Patient feedback on safety can drive improvements

Feedback from patients about the safety of care they receive in hospital, together with data from staff, can be used to drive safety improvements,  a UK study has found. Patients in 33 UK hospital wards completed a Patient Measure of Safety (PMOS) survey asking about how they perceived safety aspects of their care.
			Both the staff responses ... and the patient responses to the measure of safety survey independently predicted safety outcomes

The friends and family test

They also completed the Friends and Family test (FFT), in which they rated how likely they would be to recommend the ward to friends and family if they needed similar care.

Nurses on the wards were also asked to complete four outcome measures from the Hospital Survey of Patient Safety Culture survey, and the results were collated with publicly reported safety outcome data from each ward. 

The study found that while the Friends and Family Test was associated with patients’ perceptions of safety, it was not associated with safety outcomes.

However, both the staff responses to the patient safety culture survey and the patient responses to the measure of safety survey independently predicted safety outcomes, according to findings in the BMJ Quality and Safety journal.

When put together, those two surveys accounted for 49% in the variance in safety outcomes across the wards, the study found, and the patient safety survey was useful for identifying differences between the hospitals.

“In other words, what patients tell us about the safety of their care may partially overlap with staff perceptions, but patients tell us something that helps us understand more about the safety outcomes on hospitals wards,” the authors wrote.

Models help ALERT hospitals to high-risk patients

Patients at the greatest risk of adverse outcomes including cardiac arrest and transfer to intensive care could be identified upon admission to hospital using a scale which relies on routinely collected data, a new study suggests.

The Adverse Hospital Outcome for Medical Patients (ALERT) scale could be used to assign patients to different levels of observation, depending on the likelihood of an adverse event, the authors said.

Researchers analysed data from 4883 consecutive admissions at two hospitals in Winnipeg, Canada, to construct the ALERT scale. Its ability to predict death or cardiopulmonary resuscitation within 30 days of admission or transfer to an ICU within 48 hours of admission was then assessed through validation across four hospitals including a further 65,640 admissions.

The data measured in the ALERT scale included gender, age, degree of co-morbidity (Charlson Comorbidity Index), chronic disability (Activities of Daily Living Score), Glasgow Coma Score, systolic blood pressure, respiratory rate, heart rate and white cell count.

The model accurately identified 75% of adverse outcomes and 75% of the non-adverse outcomes, according to findings in BMJ Open.

“The primary advantage of our model is that data needed to inform the model is likely to be already collected on admission in most hospitals or easily added to data collected on admission,” the authors wrote.

Meanwhile, a separate Canadian study found the risk of a patient being readmitted to hospital within 12 months of discharge could be reasonably well predicted based on a model using administrative data.

The study of 61,924 patients, of whom 33% were readmitted within a year of discharge, found that significant predictors for re-hospitalisation included: older age, male gender, diseases of the eye, adnexa, circulatory system, neoplasms, genitourinary or musculoskeletal system and connective tissue, at least one hospital admission in the previous two years and not having a family physician.

The predictive model used in the study could help health care providers target interventions to prevent unnecessary readmissions, according to findings in the Journal of Health Services Research & Policy.

“Fix and forget” is a common approach to safety problems, study shows

Front-line hospital staff who encounter safety problems that they can resolve on the spot ‒ including near misses ‒ usually “fix and forget” the problem, rather than reporting it, a study shows.

However, this approach could lead to safety incidents being repeated or staff being constantly engaged in time-consuming workarounds, the Canadian authors warned.

The study involved in-depth interviews with 40 healthcare practitioners at a tertiary care hospital, focusing on how they dealt with front-line safety issues that they could resolve on the spot.

The research found that “fixing and forgetting” was the main choice most practitioners made in situations where they faced problems that they fix themselves, according to findings in BMJ Quality and Safety.

These included three main situations: near misses, which were seen as unworthy of reporting as the patient was not harmed; the solving of patients’ individual safety problems, which were viewed as one-off events; and encountering re-occurring safety problems that were framed as inevitable, routine events.

The authors said practitioners believe reporting of near-miss incidents such as a patient almost being given the wrong intravenous fluid would create overburdening paperwork.  Practitioners believed if a problem had not progressed to the patient, there was no need to report it.

“Choosing to be efficient in the moment may ironically cause the front-line providers to be far less efficient over time than intended,” the authors wrote.

They suggested communication and training about what should be reported, why and how should be considered more carefully, adding that recognising staff who acted as “disruptive questioners” as desirable employees could help encourage a new approach.

How do patients choose a doctor?

The factors that influence patients’ choice of doctors differs significantly depending on the condition for which they are seeking treatment, according to a new study which highlights the need to provide better targeted information about healthcare providers.

The Dutch study analysed what influenced the choice of heathcare providers in hypothetical situations posed to patients with three different conditions: knee arthrosis (616 patients), chronic depression (368 patients) and Alzheimer’s disease (421 patient representatives).

Findings in Health Services Research showed that for patients with knee arthrosis, the most important factors were effectiveness and safety of surgery.

Among patients with chronic depression, better continuity of care, a better personal match with the therapist during earlier contact, or the possibility to participate in decisions about the care process were the most important factors.

A better level of caregiver expertise, reduced travel distance and care delivery in accordance with agreements were the most important factors in the choice of doctor among the representatives of patients with Alzheimer’s disease, the study found.

The authors said the findings suggested that there was a room for quality information about healthcare providers in patients’ decision processes, and that information needed to be tailor-made to target specific patient groups.

Patient portals could widen health disparities

The push for patients to use online health portals could exacerbate inequities, according to a US study that reveals stark health literacy, educational and racial disparities in older patients’ use of an online health portal.

The findings come as the Australian federal government this month pledged a $485 million “rescue” package to revamp the stalled national e-health system (see news story above).

The US study of 534 older adults attending an urban medical clinic found that most patients had a portal access code generated for them, but only 57.5% had gone on to register their accounts.

White patients and college graduates were the more likely to have registered their patient portal accounts, as were patients with greater health literacy, the study found. For example, only 22% of patients with limited health literacy registered their portal accounts, compared with 73% of those with adequate health literacy skills.

Healthier patients were also more likely to have registered for the patient portal than those with chronic conditions, according to findings in the Journal of the American Informatics Association.

The study also showed disparities in the use of the portal among those who were registered. Highly educated patients were the most likely to use the portal for prescription refill requests and white patients were more likely to have checked test results using the portal than African American patients.

Possible barriers to patients using the portal included a “digital divide” in Internet connectivity, difficulties with usability, forgetting to enrol after being given an access code, a lack of interest in the functions available and negative attitudes towards technology, the authors said.

“Our findings suggest research should focus on addressing the barriers faced by older under-served populations at the registration stage of patient portal initiation,” they wrote. They suggested that if patient portals were implemented, intervention strategies would be needed to monitor and reduce disparities in their use.

Financial incentives help people change health behaviours ‒ but not forever

Giving people financial incentives helps to change health behaviours such as smoking and diet, a new review shows, but the effects dissipate three months after the incentive is removed.  The review and meta-analysis included 34 studies involving 10,585 adult patients who were given financial incentives to achieve sustained changes in smoking, eating and physical activity behaviours.
			Overall, the incentives increased the likelihood of patients changing their behaviour by 70% after six months and the effect was sustained for up to 18 months from the start of the intervention

Removing incentives

In more than half the studies, the incentives were worth less than $US400 ($A504), while the rest were higher, and most studies also offered other interventions such as counselling, self-help manuals, brochures, professional advice or nicotine replacement therapy concurrently.

Overall, the incentives increased the likelihood of patients changing their behaviour by 70% after six months, according to findings in Preventive Medicine, and the effect was sustained for up to 18 months from the start of the intervention.

The behaviour change was sustained for 2‒3 months after the incentive was removed, but by six months, it had dissipated.

The review also found incentives had a greater effect on the health behaviours of patients classified as highly deprived ‒ a finding that suggested incentive schemes could help reduce health inequities.

“Although the use of personal financial incentives appears useful in initiating healthier behaviours, with changes sustained for some months after incentive removal, results from this review suggest that effects may ultimately dissipate, i.e. new habits do not appear to be formed,” the authors wrote.

While the review didn’t compare the use of incentives with other behaviour‒change strategies, the authors suggested it might be worth complementing their use with behaviour‒maintenance and relapse‒prevention strategies that could be delivered after the incentive was removed.

Hospital admission doesn’t cut polypharmacy in elderly

Three quarters of elderly patients admitted to hospital are already taking five or more drugs ‒ and there is little change in their medication use when they are discharged, an Australian study shows.

The researchers said that polypharmacy ‒ defined as five or more regular prescription medications ‒ was associated with adverse outcomes among older people living in the community, but had not been well explored in a hospital setting.

The study of 1220 patients aged 70 years and over admitted to general medical units in 11 acute care hospitals in Queensland and Victoria found polypharmacy was common and one in five patients were taking 10 or more medications.

Patients were prescribed a mean of 7.1 regular medications per day on admission to hospital and 7.6 medications per day on discharge, according to findings in the MJA.

The authors said that during the hospital admission, there was “no clinically meaningful change to the number or the classification (symptom control, prevention or both) of medications, nor in the prevalence of specific drug classes such as statins, opioid analgesics, antipsychotics and benzodiazepines.”

“This may suggest that active attempts were not made to de-prescribe when appropriate,” they wrote.

While it had not been established when and where the process of detailed medication review should occur, they suggested the acute care hospital ward, under the care of physicians, could be an appropriate setting for discontinuing inappropriate drugs.

Meanwhile, a separate article in JAMA Internal Medicine proposed a five-step protocol for de‒prescribing to minimise polypharmacy and improve patient outcomes, especially in the elderly.

The steps included prioritising drugs for discontinuation that had the lowest benefit‒harm ratio and the least likelihood of adverse withdrawal reactions or disease rebound syndromes, and monitoring patients closely for improvements in outcomes or onset of adverse effects.

Paracetamol not backed for low back pain and osteoarthritis

The routine use of paracetamol to treat low back pain has been called into question, following a review showing the drug doesn’t reduce pain or disability and could put patients at risk of liver damage. The study, which also showed paracetamol provided little benefit for hip and knee osteoarthritis, prompted a call to review clinical guidelines recommending the drug a first-line treatment for both conditions.
			The review also found that patients taking paracetamol were nearly four times more likely to have abnormal results on liver function tests than those taking placebo, although it was unclear whether those results had any clinically significant impact

Surveillance failures

The researchers conducted a systematic review and meta-analysis of 13 randomised trials. Findings in the BMJ showed high quality evidence that paracetamol was ineffective for reducing pain intensity or improving quality of life in the short term in people with low back pain. 

For hip or knee osteoarthritis, there was high-quality evidence that the analgesic provided a significant, but not clinically important, effect on pain and disability in the short term, which was no better than placebo.

The review also found that patients taking paracetamol were nearly four times more likely to have abnormal results on liver function tests than those taking placebo, although it was unclear whether those results had any clinically significant impact.
 

Obesity screening falls short in general practice

Less than one quarter of patients have their BMI recorded in their medical records, according to an Australian study which urges more support for GPs to help them meet clinical guidelines on screening for overweight and obesity.

The researchers studied medical records of 270,426 adult patients from 78 Melbourne general practices to assess whether the GP had recorded patients’ BMI and waist circumference, as recommended in NHMRC guidelines for managing overweight and obesity.

Just 22% of patients had a documented BMI, while just 4.3% had their waist circumference measurement recorded, the MJA study found.

Barriers that GPs faced in screening patients for obesity included problems identifying obese patients, difficulty approaching the discussion about obesity and a perceived lack of appropriate training, as well as clinical software restrictions, the study suggested.

The authors called for further research into the barriers and enablers to increased obesity screening in general practice