Burns care variations prompt action

New evidence-based clinical guidelines are in development, after a study revealed significant variation in the management and outcomes of patients treated at specialised burn units in Australia and New Zealand. The researchers studied data from the Burns Registry of Australia and New Zealand (BRANZ) on 7184 adult burns cases treated at 10 acute adult burns units between 2010 and 2014.
			While variation is not necessarily in itself a sign of inferior treatments, it does signal the need for further investigation, especially where outcome indicators are also found to vary

Mortality rates differ among units

The findings, published in the MJA, showed there were significant differences between burns units in both the clinical management of burns injuries and in patient outcomes.

The proportion of patients admitted to intensive care units varied from 4.9% to 24.6% across burns units, and skin grafting rates ranged from 21.7% to 71.2%.  Patients’ length of stay in hospital increased in line with the extent of burns, however the study found the mean, adjusted length of stay differed by more than two days across units.

The adjusted odds of mortality also differed, with three units reporting significantly lower estimated probabilities of death than the two units with the highest estimates.

“While variation is not necessarily in itself a sign of inferior treatments, it does signal the need for further investigation, especially where outcome indicators are also found to vary," the authors wrote."For example, it may be that variations in LOS [length of stay] reflect differing rehabilitation protocols rather than delay in treatment.”

The author said the information provided by BRANZ provided a unique opportunity for signficantly improving the quality of care for burns patients in Australia and New Zealand.

In response to the findings, the Australia and New Zealand Burn Association had launched the Burns Quality Improvement Project in 2013 to develop evidence-based standards of care for burns care, and to provide a framework to drive change, they said.

VTE prevention patchy: study

Half of patients at risk of venous thromboembolism (VTE) do not receive the appropriate preventive care and management in Australian hospitals, according to a study which urges a national, system-wide approach to the problem.

Researchers assessed whether VTE indicators were met in a sample of 481 adults who were enrolled in the Caretrack Australia (CTA) study, and who were admitted to hospital overnight at least once during 2009 and 2010.

The indicators included the use of anticoagulant therapy in patients undergoing certain procedures, as well as appropriate management and investigation of hospitalised patients with suspected pulmonary embolism (PE) or deep vein thrombosis.

The study, published in BMJ Open, showed that overall compliance with the VTE indicators was 51% ‒ despite considerable efforts to promote and facilitate the uptake of clinical practice guidelines (CPG) in Australia.

Compliance with aggregated sets of indicators ranged from 34% to 64%, and compliance ranged from 45% to 70% across the 27 hospitals in the study.

“Despite the prevalence, cost, morbidity and mortality associated with VTE and PE, prophylaxis and treatment are still in line with CPGs only half of the time,” the authors wrote.

They suggested the findings were “consistent with the lack of a system-wide approach”, adding that VTE was not included in national standards and did not have a national healthcare goal.

The researchers called for agreement on national clinical standards and on the development of indicators and tools to guide, document and monitor the appropriateness of care for VTE, perhaps through a national wiki-based process.

“VTE data could then be monitored at hospital level and the data aggregated at national, and potentially at international levels, to track progress and inform policy,” they wrote.

Language barrier may impact ACS outcomes

Patients with acute coronary syndrome (ACS) for whom English is a second language have poorer outcomes than those whose first language is English, a study reveals.

Researchers analysed treatments and mortality among 6304 patients from 41 hospitals enrolled in the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE).

The 16% of patients who reported that English was their second language (ESL) were older, and were more likely to have prior myocardial infarction, heart failure and chronic renal failure than those patients whose first language was English (EFL).

Findings in the MJA showed a higher incidence of heart failure, renal failure, stroke, recurrent myocardial infarction, major bleeding and in-hospital mortality in the ESL group compared with the EFL group.

They had longer stays in hospital, but were less likely to use second-line antiplatelet agents and had lower rates of cardiac catheterisations, percutaneous coronary intervention rates and referral to a cardiac rehabilitation than the EFL group, while rates of coronary bypass grafting (CABG) were similar in the two groups.

At six-months follow-up, all-cause mortality was higher in the ESL group than among those who reported English as their first language (13.8% vs 8.3%).

The authors said previous studies had shown that deficiences in intercultural communication might play a role in adverse outcomes for patients from culturally and linguistically diverse backgrounds.

While the poorer outcomes for ACS patients in whom English was as second language may be explained by a higher prevalence of cardiovascular risk factors leading to more advanced disease, they suggested problems of culturally specific communication may also play an important role.

Tall Man lettering falls short

The commonly used typographical system of drug labelling known as “Tall Man lettering” aimed at avoiding mix-ups with medications with similar names has been brought into question by a US study, which shows it does not reduce prescribing errors in paediatric hospitals.

The Tall Man labelling system uses mix-cased labelling to visually emphasise differences in drug names that look or sound alike, for example, cefUROXime and cefOTAXime.

The system has been adopted by many drug safety bodies worldwide, including the US Food and Drug Administration (FDA), and is supported by the Australian Commission on Safety and Quality in Health Care (ACSQHC) as part of a multi-faceted approach to reducing risks associated with confusable, look-alike sound-alike medicine names.

In the study, researchers used nine-years of detailed pharmacy data for paediatric inpatients from 42 children’s hospitals, to assess the effect of the introduction of Tall Man lettering on error rates for 11 look-alike, sound-alike drug names including: clonidine-clonazepam; tramadol-trazodone; metformin-metronizadole; guanfacine-guaifenesin.

Findings in BMJ Quality and Safety showed there was no significant change in potential look-alike sound-alike error rates for the 11 drug pairs before and after the 2007 implementation of Tall Man lettering among US children’s hospitals.

While rates of errors remained extremely low during the study period, they found an increase, rather than decrease, in overall error rates for the drugs.

The researchers said the 11 drug pairs analysed were not representative of all look-alike sound-alike drug pairs and said other factors such as the introduction of computerised physician drug ordering may have impacted on the findings.

“Whether Tall Man lettering is effective in clinical practice warrants further study,” they concluded.

The ACSQHC said it was currently reviewing the National Tall Man Lettering Standard and associated National Tall Man Lettering list, and would consider the international harmonisation of medicine ingredient names being conducted by the Therapeutic Goods Administration.

Antibiotic resistance common in children with UTIs

There is a high level of antibiotic resistance in children treated for urinary tract infections (UTI) that could render some antibiotics ineffective as first-line treatments, a new review warns. The systematic review and meta-analysis included 58 observational studies in 26 countries and involved more than 77,000 Escherichia coli samples.
			The study also showed that children previously treated with antibiotics in primary care were more likely to be resistant, and that increased risk could persist for up to six months

Call to reconsider UTI management

Among children with UTIs, it revealed high rates of bacterial resistance to some of the most commonly prescribed antibiotics in primary care, such as ampicillin.

Resistance to all reported antibiotics was higher in non-OECD countries than OECD countries, but worldwide, rates of resistance to the antibiotic ampicillin were the highest, and resistance to nitrofurantoin was the lowest, according to findings in the BMJ.

The authors said the availability of antibiotics over-the-counter and weaker regulation of antibiotic use may explain the higher rates of resistance in some non-OECD countries.

US and European guidelines recommended that an antibiotic should only be selected for first line empirical treatment of UTI if the local prevalence of resistance was less than 20%, they said.

“According to these guidelines, our review suggests ampicillin, co-trimoxazole, and trimethoprim are no longer suitable first-line treatment options for urinary tract infection in many OECD countries,” they wrote, adding that guidelines may need updating.

The study also showed that children previously treated with antibiotics in primary care were more likely to be resistant, and that increased risk could persist for up to six months.

In an accompanying editorial, Professor Grant Russell of Monash University said the findings presented “compelling evidence of the need to reconsider current approaches to community-based management of paediatric urinary tract infection”.

Cutting high-risk prescribing reduces admissions

A multi-faceted intervention targeting high-risk prescribing in primary care reduces risky prescribing, as well as being associated with a fall in emergency hospital admissions for related conditions, new research shows.

The study involved 33 primary care practices in Scotland taking part in a 48-week intervention targeting high-risk prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) or selected anti-platelet agents – a common cause of medication-related emergency hospital admissions.

The intervention comprised three components: professional education; financial incentives (an initial payment of £350 ($A655) and a payment of £15 ($A28) for every patient for whom the targeted high-risk prescribing was reviewed) and the use of an informatics tool to identify patients who needed review and to provide weekly updates on rates of high-risk prescribing and review progress.

The findings, published in the New England Journal of Medicine, showed that targeted high-risk prescribing was significantly reduced, from a rate of 3.7% immediately before the intervention, to 2.2% at the end of the intervention.

The rate of hospital admissions for gastrointestinal ulcer or bleeding was also significantly reduced from 55.7 admission per 10,000 person-years before the intervention, to a rate of 27.0 after the intervention.

Similarly, the rate of admissions for heart failure fell  from 707.7 to 513.5 admissions per 10,000 person-years after the intervention. Admissions for acute kidney injury were not significantly reduced.

The authors said the blend of education, financial incentives and informatics was effective, but they could not identify which aspect of the intervention mattered most.

They said the three aspects of the intervention were feasible in any system in which primary care was delivered by physician-owned practices that use electronic medical records, and are under contract with third-party payers.

“However, complex interventions of this type inevitably require tailoring to context,” they wrote.

“Difficult” patients more likely to be misdiagnosed

Doctors are more likely to get a diagnosis wrong if the patient is regarded as “difficult”, according to a study which suggests the mental effort needed to deal with problematic behaviour distracts from the task at hand.

Dutch researchers asked 63 doctors in their last year of family medicine training to provide a diagnosis for one of two versions of six clinical case scenarios: pneumonia, pulmonary embolism, meningoencephalitis, hyperthyroidism, appendicitis and acute alcoholic pancreatitis. 

One version of the scenario portrayed a “difficult” patient with one of the six conditions, and the other described the same scenario, but with a patient who didn’t have disruptive behaviour.

The difficult behaviours portrayed included a demanding patient, an aggressive patient, a patient who questioned the doctor’s competence, a patient who ignored the doctor’s advice, one who didn't expect the doctor to take them seriously, and one who was utterly helpless.

The findings showed that doctors were 42% more likely to misdiagnose a difficult patient than a “neutral” patient in a complex case, and 6% more likely to do so in a simple case. The findings remained the same, irrespective of the time the doctor spent on diagnosis.

“The fact is that difficult patients trigger reactions that may ... affect judgements and cause errors,” the researchers wrote, adding that it may be beneficial to increase doctors’ awareness of how their emotional responses could affect their clinical reasoning and threaten safety.

In a second study, 74 trainee hospital doctors were asked to diagnose eight clinical case scenarios, half of which involved difficult behaviours (including a patient who threatens the doctor and one who accuses the doctor of discrimination) and half of which involved neutral behaviours.

Diagnostic accuracy was 20% lower for difficult patients, even though similar time was spent on the diagnosis.

The findings also showed that the doctors recalled proportionally fewer clinical findings in the difficult patient, with the researchers suggesting the mental energy need to deal with the difficult behaviour interfered with them processing clinical information correctly.

Patients unlikely to change behaviour due to genetic risk

Telling patients the results of DNA tests which signal disease risk has little impact on changing their behaviours, such as stopping smoking or altering diet, a review finds.

The findings throw doubt on the use of genetic testing to motivate patients to change risky behaviour, the researchers suggested.

The systematic review and met-analysis covered 18 studies on the effects of communicating genetic risk estimates of heart disease, cancers, Alzheimer’s disease, for which behaviour change ‒ such as smoking, alcohol consumption, diet and physical activity ‒ could reduce the risk.

The meta-analysis, published in the BMJ, showed that communicating DNA-based risk estimates had no impact on patients quitting smoking, changing their diet or their level of physical activity. There were also no effects on any other behaviours such as alcohol use and medication use and sun protection behaviour, or on patient’s motivation to change behaviour.

Communicating genetic risk had no adverse effects, such as depression or anxiety, the findings showed.

“The available evidence does not provide support for the expectations raised by researchers and proponents of personalised medicine as well as direct-to-consumer testing companies that the receipt of results from DNA based tests for gene variants that confer increased risk of common complex diseases motivates behaviour change,” the authors wrote.

They added that such tests may have a role in population health strategies if supplemented by the offer of effective behaviour change interventions.

Loneliness linked to stroke and heart attacks

Hospitals and clinics should include assessments of patients’ social integration in electronic medical records, experts have suggested, after a study confirmed that loneliness and isolation are linked to a heightened risk of heart disease and stroke. People were about 30% more likley to have a heart attack or stroke if they were lonely or isolated, according to the systematic review and meta-analysis.
			Our work suggests that addressing loneliness and social isolation may have an important role in the prevention of two of the leading causes of morbidity in high-income countries

Importance of social contacts for wellbeing

The researchers analysed 23 papers involving more than 181,000 adults and included 4628 coronary heart disease events (such as heart attacks, angina attacks and death) and 3002 strokes recorded during monitoring periods ranging from three to 21 years.

Loneliness/social isolation was associated with a 29% increased risk of a heart attack or angina attack and a 32% increased risk of having a stroke ‒ effects that the authors said were comparable to other recognised psychosocial risk factors, such as anxiety and a stressful job.

Writing in the journal Heart, the authors said the findings added weight to public health concerns about the importance of social contacts for health and wellbeing.

“Our work suggests that addressing loneliness and social isolation may have an important role in the prevention of two of the leading causes of morbidity in high-income countries,” they wrote.

In an accompanying editorial, psychologists from Brigham Young University, Utah, US, wrote that social factors should be included in medical education, individual risk assessment and in guidelines and policies applied to populations and the delivery of health services.

Hospitals and health services should routinely assess patient’s level of social integration and/or loneliness, and include the data in patients’ health records to help inform treatment, they suggested.

“This important step can identify individuals at risk ‒ which may also have multiple implications for health service delivery,” they wrote, adding that at a broader level, population-wide surveillance would also aid public health efforts.