Search

There are various models for acute neurology services in the UK, with considerable variation in practice. Patients are often admitted unnecessarily for neurology review, leading to delay in diagnosis and treatment. Alternative models, such as the Neurology Same Day Emergency Care service (Neuro-SDEC) at University College London Hospital provide a pathway that can prevent admissions and streamline patient care. Headache is one of the commonest presenting symptoms in acute neurology.This study compared the impact of Neuro-SDEC on the care for patients presenting with headache against the standard pathway.A prospective audit was undertaken from November - December 2023 to evaluate all appropriate patients seen by the Neuro-SDEC service or admitted to the ward. For Neuro-SDEC patients, each case was reviewed to see whether an admission, lumbar puncture or neurology outpatient referral was avoided. For admitted patients, length of inpatient stay, time to neurology review and discharge diagnosis was recorded.Fifty-one patients were seen by Neuro-SDEC, twenty-five of whom would have been admitted to hospital on the standard pathway. Thirty general neurology outpatient clinic referrals were prevented and 5 patients avoided a lumbar puncture. In 45% of cases, the working diagnosis changed after the patient was seen by the Neuro-SDEC team. There were seven admitted patients not seen by the service with a combined length of stay of 17 bed days. The average wait time for inpatient neurology review was 42 hours. 3 admitted patients underwent a lumbar puncture. 2 patients were referred on to neuro-SDEC to enable an earlier discharge from hospital. Migraine was the most common final diagnosis in both groups.This study highlights that Neuro-SDEC is effective at reducing hospital admissions, as well as unnecessary tests and referrals to generalneurology outpatients. For admitted patients, the service enabled earlier discharge from hospital and reduced length of stay., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: The aim of this study is to develop a method we call "cost mining" to unravel cost variation and identify cost drivers by modelling integrated patient pathways from primary care to the palliative care setting. This approach fills an urgent need to quantify financial strains on healthcare systems, particularly for colorectal cancer, which is the most expensive cancer in Australia, and the second most expensive cancer globally., Methods: We developed and published a customized algorithm that dynamically estimates and visualizes the mean, minimum, and total costs of care at the patient level, by aggregating activity-based healthcare system costs (e.g. DRGs) across integrated pathways. This extends traditional process mining approaches by making the resulting process maps actionable and informative and by displaying cost estimates. We demonstrate the method by constructing a unique dataset of colorectal cancer pathways in Victoria, Australia, using records of primary care, diagnosis, hospital admission and chemotherapy, medication, health system costs, and life events to create integrated colorectal cancer patient pathways from 2012 to 2020., Results: Cost mining with the algorithm enabled exploration of costly integrated pathways, i.e. drilling down in high-cost pathways to discover cost drivers, for 4246 cases covering approx. 4 million care activities. Per-patient CRC pathway costs ranged from $10,379 AUD to $41,643 AUD, and varied significantly per cancer stage such that e.g. chemotherapy costs in one cancer stage are different to the same chemotherapy regimen in a different stage. Admitted episodes were most costly, representing 93.34% or $56.6 M AUD of the total healthcare system costs covered in the sample., Conclusions: Cost mining can supplement other health economic methods by providing contextual, sequence and timing-related information depicting how patients flow through complex care pathways. This approach can also facilitate health economic studies informing decision-makers on where to target care improvement or to evaluate the consequences of new treatments or care delivery interventions. Through this study we provide an approach for hospitals and policymakers to leverage their health data infrastructure and to enable real time patient level cost mining., Competing Interests: Declarations. Ethics approval and consent to participate: The study received ethical approval by the Royal Melbourne Hospital Ethics Board through BioGrid application number 202003/8 (Australia). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The National Institute for Health and Care Excellence (NICE) guideline quality standard for non-ST-segment elevation acute coronary syndrome (NSTEACS) pathway states that adults who have an intermediate or higher risk of future adverse cardiovascular events should undergo coronary angiography within 72 hours of first admission to hospital.The aim was to improve compliance with the 72-hour NICE quality standard for the acute coronary syndrome pathway between one district general hospital (DGH) and its cardiac tertiary centre by reducing the time from admission to angiography by 50%.Participants were front-line staff in the DGH and staff in the cardiac catheter laboratory in the tertiary centre., Methods: Continuous data were collected prospectively on all patients entering the NSTEACS pathway with time of arrival to hospital; referral to angiography; and start of angiogram to measure the NSTEACS pathway duration against the NICE quality standard. We used process mapping, ease-benefit matrix, Pareto analyses and the Institute for Healthcare Improvement (IHI) Plan-Do-Study-Act (PDSA) method of quality improvement., Intervention: Staff in both hospitals performed process mapping of their respective parts of the NSTEACS pathway. Their data informed decisions on process changes using the ease-benefit matrix. PDSA cycles were commenced, and changes were assessed using continuous measurement of pathway duration. In the tertiary centre, Pareto analysis was performed to help identify the major service constraints., Results: Between January 2021 and March 2023, there were four separate PDSA cycles, two each in the DGH and tertiary centre. Across the four PDSA cycles, the time to complete the pathway reduced from an average of 172 to 94.72 hours, an improvement of 45%, along with an overall reduction in variability of data. In the DGH, the process changes were sustained, but in the tertiary centre they were not, as PDSA 4 required staff recruitment to enable a 6-day rather than a 5-day service per week., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cancer patient pathways (CPPs) were implemented in Norway to reduce unnecessary waiting times, regional variations, and to increase the predictability of cancer care for the patients. This study aimed to determine if 70% of cancer patients started treatment within the recommended time frames, and to identify potential delays., Methods: Patients registered with a colorectal, lung, breast, or prostate cancer diagnosis at the Cancer Registry of Norway in 2015-2016 were linked with the Norwegian Patient Registry and Statistics Norway. Adjusting for sociodemographic variables, multivariable quantile (median) regressions were used to examine the association between place of residence and median time to start of examination, treatment decision, and start of treatment., Results: The study included 20 668 patients. The proportions of patients who went through the CPP within the recommended time frames were highest among colon (84%) and breast (76%) cancer patients who underwent surgery and lung cancer patients who started systemic anticancer treatment (76%), and lowest for prostate cancer patients who underwent surgery (43%). The time from treatment decision to start of treatment was the main source of delay for all cancers. Travelling outside the resident health trust prolonged waiting time and was associated with a reduced odds of receiving surgery and radiotherapy for lung and rectal cancer patients, respectively., Conclusions: Achievement of national recommendations of the CCP times differed by cancer type and treatment. Identified bottlenecks in the pathway should be targeted to decrease waiting times. Further, CPP guidelines should be re-examined to determine their ongoing relevance., (© 2022. The Author(s).)

Purpose: This retrospective analysis focuses on treatment stage migration in patients with hepatocellular carcinoma (HCC) to identify successful treatment sequences in a large cohort of real-world patients., Methods: 1369 HCC patients referred from January 1993 to January 2020 to the tertiary center of the Heidelberg University Hospital, Germany were analyzed for initial and subsequent treatment patterns, and overall survival., Results: The most common initial treatment was transarterial chemoembolization (TACE, n = 455, 39.3%) followed by hepatic resection (n = 303, 26.1%) and systemic therapy (n = 200, 17.3%), whereas the most common 2nd treatment modality was liver transplantation (n = 215, 33.2%) followed by systemic therapy (n = 177, 27.3%) and TACE (n = 85, 13.1%). Kaplan-Meier analysis revealed by far the best prognosis for liver transplantation recipients (median overall survival not reached), followed by patients with hepatic resection (11.1 years). Patients receiving systemic therapy as their first treatment had the shortest median overall survival (1.7 years; P < 0.0001). When three or more treatment sequences preceded liver transplantation, patients had a significant shorter median overall survival (1st seq.: not reached; 2nd seq.: 12.4 years; 3rd seq.: 11.1 years; beyond 3 sequences: 5.5 years; P = 0.01)., Conclusion: TACE was the most common initial intervention, whereas liver transplantation was the most frequent 2nd treatment. While liver transplantation and hepatic resection were associated with the best median overall survival, the timing of liver transplantation within the treatment sequence strongly affected median survival.

Background: Decisions on medication treatment in children dying from cancer are often complex and may result in polypharmacy and increased medication burden. There is no information on medication burden in pediatric cancer patients at the end of life (EOL)., Objectives: To characterize medication burden during the last hospitalization in children dying from cancer., Methods: We performed a retrospective cohort study based on medical records of 90 children who died from cancer in hospital between 01 January 2010 and 30 December 2018. Demographic and clinical information were collected for the last hospitalization. We compared medication burden (number of medication orders) at hospitalization and at time of death and examined whether changes in medication burden were associated with clinical and demographic parameters., Results: Median medication burden was higher in leukemia/lymphoma patients (6 orders) compared to solid (4 orders) or CNS tumor patients (4 orders, P = 0.006). Overall, the median number of prescriptions per patient did not change until death (P = 0.42), while there was a significant reduction for some medication subgroups (chemotherapy [P = 0.035], steroids [P = 0.010]).Patients dying in the ICU (n=15) had a higher medication burden at death (6 orders) than patients dying on wards (3 orders, P = 0.001). There was a trend for a reduction in medication burden in patients with "Do not resuscitate" (DNR) orders (P = 0.055)., Conclusions: Polypharmacy is ubiquitous among pediatric oncology patients at EOL. Disease type and DNR status may affect medication burden and deprescribing during the last hospitalization.

Purpose: The purpose of this study was to disclose the variability of pathways currently taken in the treatment of adolescent patients from diagnosis to final follow-up with a view to developing a more homogenous system. Patients & methods: A cross-sectional, observational and retrospective study of the cancer diagnosis and assignment to medical care teams in adolescent patients (12-20 years) from January 2008 to December 2018 was conducted. A total of 345 adolescent patients aged between 12 and 20 years, diagnosed with cancer and treated at Hospital Clinico Universitario Virgen de la Arrixaca were included. Results: CNS tumors, followed by leukemia were the most frequent tumors. At the time of diagnosis, the highest incidences of patients were assisted in the pediatrics service adult oncology service (21.7%) and hematology (11%). Conclusion: Our aim is to highlight the need for a better transition for patients from pediatric to adult oncology and hematology services.

Background: Breast cancer (BC) presents important physical and psychological challenges that should be appropriately addressed through continuous, integrated and individualized rehabilitation programs after treatment. In this study, we aimed to collect more information on the rehabilitation patterns and utilization of healthcare services by women with BC., Methods: We retrospectively analyzed data from two archives of the Lazio Regional Health System Database to assess rehabilitation patterns in women diagnosed with BC in the Lazio region (Italy) in 2008., Results: A total of 5538 women diagnosed with BC were considered in the present study. Most patients (81.7%) received outpatient rehabilitative care, consisting mainly of pathology-related interventions and, more rarely, disability-related interventions (mainly motor rehabilitation and rarely cognitive or psychological therapy). Few patients followed an inpatient (1.3%) or an intensive outpatient rehabilitation program (1.0%)., Conclusion: Most patients do not receive adequate rehabilitation care during the first year after diagnosis. More information and better rehabilitation services should be provided to help patients with BC access rehabilitation programs. The study also suggests the importance of psychosocial and cognitive interventions, which is a major unmet need in women with BC.

The coronavirus disease 2019 (COVID-19) pandemic may have affected cancer management. We aimed to evaluate changes in every oncology care pathway essential step, from screening to treatment, during the pandemic. Monthly oncological activity differences between 2019 and 2020 (screening tests, histopathological analyzes, multidisciplinary tumor board meetings (MTBMs), diagnostic announcement procedures (DAPs), and treatments were calculated in two French areas experiencing different pandemic intensity (Reims and Colmar). COVID-19 has had a dramatic impact in terms of screening (-86% to -100%), diagnosis (-39%), and surgical treatment (-30%). This global decrease in all essential oncology care pathway steps contrasted with the relative stability of chemotherapy (-9%) and radiotherapy use (-16%). Outbreak occurred earlier and with more intensity in Colmar but had a comparable impact in both areas regarding MTMBs and DAPs. The current ONCOCARE-COV study is still in progress and with a longer follow-up to analyze postlockdown situation., (© 2020 AlphaMed Press.)

Background: Dementia is caused by a variety of neurodegenerative diseases and is associated with a decline in memory and other cognitive abilities, while inflicting an enormous socioeconomic burden. The complexity of dementia and its associated comorbidities presents immense challenges for dementia research and care, particularly in clinical decision-making., Main Body: Despite the lack of disease-modifying therapies, there is an increasing and urgent need to make timely and accurate clinical decisions in dementia diagnosis and prognosis to allow appropriate care and treatment. However, the dementia care pathway is currently suboptimal. We propose that through computational approaches, understanding of dementia aetiology could be improved, and dementia assessments could be more standardised, objective and efficient. In particular, we suggest that these will involve appropriate data infrastructure, the use of data-driven computational neurology approaches and the development of practical clinical decision support systems. We also discuss the technical, structural, economic, political and policy-making challenges that accompany such implementations., Conclusion: The data-driven era for dementia research has arrived with the potential to transform the healthcare system, creating a more efficient, transparent and personalised service for dementia.

Background: Acute myocardial infarction is a very common disease in the emergency room. Emergency percutaneous coronary intervention (PCI) is the first choice to open infarct-related artery in time to regain the active blood flow of myocardial tissue. Clinical nursing pathway (CNP), namely clinical project, is an original nursing mode with good quality, outstanding efficiency, and low treatment spending, so it has attracted more and more attention. However, few studies have reported the implementation of a CNP in PCIs. The purpose of the protocol is to assess the impact of CNP on the clinical efficacy of transradial emergency PCI., Methods: This is a randomized controlled, single center trial which will be implemented from January 2021 to June 2021. Hundred samples diagnosed with acute myocardial infarction will be included in this study. It was authorized via the Ethics Committee of Changshan County People's Hospital (CCPH002348). Patients are assigned to the following groups: control group, given normal routine care; CNP group, treated with CNP plan. The time from door to balloon, hospitalization expenses, length of stay, postoperative complications, patients' satisfaction with treatment are compared and analyzed. All data are collected and analyzed by Social Sciences software version 21.0 (SPSS, Inc., Chicago, IL) program., Results: Differences of clinical outcomes between groups ()., Conclusion: This original evidence-based nursing model can be used as the foundation for further research., Trial Registration Number: researchregistry6030.

Aim: To determine the frequency and relevance of deviations from a post pancreatoduodenectomy (PD) clinical care pathway. Materials & methods: A retrospective analysis using a prospectively maintained database of a post-PD clinical care pathway was carried out between May 2016 and March 2018. Patients were divided based on the number of factors deviating from the clinical care pathway (Group I: no deviation; Group II: deviation in 1-4 factors; Group III: deviation in 5-8 factors). The analysis included profiling of patients on different demographic and clinical as well as medical and surgical outcome parameters (discharge by postoperative day 8 and 90-day unplanned re-admission rate). Results: Post-PD clinical care pathways are feasible but deviations from the pathway are frequent (91%). An increase in frequency of deviations from the pathway was significantly associated with increased risk of POPF and delayed gastric emptying, delayed discharge, risk of mortality and 90-day unplanned re-admission rate. Conclusion: Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.

In patients with heart failure, some organizational and modifiable factors could be prognostic factors. We aimed to assess the association between the in-hospital care pathways during hospitalization for acute heart failure and the risk of readmission. This retrospective study included all elderly patients who were hospitalized for acute heart failure at the Universitary Hospital Lariboisière (Paris) during 2013. We collected the wards attended, length of stay, admission and discharge types, diagnostic procedures, and heart failure discharge treatment. The clinical factors were the specific medical conditions, left ventricular ejection fraction, type of heart failure syndrome, sex, smoking status, and age. Consistent groups of in-hospital care pathways were built using an ascending hierarchical clustering method based on a primary components analysis. The association between the groups and the risk of readmission at 1 month and 1 year (for heart failure or for any cause) were measured via a count data model that was adjusted for clinical factors. This study included 223 patients. Associations between the in-hospital care pathway and the 1 year-readmission status were studied in 207 patients. Five consistent groups were defined: 3 described expected in-hospital care pathways in intensive care units, cardiology and gerontology wards, 1 described deceased patients, and 1 described chaotic pathways. The chaotic pathway strongly increased the risk (p = 0.0054) of 1 year readmission for acute heart failure. The chaotic in-hospital care pathway, occurring in specialized wards, was associated with the risk of readmission. This could promote specific quality improvement actions in these wards. Follow-up research projects should aim to describe the processes causing the generation of chaotic pathways and their consequences.

Background: Cancer patient pathways (CPPs) were implemented in 2015 to reduce waiting time, regional variation in waiting time, and to increase the predictability of cancer care for the patients. The aims of this study were to see if the national target of 70% of all cancer patients being included in a CPP was met, and to identify factors associated with CPP inclusion., Methods: All patients registered with a colorectal, lung, breast or prostate cancer diagnosis at the Cancer Registry of Norway in the period 2015-2016 were linked with the Norwegian Patient Registry for CPP information and with Statistics Norway for sociodemographic variables. Multivariable logistic regression examined if the odds of not being included in a CPP were associated with year of diagnosis, age, sex, tumour stage, marital status, education, income, region of residence and comorbidity., Results: From 2015 to 2016, 30,747 patients were diagnosed with colorectal, lung, breast or prostate cancer, of whom 24,429 (79.5%) were included in a CPP. Significant increases in the probability of being included in a CPP were observed for colorectal (79.1 to 86.2%), lung (79.0 to 87.3%), breast (91.5 to 97.2%) and prostate cancer (62.2 to 76.2%) patients (p < 0.001). Increasing age was associated with an increased odds of not being included in a CPP for lung (p < 0.001) and prostate cancer (p < 0.001) patients. Colorectal cancer patients < 50 years of age had a two-fold increase (OR = 2.23, 95% CI: 1.70-2.91) in the odds of not being included in a CPP. The odds of no CPP inclusion were significantly increased for low income colorectal (OR = 1.24, 95%CI: 1.00-1.54) and lung (OR = 1.52, 95%CI: 1.16-1.99) cancer patients. Region of residence was significantly associated with CPP inclusion (p < 0.001) and the probability, adjusted for case-mix ranged from 62.4% in region West among prostate cancer patients to 97.6% in region North among breast cancer patients., Conclusions: The national target of 70% was met within 1 year of CPP implementation in Norway. Although all patients should have equal access to CPPs, a prostate cancer diagnosis, older age, high level of comorbidity or low income were significantly associated with an increased odds of not being included in a CPP.

Background: French Guiana faces singular health challenges: poverty, isolation, structural lag, difficulties in attracting health professionals. Hospital stays exceed the recommended durations. The present study aimed to model the impact of precariousness and geographic isolation on the hospital duration performance indicator and to recalculate the indicator after incrementing severity by 1 unit when patients were socially precarious., Methods: Cayenne hospital data for 2017 were used to model the hospital duration performance indicator (IP-DMS) using quantile regression to study the impact of geographic and social explanatory variables. This indicator was computed hypothesizing a 1 unit increment of severity for precarious patients and by excluding patients from isolated regions., Results: Most excess hospitalization days were linked to precariousness: the sojourns of precarious patients represented 47% of activity but generated 71% of excess days in hospital. Quantile regression models showed that after adjustment for potential confounders, patients from western French Guiana and Eastern French Guiana, precarious patients and the interactions terms between residence location and precariousness were significantly associated with IP-DMS increases. Recalculating the IP-DMSafter exclusion of patients from the interior and after increasing severity by 1 notch if the patient was precarious led to IP-DMS levels close to 1., Conclusion: The results show the nonlinear relationship between the IP-DMS and geographical isolation, poverty, and their interaction. These contextual variables must be taken into account when choosing the target IP-DMS value for French Guiana, which conditions funding and number of hospital beds allowed in a context of rapid demographic growth., (Copyright © 2019. Published by Elsevier Masson SAS.)

Introduction: Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services., Methods: A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports., Findings: There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

Importance: Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking., Objective: To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence., Design, Setting, and Participants: This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019., Exposures: One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health., Main Outcomes and Measures: Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment., Results: A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up., Conclusions and Relevance: Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.

Objectives: Biologic therapies have been available for inflammatory bowel disease for >20 years, but patient outcomes have not changed appreciably over this time period. To better understand medication utilization for this disease, we evaluated a novel technique for visualizing treatment pathways, including initial treatment, switching, and combination therapies., Methods: This retrospective, observational study used administrative claims data from the Truven Health MarketScan Commercial and Medicare Database. Adult patients with ≥2 consecutive health claims and newly diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) were evaluated. Treatment pathways were visualized using Sankey diagrams representing the number of patients receiving treatment and duration of each treatment., Results: In all, 28,119 patients with UC and 16,260 patients with CD were identified. The most common initial treatment for UC was 5-aminosalicylic acid monotherapy (61% of the patients), followed by corticosteroid monotherapy (25%); <1% of patients were initially treated with biologics. The most common initial treatment for CD was corticosteroid monotherapy (42%), followed by 5-aminosalicylic acid monotherapy (35%); <5% of the patients were initially treated with biologics. Significantly fewer patients followed biologic vs nonbiologic treatment pathways (UC: 6% vs 94%, CD: 19% vs 81%, both P < 0.05)., Discussion: Significantly fewer patients with inflammatory bowel disease followed treatment pathways that included biologic therapies compared with nonbiologic therapies, and very few patients were ever initiated on biologic therapy. Although we have made significant progress in treatment, our most effective medications are only being used in a small proportion of patients, suggesting barriers prevent optimized patient management.

Clinical pathways are used to support the management of patients in emergency departments. An existing document-based clinical pathway was used as the foundation on which to design and build a digital clinical pathway for acute chest pain, with the aim of improving clinical calculations, clinician decision-making, documentation, and data collection. Established principles of decision support system design were used to build an application within the existing electronic health record, before testing with a multidisciplinary team of doctors using a think-aloud protocol. Technical authoring was successful, however, usability testing revealed that the user experience and the flexibility of workflow within the application were critical barriers to implementation. Emergency medicine and acute care decision support systems face particular challenges to existing models of linear workflow that should be deliberately addressed in digital pathway design. We make key recommendations regarding digital pathway design in emergency medicine.

Background: Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU., Methods: We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data., Results: A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02)., Conclusion: The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2019 by Daedalus Enterprises.)

Background: The Centers for Disease Control and Prevention (CDC) produced a 72-page document titled "U.S. Selective Practice Recommendations for Contraceptive Use" in 2016. This document contains the medical eligibility criteria (MEC) for contraceptive initiation or continuation based on a patient's current health status. Notations such as Business Process Model and Notation (BPMN) and Decision Model and Notation (DMN) might be useful to model such recommendations., Objective: Our objective was to use BPMN and DMN to model and standardize the processes and decisions involved in initiating birth control according to the CDC's MEC for birth control initiation. This model could then be incorporated into an electronic health records system or other digital platform., Methods: Medical terminology, processes, and decisions were modeled in coordination with the CDC to ensure correctness. Challenges in terminology bindings were identified and categorized., Results: A model was successfully produced. Integration of clearly defined data elements proved to be the biggest challenge., Conclusion: BPMN and DMN have strengths and weaknesses when modeling medical processes; however, they can be used to successfully create models for clinical pathways., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS)., Methods: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement., Results: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals., Conclusions: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.

Background: National UK data on colorectal cancer (CRC) stage at diagnosis is incomplete. Site-specific fast-track (2-week wait) cancer data are not collected directly by NHS England. Policy making based on these data alone can lead to inaccuracy., Aims: To review available data on key outcomes (cancer conversion rate and stage at diagnosis) for the UK's lower gastrointestinal 2-week wait pathway., Methods: A comprehensive literature search was conducted between 2000 and 2017. Primary outcomes were cancer conversion rate and cancer stage at diagnosis. Results were expressed as proportions with 95% CIs. A random effects model was used for meta-analysis; heterogeneity was assessed by I 2 ., Results: Of 95 papers reviewed, 49 were included in analysis with a total study population of 93,655. Cancer conversion rate was 7.7% (95% CI: 6.9-8.5). The proportion presenting at Dukes A = 11.2% (95% CI 7.4-15.6), B = 36.7% (95% CI 30.8-42.8), C = 35.7% (95% CI: 30.8-40.8) and D = 11.1% (95% CI 7.3-15.5). No colonic pathology was diagnosed in 54.6% (95% CI: 46.2-62.8)., Conclusions: Only 7.7% of patients referred by the 2-week wait pathway were found to have CRC. No beneficial effect on stage at diagnosis was found compared to non-2-week wait referral pathways. Over half of patients had no colonic pathology and detection of adenomas was very low. These results should prompt a reconsideration of the benefits of the 2-week wait pathway in CRC diagnosis and outcomes, with more focus on strategies to improve patient selection., (© 2019 John Wiley & Sons Ltd.)

Rationale and Objectives: To explore downstream costs associated with incidental pulmonary nodules detected on CT., Materials and Methods: The cohort comprised 200 patients with an incidental pulmonary nodule on chest CT. Downstream events (chest CT, PET/CT, office visits, percutaneous biopsy, and wedge resection) were identified from the electronic medical record. The 2017 Fleischner Society Guidelines were used to classify radiologists' recommendations and ordering physician management for the nodules. Downstream costs for nodule management were estimated from national Medicare rates, and average costs were determined., Results: Average downstream cost per nodule was $393. Costs were greater when ordering physicians over-managed relative to radiologist recommendations ($940) vs. when adherent ($637) or under-managing ($166) relative to radiologists recommendations. Costs were also greater when ordering physicians over-managed relative to Fleischner Society guidelines ($860) vs. when under-managing ($208) or adherent ($292) to guidelines. Costs did not vary significantly based on whether or not radiologists recommended follow-up imaging ($167-$397), nor whether radiologists were adherent or under- or over-recommended relative to Fleischner Society guidelines ($313-$444). Costs were also higher in older patients, patients with a smoking history, and larger nodules. Five nodules underwent wedge resection and diagnosed as malignancies. No patient demonstrated recurrence or metastasis. Average cost per diagnosed malignancy was $3090., Conclusion: Downstream costs for incidental pulmonary nodules are highly variable and particularly high when ordering physicians over-manage relative to radiologist recommendations and Fleischner Society guidelines. To reduce unnecessary utilization and cost from over-management, radiologists may need to assume a greater role in partnering with ordering physicians to ensure appropriate, guideline-adherent, and follow-up testing., (Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Introduction: Gefitinib, erlotinib, and afatinib represent the approved first-line options for epidermal growth factor receptor ( EGFR )-mutant non-small cell lung cancer (NSCLC). Because pivotal trials frequently lack external validity, real-world data may help to depict the diagnostic-therapeutic pathway and treatment outcome in clinical practice., Methods: MOST is a multicenter observational study promoted by the Veneto Oncology Network, aiming at monitoring the diagnostic-therapeutic pathway of patients with nonsquamous EGFR -mutant NSCLC. We reported treatment outcome in terms of median time to treatment failure (mTTF) and assessed the impact of each agent on the expense of the regional health system, comparing it with a prediction based on the pivotal trials., Results: An EGFR mutation test was performed in 447 enrolled patients, of whom 124 had EGFR mutation and who received gefitinib ( n  = 69, 55%), erlotinib ( n  = 33, 27%), or afatinib ( n  = 22, 18%) as first-line treatment. Because erlotinib was administered within a clinical trial to 15 patients, final analysis was limited to 109 patients. mTTF was 15.3 months, regardless of the type of tyrosine kinase inhibitor (TKI) used. In the MOST study, the budget impact analysis showed a total expense of €3,238,602.17, whereas the cost estimation according to median progression-free survival from pivotal phase III trials was €1,813,557.88., Conclusion: Good regional adherence and compliance to the diagnostic-therapeutic pathway defined for patients with nonsquamous NSCLC was shown. mTTF did not significantly differ among the three targeted TKIs. Our budget impact analysis suggests the potential application of real-world data in the process of drug price negotiation., Implications for Practice: The MOST study is a real-world data collection reporting a multicenter adherence and compliance to diagnostic-therapeutic pathways defined for patients with epidermal growth factor receptor-mutant non-small cell lung cancer. This represents an essential element of evidence-based medicine, providing information on patients and situations that may be challenging to assess using only data from randomized controlled trials, e.g., turn-around time of diagnostic tests, treatment compliance and persistence, guideline adherence, challenging-to-treat populations, drug safety, comparative effectiveness, and cost effectiveness. This study may be of interest to various stakeholders (patients, clinicians, and payers), providing a meaningful picture of the value of a given therapy in routine clinical practice., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2019.)

Objectives: Many strategies have been either used or recommended to promote physician compliance with clinical practice guidelines and clinical pathways (CPs). This study examines the relationship between hospitals' use of financial incentives to encourage physician compliance with CPs and physician adherence to CPs., Design: A retrospectively cross-sectional study of the relationship between the extent to which patient care was consistent with CPs and hospital's use of financial incentives to influence CP compliance., Setting: Eighteen public hospitals in three provinces in China., Participants: Stratified sample of 2521 patients discharged between 3 January 2013 and 31 December 2014., Primary Outcome Measures: The proportion of key performance indicators (KPIs) met for patients with (1) community-acquired pneumonia (pneumonia), (2) acute myocardial infarction (AMI), (3) acute left ventricular failure (heart failure), (4) planned caesarean section (C-section) and (5) gallstones associated with acute cholecystitis and associated cholecystectomy (cholecystectomy)., Results: The average implementation rate of CPs for five conditions (pneumonia, AMI, heart failure, C-section and cholecystectomy) based on 2521 cases in 18 surveyed hospitals was 57% (ranging from 44% to 67%), and the overall average compliance rate for the KPIs for the five conditions was 69.48% (ranging from 65.07% to 77.36%). Implementation of CPs was associated with greater compliance within hospitals only when hospitals adopted financial incentives directed at physicians to promote compliance., Conclusion: CPs are viewed as important strategies to improve medical care in China, but they have not been widely implemented or adhered to in Chinese public hospitals. In addition to supportive resources, education/training and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs., Competing Interests: Competing interests: JB is a PhD student at the School of Public Health, Fudan University and is a staff member of Pudong Institute for Health Development., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The seasonal influenza epidemic poses a significant burden on hospitals, both in terms of capacity and costs. Beds that are occupied by isolated influenza patients result in hospitals temporary being closed to admissions and elective operations being cancelled. Improving hospital and emergency department (ED) patient flow during the influenza season could solve these problems. Microbiological point-of-care-testing (POCT) could reduce unnecessary patient isolation by providing a positive/negative result before admission, but has not yet broadly been implemented., Methods: A clinical pathway for patients with acute respiratory tract infection presenting at the ED was implemented, including a PCR-based POCT for influenza, operated by nurses and receptionists. In parallel, a temporary ward equipped with 15 beds for influenza-positive patients was established. In this retrospective observational study, we describe the results of implementing this pathway by comparison with the previous epidemic., Results: Clinical performance of the POCT within the clinical pathway was good with strongly decreased time from ED presentation to sample collection (194 vs 47 min) and time from sample collection to result (1094 vs 62 min). Hospital patient flow was improved by a decreased percentage of admitted influenza-positive patients (91% vs 73%) and shorter length of subsequent stay (median 5.86 vs 4.61 days) compared to the previous influenza epidemic. In addition, 430 patient-days of unnecessary isolation have been prevented within a time span of 18 weeks. Roughly estimated savings were almost 400,000 euros., Conclusion: We recommend that hospitals explore possibilities for improving patient flow during an influenza epidemic.

Introduction: In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions., Methods: This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher's exact test., Results: In the "before" phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001)., Conclusion: A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background: A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation., Aim: To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP)., Methods: This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196)., Results: At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones ( P < 0.001) and incidence of cholangitis complication ( P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials ( P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) ( P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups., Conclusion: Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interests to declare.

Introduction: Primary care patients with a suspected head and neck cancer are referred through the urgent suspicion of cancer referral pathway. Rates of cancer detection through this pathway are low. Evidence surrounding the pathway of these patients is lacking. This study aimed to determine the outcome of urgent suspicion of cancer referrals for head and neck cancer., Methods and Methods: All head and neck cancer urgent suspicion of cancer referrals in NHS Greater Glasgow and Clyde between June 2015 and May 2016 were analysed in regard to their clinical pathway., Results: There were 2116 urgent suspicion of cancer referrals in the one-year period. The overall cancer rate was 235 (11.8%), compared with 152 (7.6%) that resulted in a primary head and neck cancer diagnosis. Of the total, 851 (42.6%) were reassured and discharged after one clinic appointment; 536 (26.8%) were followed up for suspected benign pathology and 436 (21.8%) were actively investigated for cancer., Conclusion: A significant proportion of patients attending urgent suspicion of cancer clinic appointments can be seen and discharged in one clinic appointment, provided there is same day imaging available. Cancer identification rates through urgent suspicion of cancer pathways remain low.

Objectives: To quantify within a cohort of HIV-infected individuals the number of medical visits and procedures to be carried out according to comorbidities and risk factors to implement a personalized care pathway., Patients and Methods: Retrospective study of 915 patients consulting from January 1 to December 31, 2016 at an outpatient unit of multidisciplinary consultations, using an electronic patient record. We built an algorithm using parameters required for the application of the national guidelines for the management of HIV-infected individuals. The frequency of comorbidities was measured according to gender, transmission risk group, and nadir CD4 (200/mm 3 )., Results: Patients were mostly men (median age: 52 years), of whom 16% were aged≥60 years. Viral load was<40 copies/mL in 93.5% of treated patients and CD4 cell count≥500/mm 3 for 73%. Overall, 74.5% of patients had at least one comorbidity. The number of comorbidities was similar in men and women but was significantly higher in patients with a nadir CD4 <200/mm3 and increased with age (irrespective of gender). The minimum number of consultations to be scheduled per year was 8123: 70% for the management of comorbidities with an average of six consultations/year/patient. Overall, 53% of patients should attend a proctology consultation. The minimum number of paramedical procedures to be performed was 5115., Conclusion: The implementation of a personalized multidisciplinary management within a single facility seems to be a suitable care model to address the needs of HIV-infected individuals., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Timely initiation of antibiotics within one hour of prescription is one of the recommended antibiotic stewardship interventions when managing patients with pneumonia in the emergency department. Effective implementation of this intervention depends on effective communication, a well-established coordination process and availability of resources. Understanding what may influence this aspect of care by using process mapping is an important component when planning for improvement interventions. The aim of the study was to identify factors that influence antibiotic initiation following prescription in the Adult Emergency and Trauma Centre of the largest referral hospital in Malawi., Methods: We conducted a prospective observational case study using process mapping of two purposively selected adult pneumonia patients. One of the investigators CM observed the patient from the time of arrival at the triage area to the time he/she received initial dose of antibiotics. With purposively selected members of the clinical team; we used simple questions to analyze the map and identified facilitators, barriers and potential areas for improvement., Results: Both patients did not receive the first dose of antibiotic within one hour of prescription. Despite the situation being less than ideal, potential facilitators to timely antibiotic initiation were: prompt assessment and triaging; availability of different expertise, timely first review by the clinician; and blood culture collected prior to antibiotic initiation. Barriers were: long waits, lack of communication/coordinated care and competency gap. Improvements are needed in communication, multidisciplinary teamwork, education and leadership/supervision., Conclusion: Process mapping can have a significant impact in unveiling the system-related factors that influence timely initiation of antibiotics. The mapping exercise brought together stakeholders to evaluate and identify the facilitators and barriers. Recommendations here focused on improving communication, multidisciplinary team culture such as teamwork, good leadership and continuing professional development.

Background: The number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints., Methods: We developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams., Results: Four scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios., Conclusions: Using new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.

Background: Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service., Methods: The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics., Results: The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources., Conclusions: Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities., Epoch Trial Registration: ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.

Background: The aim of this study is to analyze and to compare data from 2015, focusing on hospital care for patients with multiple sclerosis from three French regions with different characteristics in terms of prevalence, size and number of multiple sclerosis competencies and resource centers., Methods: All hospital admissions from the PMSI MCO 2015 database, with a principal or related diagnosis (PD-RD) of G35* ("multiple sclerosis") were extracted. We also extracted chemotherapy treatments administered in hospital, during admissions with a significant associated diagnosis (SAD) of G35*, if the PD or RD was coded Z512 ("non-tumor chemotherapy"). The analyzed regions corresponded to those of 2015, some of which have since merged., Results: There were 95,359 hospital admissions for multiple sclerosis in France in 2015 among a total cohort of 21,102 patients, resulting in a total cost of € 54.1m. Patients with MS were managed mainly in the ambulatory setting, which accounted for 88.5 % of all admissions. The Rhône-Alpes region represented 7.6 % of national admissions for MS, 9.6 % of patients, and 14 % of inpatient days, contributing 10.4 % of the national cost of MS care. 58.4 % of stays were managed by the two main multiple sclerosis centers. The Nord-Pas-de-Calais region represented 9.8 % of national admissions, 10 % of patients, 6.6 % of inpatient days, and 9.1 % of the national cost. 29.8 % of stays were managed by the main multiple sclerosis center. The Centre region represented 2.7 % of stays, 2.8 % of patients, 3.1 % of inpatient days, and 2.8 % of the national cost. 28.4 % of stays were managed by the main multiple sclerosis center., Conclusion: This study highlights the diversity of multiple sclerosis hospital management and care between these three regions., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management., Objective: To characterize factors that best identify which complex patients are most suited for intensive care management., Design: We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) "good candidates" for care management, (2) "not needing" intensive care management, or (3) "needing more" than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups., Results: CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p < 0.001), prescribed more medications (p = 0.02) and had more prior year outpatient visits (p = 0.04), while the number of prior year hospital and emergency room admissions were greater than not needing but less than needing more (p < 0.001). A logistic regression model using available electronic record data predicted good candidate designation with a c statistic of 0.75. Several qualitative themes emerged that helped define appropriateness for referral, including availability of social support, patient motivation, non-medical transitions, recent trajectory of medical condition, and psychiatric or substance use issues., Conclusion: Many apparently complex patients are not good candidates for intensive care management. Current electronic medical records do not capture several of the most salient characteristics that determine appropriateness for care management. Our findings suggest that systematic collection of social support, patient motivation, and recent non-medically related life change information may help identify which complex patients are most likely to benefit from care management.

Background: Cardiac-related complaints are leading drivers of Emergency Department (ED) utilization. Although a large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. We evaluate the impact of implementing a structured transitional care pathway enrolling low-risk cardiac patients on ED discharges, 30-day revisits and admissions, and institutional revenues., Methods: We prospectively enrolled eligible patients presenting to a single-center Emergency Department over a 12-month period. Standardized risk measures were used to identify patients suitable for early discharge with cardiology follow-up within 5 days. The primary endpoints were rates of discharge from the ED and 30-day ED revisit and admission rates, with a secondary endpoint including 30-day returns for myocardial infarction. A cost analysis of the program's impact on institutional revenues was performed., Results: Among patients presenting with cardiac-related complaints, rates of discharge from the ED increased from 44.4 to 56.6% (p < 0.0001). Enrollment in the transitional care pathway was associated with a reduced risk of cardiac-related ED revisits (RR 0.22, p < 0.0001), all-cause ED revisits (RR 0.30, p < 0.0001), and admission at second ED visit (RR 0.56, p = 0.0047); among enrolled patients, the 30-day rate of return with a myocardial infarction was 0.35%. No significant reductions were seen in 30-day cardiac-related and all-cause revisits in the 12-months following transitional care pathway implementation; however, there was a significant reduction in admissions at second ED visit from 45.6 to 37.7% (p = 0.0338). An early gender disparity in care delivery was identified in the first 120 days following program implementation that was subsequently eliminated through targeted intervention. There was an estimated decline in institutional revenue of $300 per enrolled patient, driven predominantly by a reduction in admissions., Conclusions: A structured transitional care pathway identifying low-risk cardiac patients who may be safely discharged from the ED can be effective in shifting care delivery from hospital-based to lower cost ambulatory settings without adversely impacting 30-day ED revisit rates or patient outcomes.

Despite data suggesting that individuals with multiple myeloma can benefit from receiving several lines of therapy, and guidelines recommending treatment after relapse, a recent European patient chart review found that only 61% of patients receive second-line treatment. The review found that factors such as old age and previous adverse events lead to physicians deciding not to treat after relapse. However, given the large number of regimens available, treatment can be tailored to individual patients' needs and supportive care measures can help with the management of adverse effects. If approved therapies are not suitable for a patient, guidelines recommend registration in a clinical trial, yet only 7% of patients in the review were participating in such studies. A need for better education on the range of treatments available and their risk-benefit profiles is suggested. Access to new drugs should be examined to maximise the number of patients benefitting from them., (Copyright © 2018 Amgen. Published by Elsevier B.V. All rights reserved.)

Introduction: Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes., Methods: Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study., Results: The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs., Conclusions: CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.

Background: General practitioners (GPs) are fully concerned with the care of patients suffering from addiction and must have the support of a specialized network. The aim of the study was to evaluate the prevalence of the addict follow-up care by GPs, their use of addictological care facilities and their needs in communicating with specialists., Methods: Private and salaried GPs working in the 9th, 10th, 18th and 19th districts of Paris were contacted by phone, and a questionnaire was sent to those who agreed to respond., Results: One hundred and thirty-eight GPs responded (median age 57 years, 38.4% women, 54% in private practice). In total, 78.9% received at least one patient weekly for alcohol dependence, 38.1% received at least one patient monthly for opiates and 40.2% for cannabis. They managed ambulatory alcohol (46.8%) and tobacco (65.0%) withdrawal schemes. Among GPs, 86.1% worked with the support of an addictological care facility structure, 69.6% reported lack of specialists for at least one product and 75.4% for at least one specific situation., Conclusion: The majority of GPs in north Paris providing care for patients with substance use disorder, worked with addictological care facilities structures. However, they noticed a lack of specialists with whom to communicate. Optimizations are proposed to facilitate interaction., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: The Forensic medicine reform in 2011 enabled the development of forensic units specialized in multidisciplinary care of victims of criminal offences. Thanks to an annual budgetary allocation, the Ministry of Justice handles the financing of judicial acts, while the health care facilities assume the medical, psychological and social aspects. The objective of this study was to determine the direct costs of medical care provided to rape victims (such as defined in the article 222-23 of the Penal Code) in order to see how its funding could be reconsidered to prevent any additional cost that could be caused by non-sufficient medical, psychological and social care. Furthermore, this first assessment may serve as a basis for further reflection on creating other medical judicial units but also for reviewing existing structures., Methods: The direct costs for medical care of a recent rape victim (<48hours) was quantified by including staff and consumables costs, treatments, biological tests and other expenses., Results: The overall time for the entire medical care procedure was approximately three hours, for an overall cost of 673.92€, of which 41.5 % (279.90€) was paid by the Ministry of Justice. The medical, psychological and social aspects stood for the major expenditure items (394.02€), attributable mainly to the biological screening tests for sexually transmissible infections (STIs)., Conclusion: These frequent situations require the convergence of human and material needs with a financial burden shared between the Ministry of Justice and health establishments. Authors suggest that in the annual hospital budgetary allocation allotted by the Ministry of Justice, the care of victims of sexual assault be based on the rate of day hospitalization "Medicine, medical specialties part time day or night common regime", allowing to provide optimal multidisciplinary care, which lessens the risks of complications and reduces the global cost created by these situations., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Italian pediatric antimicrobial prescription rates are among the highest in Europe. As a first step in an Antimicrobial Stewardship Program, we implemented a Clinical Pathway (CP) for Community Acquired Pneumonia with the aim of decreasing overall prescription of antibiotics, especially broad-spectrum., Materials and Methods: The CP was implemented on 10/01/2015. We collected antibiotic prescribing and outcomes data from children aged 3 months-15 years diagnosed with CAP from 10/15/2014 to 04/15/2015 (pre-intervention period) and from 10/15/2015 to 04/15/2016 (post-intervention period). We assessed antibiotic prescription differences pre- and post-CP, including rates, breadth of spectrum, and duration of therapy. We also compared length of hospital stay for inpatients and treatment failure for inpatients and outpatients. Chi-square and Fisher's exact test were used to compare categorical variables and Wilcoxon rank sum test was used to compare quantitative outcomes., Results: 120 pre- and 86 post-intervention clinic visits were identified with a diagnosis of CAP. In outpatients, we observed a decrease in broad-spectrum regimens (50% pre-CP vs. 26.8% post-CP, p = 0.02), in particular macrolides, and an increase in narrow-spectrum (amoxicillin) post-CP. Post-CP children received fewer antibiotic courses (median DOT from 10 pre-CP to 8 post-CP, p<0.0001) for fewer days (median LOT from 10 pre-CP to 8 post-CP, p<0.0001) than their pre-CP counterparts. Physicians prescribed narrow-spectrum monotherapy more frequently than broad-spectrum combination therapy (DOT/LOT ratio 1.157 pre-CP vs. 1.065 post-CP). No difference in treatment failure was reported before and after implementation (2.3% pre-CP vs. 11.8% post-CP, p = 0.29). Among inpatients we also noted a decrease in broad-spectrum regimens (100% pre-CP vs. 66.7% post-CP, p = 0.02) and the introduction of narrow-spectrum regimens (0% pre-CP vs. 33.3% post-CP, p = 0.02) post-CP. Hospitalized patients received fewer antibiotic courses post-CP (median DOT from 18.5 pre-CP to 10 post-CP, p = 0.004), while there was no statistical difference in length of therapy (median LOT from 11 pre-CP to 10 post-CP, p = 0.06). Days of broad spectrum therapy were notably lower post-CP (median bsDOT from 17 pre-CP to 4.5 post-CP, p <0.0001). No difference in treatment failure was reported before and after CP implementation (16.7% pre-CP vs. 15.4% post-CP, p = 1)., Conclusions: Introduction of a CP for CAP in a Pediatric Emergency Department led to reduction of broad-spectrum antibiotic prescriptions, of combination therapy and of duration of treatment both for outpatients and inpatients.

Background: The management of pregnancy-associated-cancer (PAC) requires epidemiological evaluation of the pathways of care. The aim of this study was to describe maternal and neonatal outcomes of PAC in Martinique., Methods: A retrospective study was conducted using data from medical records and the Martinique Cancer Registry for all PAC diagnosed between 1st January 2000 and 31st December 2014., Results: Eighteen women were diagnosed with PAC: 17 during pregnancy and one during the postpartum period. Mean age at diagnosis was 35.7 ± 5.4 years. PAC were mainly gynecological cancers (12/18); the other sites were: lymphoma, brain, liver, colon, skin and unknown primary site. In most cases, PAC was detected in symptomatic individuals (72.2%). Nine women had nodal involvement or initial metastasis at diagnosis. No chemotherapy was administered in cases of preservation of pregnancy. Seven fetal losses caused by abortion and miscarriage were recorded, and 11 women conducted viable pregnancies. The main neonatal pathology observed was prematurity (58.3%)., Conclusion: Cancer management during pregnancy is a challenge for French West-Indies territories. A Caribbean Observatory of rare cancers could help to ensure a coordinated approach to support and monitoring for these patients.

Background: The aim of the REDSIAM network is to foster communication between users of French medico-administrative databases and to validate and promote analysis methods suitable for the data. Within this network, the working group "Mental and behavioral disorders" took an interest in algorithms to identify adult schizophrenia in the SNIIRAM database and inventoried identification criteria for patients with schizophrenia in these databases., Methods: The methodology was based on interviews with nine experts in schizophrenia concerning the procedures they use to identify patients with schizophrenia disorders in databases. The interviews were based on a questionnaire and conducted by telephone., Results: The synthesis of the interviews showed that the SNIIRAM contains various tables which allow coders to identify patients suffering from schizophrenia: chronic disease status, drugs and hospitalizations. Taken separately, these criteria were not sufficient to recognize patients with schizophrenia, an algorithm should be based on all of them. Apparently, only one-third of people living with schizophrenia benefit from the longstanding disease status. Not all patients are hospitalized, and coding for diagnoses at the hospitalization, notably for short stays in medicine, surgery or obstetrics departments, is not exhaustive. As for treatment with antipsychotics, it is not specific enough as such treatments are also prescribed to patients with bipolar disorders, or even other disorders. It seems appropriate to combine these complementary criteria, while keeping in mind out-patient care (every year 80,000 patients are seen exclusively in an outpatient setting), even if these data are difficult to link with other information. Finally, the experts made three propositions for selection algorithms of patients with schizophrenia., Conclusion: Patients with schizophrenia can be relatively accurately identified using SNIIRAM data. Different combinations of the selected criteria must be used depending on the objectives and they must be related to an appropriate length of time., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient's journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions., Methods: A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000-2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included., Results: Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission)., Conclusions: There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Background: Usual source of care (USC) is one of the hallmarks of primary care. We aimed to examine the status of having a USC and its patient-related sociodemographic factors among Korean adults., Methods: Data were obtained from the 2012 Korea Health Panel survey. Panel participants were selected for the study who were aged 18 years or older and who replied to questionnaire items on having a USC (n = 11,935)., Results: Of the participants, 21.5% had a usual place and 13.9% had a usual physician. Reasons for not having a USC were seldom being ill (66.1%), the preference to visit multiple medical institutions (27.9%), and others. The private community clinic was the most common type of usual place (57.0%). In patient-reported attributes of care provided by a usual physician, the percentages of positive responses for comprehensiveness and coordination were 67.2% and 34.5%, respectively. By institution type, primary care clinics showed the lowest percentage (32.8%) of positive responses for coordination. Adjusted odds ratios of having a usual physician were 3.77 (95% confidence interval, CI: 3.75-3.79) for those aged 65 years or older (vs. aged 18-34 years), 1.31 (CI: 1.30-1.31) for females (vs. males), 0.72 (CI: 0.72-0.73) for unmarried people (vs. married), 1.16 (CI: 1.16-1.16) for college graduates or higher (vs. elementary school graduate or less), 0.64 for the fifth quintile (vs. the first quintile) by household income, 1.53 (CI: 1.52-1.54) for Medical Aid (vs. employee health insurance) for type of health insurance, and 4.09 (CI: 4.08-4.10) for presence (vs. absence) of a chronic diseases., Conclusions: The proportion of Korean adults who have a USC is extremely low, the most influential factor of having a USC is having a chronic disease or not, and Korean patients experience much poorer health care coordination than do patients in other industrialized countries. The findings of this study will give insight to researchers and policy makers regarding the potential facilitators of and barriers to promoting having a USC in the general Korean public.

Background: Despite recognition of the importance of timely presentation to HIV care, research on pathways to care is lacking. The adverse impact of depression upon adherence to antiretroviral therapy is established. There is emerging evidence to suggest depression may inhibit initial engagement with care. However, the effect of depression and other psychosocial factors upon the pathway to care is unknown., Methods: We used mixed methods to explore pathways to care of people accessing testing and treatment in Goa, India. Questionnaires including measures of common mental disorder, hazardous alcohol use, cognition and assessment of pathways to care (motivations for testing, time since they were first aware of this reason for testing, whether they had been advised to test, who had given this advice, time elapsed since this advice was given) were administered to 1934 participants at the time of HIV testing. Qualitative interviews were carried out with 15 study participants who attended the antiretroviral therapy treatment centre. Interview topic guides were designed to elicit responses that discussed barriers and facilitators of accessing testing and care., Results: Pathways were often long and complex. Quantitative findings revealed that Common Mental Disorder was associated with delayed testing when advised by a Doctor (the most common pathway to testing) (AOR = 6.18, 2.16-17.70). Qualitative results showed that triggers for testing (symptoms believed to be due to HIV, and for women, illness or death of their husband) suggested that poor health, rather than awareness of risk was a key stimulus for testing. The period immediately before and after diagnosis was characterised by distress and fear. Stigma was a prominent backdrop to narratives. However, once participants had made contact with care and support (HIV services and non-governmental organisations), these systems were often effective in alleviating fear and promoting confidence in treatment and self-efficacy., Conclusion: The effectiveness of formal and informal systems of support around the time of diagnosis in supporting people with mental disorder is unclear. Ways of enhancing these systems should be explored, with the aim of achieving timely presentation at HIV care for all those diagnosed with the disease.

Background: The provision of primary percutaneous coronary intervention (PPCI) in the emergency management of ST-elevation myocardial infarction (STEMI) is expensive and resource intensive. Accurate data collection is essential not only for outcomes analysis but also to characterize activity and performance for regions, centers, and operators. Inconsistency in the use of denominators currently creates problems in data interpretation., Objective: To establish a system of denominator groupings, seeking to better describe the range of clinical activity resulting from an unselected series of PPCI activations., Methods: The HEAT-SEALED pathway designates a key denominator group (n1-n9) to each phase of PPCI activity and identifies a final "destination category" for each patient leaving the pathway. HEAT-PPCI (How Effective are Antithrombotic Therapies in Primary Percutaneous Coronary Intervention) is a true "all-comers" trial and provides an ideal platform to collect data for prospective validation of the pathway. We report data from all PPCI activation events for the HEAT-PPCI trial., Results: Our findings demonstrate important differences between the sizes of key PPCI denominator groups and hence the potential for variation in reported outcomes depending on the denominator category selected. The main figures are: all activations (n1 = 2490); all suspected MI cases (n4 = 1940; 77.91%); patients in whom angiography was performed (n5 = 1904; 76.46%); cases in which diagnosis was confirmed with a probable culprit lesion (n6 = 1657; 66.54%), and cases with complete PCI success (n9 = 1441; 57.87%)., Conclusion: The HEAT-SEALED pathway offers a practical and comprehensive solution to the problem of describing denominators in STEMI and PPCI. Routine application would facilitate a more consistent and precise description of activity and outcome.

Background: Increased use of echocardiography (echo) raises questions of whether echo is an overused diagnostic procedure in the United States., Objectives: This study investigated national trends, practice patterns, and patient outcomes associated with inpatient echo use reported in the Nationwide Inpatient Sample (NIS)., Methods: We identified admission diagnoses most commonly associated with echo use and performed multivariate logistic regression within each diagnosis cohort to assess whether echo use was associated with all-cause inpatient mortality. Secondary analysis was performed within our institution to validate use trends identified in the NIS database., Results: Between 2001 and 2011, the absolute volume and incidence of echo steadily increased at average annual rates of 3.41% and 3.04%, respectively. In 2010, the use of echo was associated with lower odds of inpatient mortality among hospitalizations for acute myocardial infarction (adjusted odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.63 to 0.86; p < 0.001), cardiac dysrhythmia (adjusted OR: 0.72; 95% CI: 0.55 to 0.94; p = 0.02), acute cerebrovascular disease (adjusted OR: 0.36; 95% CI: 0.31 to 0.42; p < 0.001), congestive heart failure (adjusted OR: 0.82; 95% CI: 0.72 to 0.94; p = 0.005), and sepsis (adjusted OR: 0.77; 95% CI: 0.70 to 0.85; p < 0.001). In 2010, these 5 diagnoses accounted for 3.7 million hospital admissions (9% of all hospitalizations); however, echo was reported in only 8% of cases. Secondary analysis of imaging practices at our institution confirmed underuse of echo among patients who died during hospitalization for indications identified in the NIS database., Conclusions: Despite increasing rates of performance, echo may be underused during critical cardiovascular hospitalizations., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)