifies potentially serious DDIs in real-world patients. Re-recruiting primary care physicians (PCPs) from our first randomized, controlled, simulated-patients study on DDIs, we experimentally introduced a definitive, urine-based mass spectrometry test intervention that the physicians could use when caring for their eligible patients. Patients were eligible if taking four or more prescription medications or suspected of taking other non-prescribed substances with potential medication interactions. The primary outcome was whether DDI testing changed clinical care. We explored a secondary outcome to see if the change in practice improved symptoms in patients with potential DDIs. A total of 169 control and 162 intervention patients were enrolled in the study, and their medical records were abstracted. In real-world patients, intervention physicians identified and/or treated a DDI at 3.0x the rate in their patient population compared to controls (21.6% vs. 7.1%, p < 0.001). Intervention physicians were more likely to discontinue or adjust the interacting agent compared to controls (62.9% vs. 8.3%, p = 0.001), and patient-reported symptoms also significantly declined (29.6% vs. 20.1%, p = 0.045). These results were nearly identical to concurrent measurements that used simulated patients, wherein intervention was more likely to both make a DDI diagnosis (56.3% vs. 21.6%, p < 0.001) and stop the interacting medications (58.3% versus 26.6%, p < 0.001). Bringing a new diagnostic test to market, particularly for an under-recognized clinical problem, requires robust data on both clinical validity and clinical utility. The results of this follow-up study showed that the use of DDI testing in real-world patients significantly improved (1) primary care patient management of drug interactions and (2) patient outcomes.

A nationwide program to improve clinical care quality in the Kyrgyz Republic.

BACKGROUND: To assess baseline quality of care in the Kyrgyz Republic in 2019 and determine the effect of online simulated patients in changing doctors' practice in three specific disease areas: non-communicable disease, neonatal/child health, and maternal health. METHODS: Over 2000 family health, pediatric, neonatology, therapy, and obstetric-gynecologic doctors from every rayon (district) hospital and at least one associated family health (Primary) care clinic participated. To adequately scale the project, the Ministry of Health used online simulated Clinical Performance and Value (CPV) vignettes. All doctors cared for the same set of patients in their clinical area. Over eight months in 2019, we gathered three rounds of CPV data in seven oblasts. RESULTS: Overall quality scores were highly variable at baseline (59.2% + 13.5%). After three rounds the average score increased 6.5% (P < 0.001). By the end of round three, the lowest scoring oblast was providing higher quality care compared to the highest scoring oblast in the initial round (64.2% in round 3 vs 62.4% in round 1), indicating greater adherence to the evidence base. Additionally, family health doctors ordered 26% fewer unnecessary tests (P < 0.05), while specialists ordered 39% fewer unnecessary tests (P < 0.05). If trends continue, this translates into a net annual savings of 63 million Kyrgyz som. CONCLUSIONS: This study demonstrates serial measurement of care provided by over 2000 physicians in the Kyrgyz Republic can be improved as measured by CPVs. This project may be a useful template to improve health care quality at a national level in other low- and middle-income country settings.

Randomized Trial on the Clinical Utility of a Novel Biomarker Panel to Identify Treatable Determinants of Chronic Pain.

Millions suffer daily from chronic pain diagnosed anatomically and treated with opioids. Research shows that underlying nutritional, metabolic and oxidative stressors, which drive the development or worsening of chronic pain, are not diagnosed despite the fact that treatment of these primary pain pathways relieves pain and increases function. One of the main reasons for this gap in care is the lack of a simple diagnostic assay to help clinicians make these diagnoses. We examined the clinical utility of a urine-based pain biomarker panel. Primary care physicians were randomized into the test group and compared to controls. We measured their ability to make the diagnosis and treat a total of nine standardized patients, with common but challenging cases of chronic pain, over two rounds of data collection in a pre-post design using a fixed-effects model. Intervention doctors received educational materials on a novel pain biomarker panel after the baseline round and had access to biomarker test results. Provider responses were measured against evidence-based criteria. The two study arms at baseline provided similar, poor care for three different primary pain pathways: nutritional deficiencies (5.0% control versus 9.2% intervention treated, p = 0.208), metabolic abnormalities (1.0% control versus 0% for intervention treated, p = 0.314), and oxidative stress (1.2% control versus 0% intervention treated, p = 0.152). After the introduction of the Foundation Pain Index (FPI) biomarker test, physicians in the intervention group were 41.5% more likely to make the diagnosis of a micronutrient deficiency, 29.4% more likely to identify a treatable metabolic abnormality and 26.1% more likely to identify an oxidative stressor. These diagnostic and treatment improvements were seen across all three case types, ranging from a relative +54% (p = 0.004) for chronic neuropathic pain to +35% (p = 0.007) in chronic pain from other causes to +38% (p = 0.002) in chronic pain with associated mental health issues. Intervention doctors were also 75.1% more likely to provide a non-opioid treatment to patients on chronic opioids (O.R. 1.8, 95% C.I. 0.8-3.7), 62% less likely to order unnecessary imaging for their patients with low back pain (O.R. 0.38, 95% C.I. 0.15-0.97) and 66% less likely to order an unnecessary pain referral (O.R. 0.34, 95% C.I. 0.13-0.90). This experimental study showed significant clinical utility of a validated pain biomarker panel that determines nutritional deficiencies, metabolic abnormalities and oxidative stressors that drive underlying treatable causes of pain. When integrated into routine primary care practice, this testing approach could considerably improve diagnostic accuracy and provide more targeted, non-opioid treatments for patients suffering from chronic pain.

Reducing Unwarranted Oncology Care Variation Across a Clinically Integrated Network: A Collaborative Physician Engagement Strategy.

PURPOSE: Addressing unwarranted clinical variation in oncology is a high priority for health systems that aspire to ensure consistent levels of high-quality and cost-effective care. Efforts to improve clinical practice and standardize care have proven challenging. Advocate Physician Partners undertook a patient simulation-based practice measurement and feedback project that was focused on breast and lung cancer to engage oncologists in the care standardization process. METHODS: One hundred three medical oncologists cared for online simulated patients using the Clinical Performance and Value platform, receiving feedback on how their care decisions compared with evidence-based guidelines and their peers. We repeated this process every 4 months over six rounds, measuring changes in quality-of-care scores. We then compared simulated patient results with available patient-level claims data. RESULTS: Over the course of the project, overall quality-of-care scores improved 11.9% (P < .001). Diagnostic accuracy increased 6.7% (P < .001) and correlated with improved treatment scores, including a nearly 10-percentage point increase in evidence-based chemotherapy regimens (P = .009) and a 56% increase in addressing palliative needs for patients with late-stage disease (P < .001). Unnecessary test ordering declined 25% (P < .001). We compared these results with available patient data and observed concordance with the metastatic imaging workup order rate for early-stage breast cancer. As unnecessary workups declined in the simulations and became more closely aligned with evidence-based guidelines, we saw similar rates of decline in the patient-level data. CONCLUSION: This study demonstrates that an oncology care standardization system that combines simulated patients with serial feedback increases evidence-based and cost-effective clinical decisions in patient simulations and patient-level data.

Reducing Unneeded Clinical Variation in Sepsis and Heart Failure Care to Improve Outcomes and Reduce Cost: A Collaborative Engagement with Hospitalists in a MultiState System.

OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants. METHODS: We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups. RESULTS: 107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%; P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs 72.1%; P = .038). In study year one, average LOS observed/expected (O/E) rates dropped by 8% for participants, compared to 2.5% in the comparator group, equating to an additional 570 hospital days saved among project participants. In study year two, cost O/E rates improved from 1.16 to 0.98 for participants versus 1.14 to 1.01 in the comparator group. Based on these improvements, we calculated total cost savings of $6.2 million among study participants, with $3.8 million linked to system-wide improvements and an additional $2.4 million in savings attributable to this project. CONCLUSIONS: CPV case simulation-based measurement and feedback helped drive improvements in evidence-based care that translated into lower costs and LOS, above-and-beyond other improvements at AdventHealth.

Standardising hospitalist practice in sepsis and COPD care.

BACKGROUND: Hospitalist medicine was predicated on the belief that providers dedicated to inpatient care would deliver higher quality and more cost-effective care to acutely hospitalised patients. The literature shows mixed results and has identified care variation as a culprit for suboptimal quality and cost outcomes. Using a scientifically validated engagement and measurement approach such as Clinical Performance and Value (CPV), simulated patient vignettes may provide the impetus to change provider behaviour, improve system cohesion, and improve quality and cost efficiency for hospitalists. METHODS: We engaged 33 hospitalists from four disparate hospitalist groups practising at Penn Medicine Princeton Health. Over 16 months and four engagement rounds, participants cared for two patients per round (with a diagnosis of chronic obstructive pulmonary disease [COPD] and sepsis), then received feedback, followed by a group discussion. At project end, we evaluated both simulated and real-world data to measure changes in clinical practice and patient outcomes. RESULTS: Participants significantly improved their evidence-based practice (+13.7% points, p<0.001) while simultaneously reducing their variation (-1.4% points, p=0.018), as measured by the overall CPV score. Correct primary diagnosis increased significantly for both sepsis (+19.1% points, p=0.004) and COPD (+22.7% points, p=0.001), as did adherence to the sepsis 3-hour bundle (+33.7% points, p=0.010) and correct admission levels for COPD (+26.0% points, p=0.042). These CPV changes coincided with real-world improvements in length of stay and mortality, along with a calculated $5 million in system-wide savings for both disease conditions. CONCLUSION: This study shows that an engagement system-using simulated patients, benchmarking and feedback to drive provider behavioural change and group cohesion, using parallel tracking of hospital data-can lead to significant improvements in patient outcomes and health system savings for hospitalists.

Impact of a protein-based assay that predicts prostate cancer aggressiveness on urologists' recommendations for active treatment or active surveillance: a randomized clinical utility trial.

BACKGROUND: Of the more than 1.1 million men diagnosed worldwide annually with prostate cancer, the majority have indolent tumors. Distinguishing between aggressive and indolent cancer is an important clinical challenge. The current approaches for assessing tumor aggressiveness are recognized as insufficient. A validated protein-based assay has been shown to predict tumor aggressiveness from prostate biopsy. The main objective of this study was to measure the clinical utility of this new assay in the management of early-stage prostate cancer. METHODS: One hundred twenty nine board-certified urologists were asked to participate in a randomized, two-arm experiment. We collected data over 2 rounds using simulated clinical cases administered via an online platform. The cases were all newly diagnosed Gleason 3 + 3 or 3 + 4 prostate camcer patients. Urologists in the intervention arm received a 15-min webinar on this protein-based assay and given assay test results for their simulated patients in round 2. Each case had a preferred recommendation of either active surveillance or active treatment. The measured outcome was rate of preferred recommendation, defined as urologists who recommended the proper treatment course. Analyses were done using difference-in-difference estimations. RESULTS: Using multinomial logistical regression, urologists who were given the assay results were significantly more likely to choose the preferred recommendation (active surveillance or active treatment) compared to controls (p = 0.004). These urologists were also significantly more likely to involve their patients in the treatment decision compared to controls (p = 0.001). CONCLUSIONS: By providing additional information to inform the physician's treatment plan, a protein-based assay shows demonstrable clinical utility confirmed through a rigorous randomized controlled study design and regression analyses to test for effects.

Dietary primary prevention of allergic diseases in children: the Philippine guidelines.

Allergic diseases, such as asthma, allergic rhinitis, eczema, and food allergy, are preventable diseases. Primary prevention strategies of allergic diseases have been in scrutiny. Effective prevention strategies maybe started prenatally, postnatally, during infancy, and even during childhood. These guidelines have been prepared by the Philippine Society of Allergy, Asthma and Immunology and the Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition. They aim to provide evidence-based recommendations for the dietary primary prevention of allergic diseases in children. The primary audience of these guidelines is all healthcare practitioners who manage patients with potential allergic conditions. These guidelines are based on an exhaustive review of evidences, mostly systematic reviews, randomized controlled trials, and cohort studies. However, there are still many gaps in the evidence of dietary primary prevention of allergic diseases.

Misdiagnosis of obstetrical cases and the clinical and cost consequences to patients: a cross-sectional study of urban providers in the Philippines.

BACKGROUND: Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia. DESIGN: Identical simulated cases were used to measure diagnostic accuracy for every provider (n=103). We linked misdiagnosis - identified by the simulated cases - to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews. RESULTS: The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39-3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients. CONCLUSION: Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient.

Longitudinal cohort study to determine effectiveness of a novel simulated case and feedback system to improve clinical pathway adherence in breast, lung and GI cancers.

OBJECTIVES: This study examined whether a measurement and feedback system led to improvements in adherence to clinical pathways. DESIGN: The M-QURE (Moffitt-Quality, Understanding, Research and Evidence) Initiative was introduced in 2012 to enhance and improve adherence to pathways at Moffitt Cancer Center (MCC) in three broad clinical areas: breast, lung and gastrointestinal (GI) cancers. M-QURE used simulated patient vignettes based on MCC's Clinical Pathways to benchmark clinician adherence and monitor change over three rounds of implementation. SETTING: MCC, located in Tampa, Florida, a National Cancer Institute Comprehensive Cancer Center. PARTICIPANTS: Three non-overlapping cohorts at MCC (one each in breast, lung and GI) totalling 48 providers participated in this study, with each member of the multidisciplinary team (composed of medical oncologists, radiation oncologists, surgeons and advanced practice providers) invited to participate. INTERVENTIONS: Each participant was asked to complete a set of simulated patient vignettes over three rounds within their own cancer specialty. Participants were required to complete all assigned vignettes over each of the three rounds, or they would be excluded from this study. PRIMARY OUTCOME MEASURE: Increased domain and overall provider care adherence to clinical pathways, as scored by blinded physician abstractors. RESULTS: We found significant improvements in pathway adherence between the third and first rounds of data collection particularly for workup and treatment of cancer cases. By clinical grouping, breast improved by 13.6% (p<0.001), and lung improved by 12.1% (p<0.001) over baseline, whereas GI showed a decrease of 1.4% (p=0.68). CONCLUSIONS: Clinical pathway adherence improved in a short timeframe for breast and lung cancers using group-level measurement and individual feedback. This suggests that a measurement and feedback programme may be a useful tool to improve clinical pathway adherence.

Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study.

BACKGROUND: Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care. METHODS: The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value(®) (CPV(®)) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways. RESULTS: Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline. CONCLUSION: We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made.