Audio recordings of consults a useful patient aid

Conducting an audio recording of outpatient consultations, which patients can listen to later at home, can be a useful information aid, a new study shows. In the study, 2784 Danish patients attending outpatient clinics in paediatrics, orthopaedics, internal medicine and urology had their consultations with doctors recorded.
			One in five adult patients and 18% of parents said they replayed the consults due to difficulties remembering or understanding information from the consultation.

Many patients replayed recordings

The recordings were made using digital audio recording technology via a wireless telephone, and patients were able to replay them later using any telephone, by entering a social security number and PIN code.

Of the 2784 recorded consultations, 31% were replayed by the patient, a relative or a combination of the two within 90 days of the consultation. A further 19 recordings were replayed later, the study found.

One in three recordings from the adult outpatient clinics and one in five paediatric recordings were replayed later.

Findings in the International Journal for Quality in Health Care showed that the majority of patients had no difficulty in replaying their consultation.

One in five adult patients and 18% of parents said they replayed the consults due to difficulties remembering or understanding information from the consultation. A further 15% of adult patients and 30% of parents replayed the consultation in order to share it with relatives.

While the authors suggested further research was needed on the feasibility of offering audio recordings in paediatric clinics, they said the technology was worth considering in time-pressured adult clinics.

“DAR [Digital Audio Recordings] could become a resource in outpatient clinics, where there is limited time for interaction with the health professional and increasing pressure for patients to become active participants,” they wrote.

Patients told about ED wait times are more satisfied

Patient are more satisfied with their care in emergency departments (EDs) if they are told at triage how long they are likely to wait for a bed, a study suggests.

The US study involved 1209 adult patients attending the ED: 322 were told at triage how long they were likely to wait for an ED bed, and 887 were not given any estimate of waiting time. All filled out a patient satisfaction questionnaire on discharge.

The expected wait time was estimated using a model based on time of day, day of the week and triage levels.

“The main goal of the intervention was to improve communications of delays and managing the patients’ perceptions of wait time without affecting clinical care and/or reducing operational inefficiencies,” they wrote.

The communication of delays didn’t result in improved patient satisfaction for the “satisfied with wait time in triage” and “informed about delays” questions on the patient satisfaction survey, the study found. However, it was associated with the overall rating of the ED visit question.

Patients who received no communication about delays were between 1.42 and 5.48 times more likely to rate the three satisfaction questions lower than “very good”, according to findings in the Patient Experience Journal.

Nearly 15% more patients who were told about delays rated satisfaction questions as “very good” than those who didn’t receive wait time information. They were also less likely to give a “very poor/poor” satisfaction rating than patients given no information about delays.

“This indicates that patients are more likely to accept longer wait times provided their expectations are managed via communications,” the authors wrote.

They called for further research into more effective ways to manage patient expectations and into compliance with such initiatives through staff training, incentives, standardisation of processes and technological developments.

Push for better tools to measure patient experience

Research is needed about new ways to measure patient experience that can capture real-time data and feed it back to frontline clinicians, according to the authors of a review of tools used to measure patients’ hospital experiences.

Health professionals worldwide were broadening their focus to include the experiences of patients and their families as a means of assessing the quality of patient-centred care, the Australian researchers said.

They conducted a literature review to identify instruments specifically designed to measure inpatient hospital experiences, which identified 17 studies and 13 relevant instruments, including the Australian-developed Patient Evaluation of Emotional Care during Hospitalisation (PEECH) survey.

All the instruments they identified were survey-based and provided predominantly quantitative data. Five of the surveys were designed to collect information during the patient’s hospital stay, but most were completed by patients after they were discharged.

Writing in the Patient Experience Journal, the researchers said the literature search found no validated instruments that were designed to capture qualitative data.

However, they suggested that developing more detailed surveys was not the solution to obtaining richer data.

“While surveys tend to have positive response rates, length of survey can actually be a deterrent to complete thereby impacting response and value of information,” they wrote.

Rather, they suggested patients needed to be involved in the development of a survey that could collect data while the patient was still in hospital, with a corresponding feedback process to healthcare staff.

“Ideally such an instrument could be designed using a participatory research methodology, whereby patients, friends, family and healthcare clinicians are equal co-developers,” they wrote.

Printed handover notes outdated in just three hours, study shows

The common hospital practice of using printed patient handover documents has been thrown into question by a study that shows the information on such documents becomes inaccurate and outdated very quickly.

The US study analysed a sample of 100 adult patient records over a single 24-hour period at an academic medical centre to determine the ‘half-life’ of the printed handoff documents – or the time at which half the patients would be expected to have inaccurate information on such a document.

They looked at changes in the patient orders on such documents such as those related to medication, diet, code status and patient location.

The half-life of the printed document on the 12-hour night shift was just six hours, they found.

“A typical resident getting sign-out on 20 patients overnight could safely assume that the data for 10 of them would be inaccurate or outdated within six hours, and that it would be inaccurate on another two by the morning,” the authors wrote in BMJ Quality and Safety.

On the day shift, inaccuracies accumulated even more quickly, with the half-life of documents found to be just 3.3 hours.

They said 92% of patients had at least one change on their orders within a 24-hour period, with most changes related to medication.

The authors suggested that minimising printing of documents would drive providers to look at information updated in real time, such as medication lists on electronic health records (EHR).

“Easy access to and usage of online handoff reports contained in EHR present a potential solution to this problem,” they concluded.

Patients’ experiences of adverse events overlooked, review finds

Few studies comprehensively report on patients’ experiences of adverse events, despite an increasing policy focus on enhancing patient engagement in healthcare, a study shows. The Australian-led review of 33 studies found that patients had a different view of adverse events (AEs) to health professionals, yet data on their experiences was not routinely captured and utilised to develop effective system-wide policies to minimise adverse events.
			The frequency of adverse events reported by patients varied widely, but the most common events identified by patients were medication errors and communication breakdowns, the review found.

Patients can recognise things that go wrong

Patients reported a large number and type of adverse events, according to the study, which the authors said demonstrated that patients were able to recognise things that went wrong in their care.

However, it found patients often defined adverse events more broadly than health professionals’ definition of such events. For example, in one study, nearly half of patient-identified adverse events were described by health professionals as “misunderstandings” and a further 19% were described as “miscommunications” rather than mistakes.

“The studies highlight that an AE from a patient’s perspective is a chain of problems in care, connecting problematic care before an event, the event itself (clinically defined) and ‘care’ (or lack of satisfactory care) in response to the event,” the authors wrote in the International Journal for Quality in Health Care.

The frequency of adverse events reported by patients varied widely, but the most common events identified by patients were medication errors and communication breakdowns, the review found.

The authors said patient involvement was now a core component of health service policy internationally, and the findings suggested patient reporting of adverse safety events could add value to the quality of data that was captured.

“The information from patients is critical to identifying incidents and ultimately to reducing patient harm, but they are not routinely asked to provide these data,” the authors wrote.

Warning over adverse events linked to off-label prescribing

Researchers have urged caution in prescribing drugs for off-label use, after finding that the practice is associated with a high rate of adverse events, especially when there is a lack of strong scientific evidence to support the off-label use of drugs.

The researchers used electronic health records to analyse adverse drug events (ADEs) in a cohort of 46,000 patients prescribed medications through primary care clinics in Quebec, Canada.

Off-label use ‒ when a drug is prescribed for an indication, a route of administration, or a patient group that is not included in the approved product information document for that drug ‒ was reported in 11.8% (17,847) of the scripts. In four out of five of those cases, the off-label use lacked strong scientific evidence.

Findings in JAMA Internal Medicine showed that physicians discontinued 3484 drug treatments due to adverse drug events, most of which occurred in the first year of treatment.

The overall incidence rate of ADEs was 13.2 per 10,000 person-months, but adverse events were 44% higher for off-label prescribing, compared with on-label prescribing, after adjusting for patient and drug characteristics.

There were 19.7 ADEs per 10,000 person-months for off-label prescribing, compared with 12.5 for on-label prescribing and the rate of adverse events related to off-label scripts for drugs without strong scientific evidence was higher than if the drugs’ usage was evidence-based.

The authors estimated that the mean cost per adverse drug event ranged from $US759 to $1214.

They said doctors and medical organisations should “recognise the enormity of the problem”, and suggested future electronic health records should be designed to enable post-marketing surveillance of treatment indications and outcomes, to help monitor the safety of both on- and off-label uses of drugs.

Review reveals high rates of depression among junior doctors

More than one in four physicians-in-training experiences depression or depressive symptoms, according to a review which calls for further research into strategies to prevent mental illness in junior doctors.

The systematic review and meta-analysis of 54 studies involving 17,560 physicians-in-training showed that between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency, depending on the instrument used to measure symptoms.

The overall pooled prevalence of depression or depressive symptoms was 28.8%, according to findings in JAMA.

“Because the development of depression has been linked to a higher risk of future depressive episodes and greater long-term morbidity, these findings may affect the long-term health of resident doctors,” the authors wrote.

They added that depression among residents may also affect patients, with previous research having established associations between physician depression and lower-quality care.

The study found an increase in depressive symptoms among residents over time, and secondary analysis of seven longitudinal studies showed depressive symptoms increased by an average of 15.8% after the start of residency, suggesting that the causes of depression were linked to the residency experience.

The authors said the findings highlighted an “important issue in graduate medical education” and called for further research into effective strategies to prevent and treat depression in medical graduates.

Shared patient-physician financial incentives most effective

Offering both patients and doctors financial incentives is an effective strategy to reduce patient cholesterol levels, but paying incentives to either patients or physicians alone has little effect, according to a new study.

The US study involved 340 primary care physicians and 1503 patients at increased risk of cardiovascular disease who were divided into four groups: control group, physician incentives, patient incentives or shared physician-patient incentive.

Those in the physician incentive group were eligible to receive up to $1024 per patient who met LDL-cholesterol goals through use of statin medication, while patients in the patient incentive group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. The doctors and patients in the shared incentive group shared the incentives, while the control group received no incentives tied to outcomes.

After 12 months, only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels that were statistically different from those in the control group, according to findings in JAMA.

Almost half of those in the shared patient and physician incentive group (49%) achieved the cholesterol goal, compared with between 36% and 40% in the other three groups.

“The lack of improvement in LDL-C levels, despite potential physician incentives of up to $1024 per patient, offers the first controlled evidence that adding these incentives to a fee-for-service payment model may not improve medication-related intermediate outcomes,” the authors wrote.

They also highlighted that the use of daily lotteries for patients’ medication adherence had only had a modest effect on cholesterol levels, and that medication adherence remained low in all groups.

Engaging clinicians in research has broad benefits: review

Getting clinicians involved in medical research can contribute to improved healthcare performance, according to a review of studies which lends support to a growing number of research networks across healthcare organisations. The review included 33 papers, with the majority (28 studies) showing positive associations between clinicians’ or organisations’ involvement in research and healthcare performance.
			It is reasonable to suggest that when clinicians and healthcare organisations engage in research there is the likelihood of improvement in their healthcare performance, even when that has not been the aim of the research.

Improvements in processes and outcomes

Improvements were largely in processes of care, but some improved health outcomes were reported.

For example, one study showed that patients treated for unstable angina in US hospitals participating in clinical trials had significantly lower mortality than those treated in non-participating hospitals. Two US studies of patients treated for breast cancer at facilities that were members of cancer research networks found that they were more likely to receive guideline-concordant treatment or be given innovative treatments than those in hospitals that were not network members.

“It is reasonable to suggest that when clinicians and healthcare organisations engage in research there is the likelihood of improvement in their healthcare performance, even when that has not been the aim of the research,” the authors wrote in BMJ Open.

The authors said the findings came as the number of research networks was growing and the contribution of collaborative approaches to research was developing.

They urged further research into the impact of research engagement on healthcare outcomes, “particularly given the pressure to justify research spending in healthcare systems and to encourage its implementation”.

Meanwhile, a separate study published in JAMA in which researchers reviewed the literature on educating physicians to deliver high-value, cost-conscious care outlined three key factors: 

• Knowledge transmission ‒ for example, teaching trainees how to judge medical value and gain insight into patients’ personal values
• Reflective practice, such as providing feedback or asking reflective questions regarding aspects such as prescribing to give trainees insight into their past and current behaviour
• Creation of a supportive environment with a culture of high-value, cost-conscious care.