Search

Surveillance after complete remission of intestinal metaplasia (CRIM) is essential. Current recommendations are to sample visible lesions first, followed by random 4-quadrant biopsy sampling of the original Barrett's esophagus (BE) length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance, and histology of BE recurrences. We performed an analysis of 216 patients who achieved CRIM after endoscopic eradication therapy for dysplastic BE at a Barrett's Referral Unit between 2008 and 2021. The anatomic location, recurrence histology, and endoscopic appearance of dysplastic recurrences were evaluated. After a median of 5.5 years (interquartile range, 2.9-7.2) of follow-up after CRIM, 57 patients (26.4%) developed nondysplastic BE (NDBE) recurrence and 18 patients (8.3%) developed dysplastic recurrence. From 8158 routine surveillance biopsy samplings of normal-appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. One hundred percent of dysplastic tubular esophageal recurrences were visible and in BE islands, whereas 77.8% of gastroesophageal junction dysplastic recurrences were nonvisible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: buried or subsquamous BE, irregular mucosal pattern, loss of vascular pattern, and nodularity or depression. The yield of routine surveillance biopsy sampling of normal-appearing tubular esophageal neosquamous epithelium was zero. BE islands with indistinct mucosal or loss of vascular pattern, nodularity or depression, and/or signs of buried BE should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy sampling protocol with a focus on meticulous inspection, followed by targeted biopsy sampling of visible lesions and random 4-quadrant biopsy sampling of the gastroesophageal junction. [ABSTRACT FROM AUTHOR]

Context: Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level.Objectives: This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making.Methods: Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser.Results: About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120).Conclusion: Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: The aims of this study were to quantify the frequency of adverse outcomes after elective knee arthroscopies in Victoria, Australia, and to identify risk factors associated with adverse outcomes. Methods: We performed a retrospective, longitudinal cohort study of elective orthopaedic admissions using the Victorian Admitted Episodes database, a routinely collected public and private hospital episodes database linked to death registry data, from July 1, 2000, to June 30, 2009. Adverse outcome measures included pulmonary embolism (PE), deep vein thrombosis (DVT), hemarthrosis, effusion and synovitis, cellulitis, wound infection, synovial fistula, acute renal failure, myocardial infarct, stroke, and death. Patients were excluded if they had an additional procedure performed during the arthroscopy admission. We identified complications during the admission and within readmissions up to 30 days after the procedure. PE, DVT, and death within 90 days of the arthroscopy episode were also examined. We used logistic regression analysis to identify risk factors associated with complications. Results: After we excluded 16,807 patients (8.5%) with an additional procedure during their admission, there were 180,717 episodes involving an elective arthroscopy during the period studied. The most common adverse outcomes within 30 days were DVT (579, 0.32%), effusion and synovitis (154, 0.09%), PE (147, 0.08%), and hemarthrosis (134, 0.07%). The 30-day orthopaedic readmission rate was 0.77%, and there were 55 deaths (0.03%). Within 90 days of arthroscopy, we identified 655 events of DVT (0.36%) and 179 PE events (0.10%). Logistic regression analysis identified that potential risk factors for complications were older age, presence of comorbidity, being married, major mechanical issues, and having the procedure performed in a public hospital. Conclusions: Our study found 6.4 adverse outcomes per 1,000 elective knee arthroscopy procedures (0.64%), with the 3 most common complications being DVT, effusion and synovitis, and PE. We have also identified risk factors for adverse outcomes, particularly chronic kidney disease, myocardial infarction, cerebrovascular accident, and cancer. Level of Evidence: Level III, retrospective cohort study. [Copyright &y& Elsevier]

Abstract: Background and objective: The ICD-9-CM adaptation of the Charlson comorbidity score has been a valuable resource for health services researchers. With the transition into ICD-10 coding worldwide, an ICD-10 version of the Deyo adaptation was developed and validated using population-based hospital data from Victoria, Australia. Methods: The algorithm was translated from ICD-9-CM into ICD-10-AM (Australian modification) in a multistep process. After a mapping algorithm was used to develop an initial translation, these codes were manually examined by the coding experts and a general physician for face validity. Because the ICD-10 system is country specific, our goal was to keep many of the translated code at the three-digit level for generalizability of the new index. Results: There appears to be little difference in the distribution of the Charlson Index score between the two versions. A strong association between increasing index scores and mortality exists: the area under the ROC curve is 0.865 for the last year using the ICD-9-CM version and remains high, at 0.855, for the ICD-10 version. Conclusion: This work represents the first rigorous adaptation of the Charlson comorbidity index for use with ICD-10 data. In comparison with a well-established ICD-9-CM coding algorithm, it yields closely similar prevalence and prognosis information by comorbidity category. [Copyright &y& Elsevier]

Objectives: To evaluate key quality indicators for acute care and one-year outcomes following acute ischaemic stroke (IS), intracerebral haemorrhage (ICH), or transient ischaemic attack (TIA) by diabetes status.Materials and Methods: Observational cohort study (2009-2013) using linked data from the Australian Stroke Clinical Registry and hospital records. Diabetes was ascertained through review of hospital records. Multilevel regression models were used to evaluate the association between diabetes and outcomes, including discharge destination, and mortality and hospital readmissions within one-year of stroke/TIA.Results: Among 14,132 patients (median age 76 years, 46% female), 22% had diabetes. Compared to patients without diabetes, those with diabetes were equally likely to receive stroke unit care, but were more often discharged on antihypertensive agents (79% vs. 68%) or with a care plan (50% vs. 47%). In patients with TIA, although 86% returned directly home after acute care, those with diabetes more often had a different discharge destination than those without diabetes. Diabetes was associated with greater all-cause mortality (hazard ratio 1.13, 95% CI 1.04-1.23) in patients with IS/ICH; and with both greater all-cause (1.81, CI 1.35-2.43) and CVD mortality (1.75, CI 1.06-2.91) in patients with TIA. Similarly, diabetes was associated with greater rates of all-cause readmission in both patients with IS/ICH and TIA.Conclusions: Despite good adherence to best care standards for acute stroke/TIA, patients with comorbid diabetes had worse outcomes at one-year than those without comorbid diabetes. Associations of diabetes with poorer outcomes were more pronounced in patients with TIA than those with IS/ICH. [ABSTRACT FROM AUTHOR]

Background: The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) codes are commonly used to identify patients with diseases or clinical conditions for epidemiological research. We aimed to determine the diagnostic agreement and factors associated with a clinician-assigned stroke diagnosis in a national registry and the ICD-10-AM codes recorded in government-held administrative data.Materials and Methods: Data from 39 hospitals (2009-2013) participating in the Australian Stroke Clinical Registry (AuSCR) were linked and merged with person-level administrative data. The AuSCR clinician-assigned stroke diagnosis was the reference standard. Concordance was defined as agreement between the clinician-assigned diagnosis and the ICD-10-AM codes for acute stroke or transient ischemic attack (TIA) (ICD-10-AM codes: I61-I64, G45.9). Multivariable logistic regression was undertaken to assess factors associated with coded diagnostic concordance.Results: A total of 14,716 patient admissions were included (46% female, 63% ischemic, 14% intracerebral hemorrhage [ICH], 18% TIA and 5% unspecified stroke based on the reference standard). Principal ICD-10-AM code concordance was ICH: 76.7%; ischemic stroke: 72.2%; TIA: 80.2%; unspecified stroke: 50.8%. Factors associated with a greater odds of ischemic stroke concordance included: treatment in a stroke unit (adjusted Odds Ratio, aOR:1.58; 95% confidence interval (CI) 1.37, 1.82); length of stay >4 days (aOR:1.30; 95% CI 1.17, 1.45); and discharge destination other than home (Residential care aOR:1.57; 95% CI 1.24, 1.96; Inpatient rehabilitation aOR:1.63; 95% CI 1.43, 1.86).Conclusions: Diagnostic concordance varied based on stroke type. Future research to improve the quality of coding for stroke should focus on patients not treated in stroke units or with shorter lengths of stay where documentation in medical records may be limited. [ABSTRACT FROM AUTHOR]

Background: Identification and modification of risk factors are essential for preventing intracerebral hemorrhage (ICH). Prior hospital admissions provide opportunities to intervene. We reported hospital admissions prior to primary ICH and investigated factors associated with survival.Methods: Cohort design using patient-level data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative datasets from four states (VIC, NSW, WA, QLD). Prior hospital admission is divided into within 90 days and more than 90 days prior to the index ICH event. The International Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes were used to define principal diagnoses of previous admissions/presentations and comorbidities. Factors associated with survival after ICH were investigated using Cox proportional hazards regression.Results: Among 15,482 admissions for stroke, 2,098 (14%) had an ICH (median age 76 years, 52% male), 1,732 patients (83%) had a prior hospital admission, including 440 patients (21%) within 90 days of their index ICH admission. Patients with prior admission were older, had more comorbidities, and greater hospital frailty risk score than those without prior admission. Diseases of the circulatory system (14%) were the most common principal diagnoses for hospital admissions prior to ICH. Of the comorbidities associated with survival, neoplasms conferred the greatest hazard of death at 180 days after ICH (adjusted hazard ratio 1.42, 95% confidence interval 1.15 - 1.76, p = 0.001).Conclusion: Hospital presentations in the 90 days prior to ICH are common. Future research should be focussed on identifying opportunities for preventing ICH. [ABSTRACT FROM AUTHOR]

Abstract: There is interest in evaluating the quality of critical care by auditing patient outcomes after hospital discharge. Risk adjustment using acuity of illness scores, such as Acute Physiology and Chronic Health Evaluation (APACHE III) scores, derived from clinical databases is commonly performed for in-hospital mortality outcome measures. However, these clinical databases do not routinely track patient outcomes after hospital discharge. Linkage of clinical databases to administrative data sets that maintain records on patient survival after discharge can allow for the measurement of survival outcomes of critical care patients after hospital discharge while using validated risk adjustment methods. Objective: The aim of this study was to compare the ability of 4 methods of risk adjustment to predict survival of critically ill patients at 180 days after hospital discharge: one using only variables from an administrative data set, one using only variables from a clinical database, a model using a full range of administrative and clinical variables, and a model using administrative variables plus APACHE III scores. Design: This was a population-based cohort study. Patients: The study sample consisted of adult (>15 years of age) residents of Victoria, Australia, admitted to a public hospital intensive care unit between 1 January 2001 and 31 December 2006 (n = 47,312 linked cases). Logistic regression analyses were used to develop the models. Results: The administrative-only model was the poorest predictor of mortality at 180 days after hospital discharge (C = 0.73). The clinical model had substantially better predictive capabilities (C = 0.82), whereas the full-linked model achieved similar performance (C = 0.83). Adding APACHE III scores to the administrative model also had reasonable predictive capabilities (C = 0.83). Conclusions: The addition of APACHE III scores to administrative data substantially improved model performance to the level of the clinical model. Although linking data systems requires some investment, having the ability to evaluate case ascertainment and accurately risk adjust outcomes of intensive care patients after discharge will add valuable insights into clinical audit and decision-making processes. [ABSTRACT FROM AUTHOR]

Aims: To assess trends in hospital admissions for non-traumatic lower extremity amputations (LEAs) and for mortality following LEAs in adult patients with type 1 diabetes (T1DM) or type 2 diabetes (T2DM) admitted to hospitals in Victoria, Australia during 2004-2016.Methods: Using hospital discharge data, we calculated age- and sex- adjusted admission rates for incident cases of any LEA, minor LEAs, major LEAs and 12-month mortality following any LEAs for patients according to diabetes type. Joinpoint regression analysis was used to identify changes in linear trends that were described as average annual percentage change (AAPC).Results: Significant declines in rates of admission for any LEA (AAPC -4.9), minor LEAs (-3.0 %) and major LEAs (AAPC -11.5 %) were seen for patients with T2DM. Overall, admission rates for any LEA did not significantly change for patients with T1DM during 2004 and 2016, however, we detected a significant rise in admissions for any LEAs (AAPC +5.1) in female patients with T1DM. This increase was most prominent in younger (<60 years) patients undergoing minor LEAs. During 2009-2016, younger patients with type 1 DM, regardless of sex, also experienced significant increases in admissions for any LEA (AAPC +14) and major LEAs (AAPC +15). Mortality associated with LEAs in T2DM declines, with a 12-month mortality rate of 6.3 %) associated with LEAs in T2M decline (AAPC -4.2 %) whereas rates for T1DM remained stable (1.9 %) during 2004-2016.Conclusions: There were significant differences in LEA hospital admission trends by type of diabetes, age and sex. The decline in LEAs and its associated mortality is welcome news for patients with T2DM. However, reasons for the increase in LEAs in younger patients with T1DM remain to be determined. [ABSTRACT FROM AUTHOR]

Specialist palliative care services must balance provision of needs-based care within resource restraints. The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based, 7-item prioritization tool, with recommended response times for any given score. To investigate the acceptability and appropriateness of the RUN-PC Triage Tool implemented into clinical practice. A single-arm, multisite, prospective implementation pilot conducted at 12 community/inpatient palliative care services, using Quality Improvement methodology with Plan-Do-Study-Act cycles. Data collected for each triage episode included demographics, scoring, user feedback and clinical outcomes. Group differences were tested by chi-squared, Wilcoxon Rank Sum or Kruskal Wallis tests. A total of 5418 triage episodes were captured, 1509 with outcome data. Referrals to inpatient services were of higher acuity than those to community (median score 24 vs. 14). Whilst high numerical scores were unusual, a significant proportion of cases were clinically urgent. Admissions occurred within recommended response times in over 80% of triage episodes; 5.8% of referred patients died before being admitted. Users reported the tool was easy to complete (99.3% of applications), rarely requiring additional time (0.07%), and appropriate in its triage determination (96.0% of applications). The RUN-PC Triage Tool is feasible to implement, with high clinician acceptability and virtually no additional time required. The recommended response times are feasible and highlight target areas for improvement. Implementation of the tool enables palliative care services to better characterize their referral population and, in turn, improve transparency around access to care. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Patients diagnosed with Primary Malignant Glioma (PMG) face substantial challenges with poor prognosis, high symptom burden and care needs. This study aims to collate current literature detailing the supportive and palliative care needs of patients with PMG and their carers, and to subject it to a novel approach of formal evaluation. Methods: Medline, EMBASE, CINAHL, PsychInfo were searched with core concepts: (1) glioma, (2) high-grade disease, and (3) palliative and supportive care needs. A narrative synthesis approach was undertaken including a quality appraisal of the 21 included studies. Results: Key themes related to the need for consistent well-delivered information around disease sequelae, treatment, and resources available; health service needs including a key professional identified to coordinate care; the need for psychological and social supports, and clear avenues of communication with treating professionals. Conclusion: The literature remains limited in the number and quality of evidence with two Level I, eight Level II, and eleven Level III studies. The findings call for improved information, communication and support practices to address the complexity and breadth of needs. Practice implications: Specialised and individually tailored information, attention to clear, consistent communication and support practices should be incorporated into a future needs-based model of care. [Copyright &y& Elsevier]

Context: Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care?Objectives: To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool.Methods: Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study.Results: Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92).Conclusion: Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes. [ABSTRACT FROM AUTHOR]