Search

BackgroundEffective clinical decision support systems require accurate translation of practice recommendations into machine-readable artifacts; developing code sets that represent clinical concepts are an important step in this process. Many clinical coding systems are currently used in electronic health records, and it is unclear whether all of these systems are capable of efficiently representing the clinical concepts required in executing clinical decision support systems. ObjectiveThe aim of this study was to evaluate which clinical coding systems are capable of efficiently representing clinical concepts that are necessary for translating artifacts into executable code for clinical decision support systems. MethodsTwo methods were used to evaluate a set of clinical coding systems. In a theoretical approach, we extracted all the clinical concepts from 3 preventive care recommendations and constructed a series of code sets containing codes from a single clinical coding system. In a practical approach using data from a real-world setting, we studied the content of 1890 code sets used in an internationally available clinical decision support system and compared the usage of various clinical coding systems. ResultsSNOMED CT and ICD-10 (International Classification of Diseases, Tenth Revision) proved to be the most accurate clinical coding systems for most concepts in our theoretical evaluation. In our practical evaluation, we found that International Classification of Diseases (Tenth Revision) was most often used to construct code sets. Some coding systems were very accurate in representing specific types of clinical concepts, for example, LOINC (Logical Observation Identifiers Names and Codes) for investigation results and ATC (Anatomical Therapeutic Chemical Classification) for drugs. ConclusionsNo single coding system seems to fulfill all the needs for representing clinical concepts for clinical decision support systems. Comprehensiveness of the coding systems seems to be offset by complexity and forms a barrier to usability for code set construction. Clinical vocabularies mapped to multiple clinical coding systems could facilitate clinical code set construction.

BackgroundIn Belgium, the construction of a national electronic point-of-care information service, EBMPracticeNet, was initiated in 2011 to optimize quality of care by promoting evidence-based decision-making. The collaboration of the government, health care providers, evidence-based medicine (EBM) partners, and vendors of electronic health records (EHR) is unique to this project. All Belgian health care professionals get free access to an up-to-date database of validated Belgian and nearly 1000 international guidelines, incorporated in a portal that also provides EBM information from other sources than guidelines, including computerized clinical decision support that is integrated in the EHRs. ObjectiveThe objective of this paper was to describe the development strategy, the overall content, and the management of EBMPracticeNet which may be of relevance to other health organizations creating national or regional electronic point-of-care information services. MethodsSeveral candidate providers of comprehensive guideline solutions were evaluated and one database was selected. Translation of the guidelines to Dutch and French was done with translation software, post-editing by translators and medical proofreading. A strategy is determined to adapt the guideline content to the Belgian context. Acceptance of the computerized clinical decision support tool has been tested and a randomized controlled trial is planned to evaluate the effect on process and patient outcomes. ResultsCurrently, EBMPracticeNet is in "work in progress" state. Reference is made to the results of a pilot study and to further planned research including a randomized controlled trial. ConclusionsThe collaboration of government, health care providers, EBM partners, and vendors of EHRs is unique. The potential value of the project is great. The link between all the EHRs from different vendors and a national database held on a single platform that is controlled by all EBM organizations in Belgium are the strengths of EBMPracticeNet.

Background: Uptake of advance care planning in routine nursing home care is low. Through extensive literature review, theoretical development, and stakeholder involvement, we developed the ACP+ intervention. Aims: To evaluate the effects of ACP+ on the knowledge and self-efficacy (confidence in own skills) of nursing home care staff concerning advance care planning. Design: Cluster randomized controlled trial, conducted between February 2018 and January 2019 (NCT03521206, clinicaltrials.gov). ACP+ is a multicomponent intervention aimed at training and supporting nursing home staff and management in implementing advance care planning in nursing home practice through a train-the-trainer approach over 8 months. Fourteen nursing homes were randomized using a matched-pairing strategy, seven received ACP+, seven followed usual practice. Analyses (intention-to-treat) involved linear mixed models. Setting/participants: Nursing homes in Flanders (Belgium). Results: 694 of 1017 care staff (68% response rate) at baseline and 491 of 989 care staff (50%) post-intervention (8 months) returned questionnaires. Post-intervention, care staff's self-efficacy concerning advance care planning was significantly higher in the intervention than in the control group (baseline-adjusted mean difference 0.57; 95% CI 0.20–0.94; p = 0.003; Cohen's d = 0.30). Advance care planning knowledge (95% CI 0.95–1.15; p = 0.339; ratio: 1.04) did not differ significantly between groups. Conclusions: The ACP+ intervention for nursing homes improved care staff's self-efficacy but not their knowledge concerning advance care planning. Considering the comprehensive and multi-component approach used, these effects were smaller than expected. Reasons for this may be related to the chosen follow-up period, outcomes and measurements, or to the intervention itself and its implementation. [ABSTRACT FROM AUTHOR]

Featured Application: This work will inform the revision process of the ISO Standard ISO 11239:2012 on dose forms of medicinal products and provide tools for training and supporting experts in the pharmaceutical industry and in regulatory affairs, during the standardization of national drug dictionaries to the global terminology for dose forms of EDQM. The aim was (1) to analyse the features of the EDQM terminology, (2) to formulate proposals for minor changes and (3) to create a small ontology of dose forms, based on characteristics of EDQM, and suitable for alignment with other dose form terminologies. The 428 Pharmaceutical Dose Forms (PDF) ("human and veterinary" only) were extracted from the EDQM Standard Terms database. A quantitative and qualitative analysis of the textual definitions of the terms was conducted. Through an analysis of unique combinations of different sets of descriptors and characteristics, a small ontology was built in three levels. For the 143 transformable PDFs, the administrable dose form was made explicit, with 121 requiring only one transformation and 22 multiple transformations, of which 10 include "no transformation". Different levels of aggregations of the 428 PDFs were tested in 4 analyses, ranging from 206 to 383 unique combinations. An ontology in Webprotégé was created of 22 higher-level concepts (based on the intended site characteristics) and 69 intermediate-level terms (newly created) to accommodate the 428 PDFs of EDQM. EDQM Dose Form terminology is suitable terminology in terms of granularity, for defining dose forms of medicinal products, to enable fair comparison of similar medicinal products, and global identification of medicinal products (IDMP). Recommendations for minor improvements and a simple ontology for dose forms are proposed. [ABSTRACT FROM AUTHOR]

Background. Elderly hospitalized patients have low survival rates after cardiopulmonary resuscitation, especially in the long tenn. This study aims to investigate the prevalence of patients with do-not-resuscitate (DNR) status on acute geriatric wards and the characteristics of the preceding decision-making process. Methods. On all 94 geriatric wards in Flanders, Belgium (2002), the geriatrician who performed the bulk of clinical work was asked to fill in a retrospective structured mail questionnaire. Results. The response rate was 72.3%. A DNR status was attributed to 20.3% of patients. A significant higher prevalence of patients with DNR status was found on wards with a geriatrician who had been active in patient care for 15 years or less and on wards with a DNR policy. Mostly, DNR status was attributed when the patient's condition declined (34.0%) or became critical (29.0%). Geriatricians consulted at least one person in 81.0% of the cases: (head) nurses in 72.2%, next of kin in 61.9%, the patient's general practitioner in 22.6%, and the patient him- or herself in 15.7%. Reasons stated to make a DNR decision were the prognosis (68.1%) and the physical condition of the patient (62.2%). Age was mentioned in only 21.1% of the cases, always in combination with other reasons. Conclusions. One fifth of patients on acute geriatric wards in Flanders have DNR status. The decision to attribute DNR status is most often made late in the course of the disease. (Head) nurses and the patient's next of kin are often consulted, the patient and his or her general practitioner rarely.

Background: A team-based approach has been advocated for advance care planning in nursing homes. While nurses are often put forward to take the lead, it is not clear to what extent other professions could be involved as well. Objectives: To examine to what extent engagement in advance care planning practices (e.g. conversations, advance directives), knowledge and self-efficacy differ between nurses, care assistants and allied care staff in nursing homes. Design: Survey study. Participants/setting: The study involved a purposive sample of 14 nursing homes in Flanders, Belgium. Nurses, care assistants and allied care staff (e.g. social workers, physical therapists) completed a survey. Ethical considerations: The study was approved by the University Hospital of Brussels (B.U.N. 143201834759), as part of a cluster randomized controlled trial (clinicaltrials.gov NCT03521206). Results: One hundred ninety-six nurses, 319 care assistants and 169 allied staff participated (67% response rate). After adjusting for confounders, nurses were significantly more likely than care assistants to have carried out advance care planning conversations (odds ratio 4; 95% confidence interval 1.73–9.82; p < 0.001) and documented advance care planning (odds ratio 2.67; 95% confidence interval 1.29–5.56; p < 0.001); differences not found between allied staff and care assistants. Advance care planning knowledge total scores differed significantly, with nurses (estimated mean difference 0.13 (score range 0–1); 95% confidence interval 0.08–0.17; p < 0.001) and allied staff (estimated mean difference 0.07; 95% confidence interval 0.03–0.12; p < 0.001) scoring higher than care assistants. We found no significant differences regarding self-efficacy. Discussion: While nursing home nurses conducted more advance care planning conversations and documentation than allied care staff and care assistants, these two professional groups may be a valuable support to nurses in conducting advance care planning, if provided with additional training. Conclusions: Allied care staff and care assistants, if trained appropriately, can be involved more strongly in advance care planning to enhance relational and individual autonomy of nursing home residents, alongside nurses. Future research to improve and implement advance care planning should consider this finding at the intervention development stage. [ABSTRACT FROM AUTHOR]