Evidence-based Clinical Pathway Research Articles

Advances in the Management of Localized Scleroderma: A Systematic Review of Laser Therapy and Injectable Filler Approaches.

Localized scleroderma (LS), commonly known as morphea, presents a significant clinical challenge due to its chronic, inflammatory nature affecting the skin and potentially underlying tissues. This systematic review explores the innovative approach of combining laser therapy and injectable fillers, specifically hyaluronic acid, for the treatment of LS. We conducted a comprehensive literature review following PRISMA guidelines, examining articles from MEDLINE/PubMed to assess the combined efficacy of these treatments in improving both esthetic and functional outcomes for LS patients. The search yielded 64 articles, with six selected for in-depth analysis for a total of nine patients, covering a range of patient demographics and treatment types. Our review highlights cases where fractional CO2 laser therapy promoted long-term tissue remodeling and instances where hyaluronic acid fillers effectively addressed skin atrophy and volume loss, enhancing both immediate and long-lasting esthetic improvements. The synergy between these treatments suggests a promising dual approach, aiming to maximize esthetic outcomes and to improve the quality of life for LS patients. This review underscores the necessity of further research to establish a comprehensive, evidence-based clinical pathway integrating both treatments for managing LS, thereby enhancing patient satisfaction and addressing the multifaceted nature of this challenging dermatological condition.

Does regional implementation of a clinical pathway for older adult patients with pelvic fragility fractures after low-energy trauma improve patient outcomes (PELVIC): a multicentre, stepped-wedge, randomised controlled trial

IntroductionPatients with pelvic fragility fractures suffer from high morbidity and mortality rates. Despite the high incidence, there is currently no regional or nationwide treatment protocol which results in a wide...

Development of a Clinical Pathway for Acute Coronary Syndrome at Philippine General Hospital

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION: Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS. KEYWORDS: acute coronary syndrome, clinical pathway, quality of care

The clinical pathway in ADMiRE, Ireland's first public specialist service for children and adolescents with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder occurring in approximately one in twenty young people in Ireland, and in one-third of those attending Irish Child and Adolescent Mental Health Services (CAMHS). It is important to treat ADHD, as un/poorly treated ADHD is associated with a raft of negative health and socio-economic outcomes. Effective interventions for ADHD are available, and the use of standardised, evidence-based pathways for assessment and management of ADHD optimises outcomes. Despite this, there is no national standardised clinical pathway for assessment and treatment of ADHD in Ireland. ADMiRE, the first public healthcare specialist service for children and adolescents in Ireland, has developed a strongly evidence-based, efficient, effective and safe clinical pathway for assessment and management of ADHD. This paper describes the ADMiRE Clinical Pathway and references ADMiRE resources that are available to other services.

Clinicians' experiences and perspectives of a web-based lung cancer referral pathway.

e13539 Background: Efficient and streamlined referral of patients with suspected lung cancer is an integral part of providing optimal care for these patients. There is emerging evidence that use of online care pathways, such as HealthPathways is associated with improved referral quality from primary care, more timely access to secondary care and standardization of clinical management decisions by general practitioners (GPs). The Townsville Lung Cancer Referral Pathway (TLCRP) is part of ' Townsville HealthPathways', which is the evidence-based clinical pathway portal used in the Townsville Hospital and Health service in northern Australia. This study aimed to explore the experiences and perspectives of clinicians about TLCRP. Methods: This was a descriptive qualitative study nested within a larger project evaluating TLCRP, utilising a broader implementation science framework. In-depth, semi-structured interviews of GPs and lung cancer specialists were conducted. An iterative, inductive thematic analysis of interview transcripts was undertaken to derive key codes and themes regarding participant experiences and perceptions. Results: Twenty interviews were conducted, 14 with GPs and six with specialists across disciplines of respiratory medicine, oncology, and cardiothoracic surgery. Of the GPs, 11 were practicing in the regional locality of Townsville and three practiced in surrounding rural areas. Interview analysis identified two major themes and several sub-themes (Table). Several enablers and barriers to implementing TLCRP were identified. Barriers to adaptation of TLCRP included lack of clinical time, resistance to changing referral patterns, lack of familiarity or experience with HealthPathways and technology issues. Enablers included clinical usefulness of TLCRP, support from HealthPathways implementing team, integration of TLCRP with the electronic referral system and positive feedback from specialists. Conclusions: Emerging themes from this study may be used to reduce the barriers and improve uptake of TLCRP and other health care pathways in the local health service. Improving the uptake of TLCRP may mean that more patients in our region experience a streamlined journey to more timely specialist lung cancer care and improved health outcomes. [Table: see text]

Clinical Care Pathway and Management of Major Bleeding Associated with Nonvitamin K Antagonist Oral Anticoagulants: A Modified Delphi Consensus from Saudi Arabia and UAE.

The nonvitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major DOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management.

A Multimodal Intervention to Reduce C. difficile Infections and Stool Testing.

The introduction of multiplex gastrointestinal panels at our institution resulted in increased Clostridioides difficile (C. difficile) detection and stool test utilization. We aimed to reduce hospital-onset C. difficile infections (HO-CDIs), C. difficile detection, and overall stool testing by 20% within 1 year. We conducted a quality improvement project from 2018 to 2020 at a large children's hospital. Interventions included development of a C. difficile testing and treatment clinical care pathway, new options for gastrointestinal panel testing with or without C. difficile (results were suppressed if not ordered), clinical decision support tool to restrict testing, and targeted prevention efforts. Outcomes included the rate of HO-CDI (primary), C. difficile detection, and overall stool testing. All measures were evaluated monthly among hospitalized children per 10 000 patient-days (PDs) using statistical process-control charts. For balancing measures, we tracked suppressed C. difficile results that were released during real-time monitoring because of concern for true infection and C. difficile-related adverse events. HO-CDI decreased by 55%, from 11 to 5 per 10 000 PDs. C. difficile detection decreased by 44%, from 18 to 10 per 10 000 PDs, and overall test utilization decreased by 29%, from 99 to 70 per 10 000 PDs. The decrease in stool tests resulted in annual savings of $55 649. Only 2.3% of initially suppressed positive C. difficile results were released, and no patients had adverse events. Diagnostic stewardship strategies, coupled with an evidence-based clinical care pathway, can be used to decrease C. difficile and improve overall test utilization.

Australian medical practitioners' perspectives about current practice relating to fitness to drive assessment for older people with dementia and mild cognitive impairment: A qualitative study.

To describe the perspectives of Australian medical practitioners about current practice, and the potential benefit of tools and resources to support fitness to drive assessment for older people with dementia and mild cognitive impairment (MCI). Semi-structured interviews with 22 medical practitioners from cognitive/memory clinics, hospitals, general practice and driving fitness assessment services in Australia. Reflexive thematic analysis was conducted. Two overarching themes were generated: (1) Uncomfortable decisions, describing feelings of discomfort expressed by practitioners about making fitness to drive recommendations, with two subthemes: (a) 'Feeling uncertain' and (b) 'Sticking your neck on the line'; and (2) Easing the discomfort, describing participants' desire for tools/resources to support practitioners to increase comfort with fitness to drive recommendations, with two subthemes: (a) 'Seeking certainty' and (b) 'Focusing on the process' conveying two different perspectives about how this may be achieved. There was a desire for a new in-office assessment tool capable of accurately predicting fitness to drive outcomes and views that an evidence-based clinical pathway could improve practitioners' confidence in decision-making. Perceptions of discomfort relating to fitness to drive assessment of older people with dementia and MCI exist amongst medical practitioners from health-care settings across Australia. In the absence of a well-validated in-office assessment tool, practitioners may benefit from an evidence-based clinical pathway to guide driving recommendations.

Multi-stakeholder Engagement and Development of a Virtual Care Toolkit for Integrated Guideline-Based Low Back Pain Management

Introduction: The abrupt COVID-19 related healthcare closures across Ontario, Canada resulted in a rapidly growing backlog of patients referred to the Provincial Rapid Access Clinics (RACs) Program, designed to manage patients suffering from unmanageable low back pain (LBP). Left untreated or poorly treated, LBP can lead to a significant burden on patients and the health system. Expeditious implementation of virtual care (VC) became a necessity, however, frontline clinicians identified lack of confidence and experience with LBP-VC. To ensure continuity in patient-centered care, a Toolkit was developed to enable delivery of a standardized guideline-based integrated LBP pathway through VC.
 Aims, Objectives, Theory or Methods: A coordinated in-depth multi-stakeholder engagement process was utilized to address clinicians’ concerns to promote confident adoption of VC. A system-level rapid response approach led through a centralized clinical and digital provincial infrastructure was used for Toolkit development. Toolkit structure, content and refinement was determined through an iterative mix-methods approach undertaken with provincial LBP stakeholders on how best to implement an established evidence-based shared-care LBP clinical pathway through VC. This approach facilitated acceptable strategies for barrier mitigation and enabled optimization to be rapidly developed on a provincial level with necessary resources and guidelines to deliver standardized LBP-VC across Ontario.
 Highlights or Results or Key Findings: Toolkit resources have been adopted across 16 urban and rural regions in Ontario. Engaging front-line clinicians, (including spine surgeons), was critical for active implementation of VC that was safe, effective, and met professional requirements. Stakeholders for operational oversight included government, hospital and regional administrators, and professional colleges and associations. With collaborative provincial leadership, barriers and enablers to LBP-VC were systematically identified. Extensive multi-stakeholder consultation which included patient feedback, provided pragmatic information related to privacy; informed consent; professional standards; regional variations, and clinical and patient barriers and enablers. Emergent themes included technology requirements, administrative processes, educational needs, and professional standards. Four hundred and forty LBP-VC patient satisfaction questionnaires were completed (June 2020-May 2021). Based on a 5-point Likert scale, (5 most positive), overall satisfaction and likelihood of participating again was 4.7/5. Qualitative analysis revealed three themes with VC, importance of human connection, patient-perceived virtual physical examination limitations and VC efficiencies.
 
 Conclusions: A Toolkit enabled a standardized province-wide approach to LBP-VC. Multi-stakeholder engagement was utilized to understand barriers, identify enablers, and ultimately promote patient and provider adoption and confidence with LBP-VC. With collaborative leadership, and extensive engagement, clinical resources and guidelines were developed and implemented province-wide with excellent face-validity based on patient and provider feedback and uptake. 
 Implications for applicability/transferability, sustainability and limitations: There is a need to further assess patient preference for care delivery during normal and non-emergency circumstances (COVID-19). Future directions include validating LBP-VC physical examination findings compared to hands-on assessment. There is also a need to explore cost-effectiveness of LBP-VC at scale; patient-related factors including demographics, satisfaction, preference, and acceptance with LBP-VC; treatment outcomes, including surgical; safety considerations such as security of online platforms, physical patient safety during the assessment; and comparing rate of escalation to surgeon with in-person and virtual assessment.
 

A quality improvement initiative to reduce antibiotic use in transient tachypnea of the newborn.

Evidence suggests that antibiotics are unnecessary in infants with transient tachypnea of the newborn (TTN) that are low-risk for early-onset sepsis. The aim was to reduce ampicillin and gentamicin days of therapy (DOT) in infants with suspected TTN by 10% within 12 months. We used the Model for Improvement to test interventions from August 2019 to September 2021 to decrease antibiotic utilization in low-risk infants with TTN. Interventions included the creation of an evidence-based clinical pathway, admission huddles, and prescriber audit and feedback. We reduced ampicillin and gentamicin use by 26% and 23%, respectively. In 123 infants with suspected TTN, we sequentially decreased starting antibiotics in this group from 71% to 41%, 13% and 0%. There were no cases of missed bacteremia. Creation of a multidisciplinary antimicrobial stewardship QI team and subsequent interventions were successful in safely reducing antibiotic use in infants with TTN.

Implementation of EMR-integrated ovarian cancer clinical pathways.

577 Background: Adhering to National Comprehensive Cancer Network (NCCN) Guidelines correlates with higher survival in ovarian cancer and serves as a measure of care quality. Adherence to guidelines however is relatively low, routinely reported to be less than 50%. Integration of clinical pathways into the Electronic Medical Record (EMR) is a practical approach to incorporate decision-making tools in a user-friendly interface, ensuring appropriate diagnostic testing and treatment is offered to all ovarian cancer patients. Kaiser Permanente (KP) is an integrated national healthcare delivery organization caring for 12.7 million patients across the United States. Embedded clinical pathways created by KP optimize clinical decision-making and provide treatment recommendations according to established evidence-based guidelines. This report presents data on the adherence to ovarian cancer clinical pathways within KP. Methods: Beginning in January 2021 a multidisciplinary national team at KP (gynecologic and medical oncologists, pharmacists, geneticists, pathologists, and radiation oncologists) established evidence-based clinical pathways for ovarian cancer treatment which were subsequently integrated into the Epic Systems EMR. Oncologists can use the pathways to place diagnostic and treatment orders for patient care. EMR data analytics were utilized to track adherence to the consensus-defined clinical pathways among treatment orders placed for ovarian cancer within KP nationally between January 2021 and February 2023. Treatments were considered adherent for which the order was placed through the pathway; treatments for ovarian cancer indications ordered outside of the pathway interface were non-adherent. Results: Between January 2021 and February 2023, 3721 treatment plans were initiated within KP nationally for ovarian cancer, for a median 144 plans monthly. Adherence nationally to the ovarian cancer treatment pathway varied from 16% monthly at inception to 64% in early 2023 with a high of 71% in late 2022. The median pathway adherence rates per quartile were 20%, 37%, 59%, 55% in 2021, and 62%, 66%, 70%, 67% in 2022, and 64% in January through February 2023. The increases in adherence were consistent between geographic regions and indications of treatment. Conclusions: Integration of clinical pathways into the EMR is a promising means of encouraging appropriate testing and therapy for ovarian cancer. As clinicians retained the option to initiate treatment orders outside of the embedded KP pathways, our data is limited to measuring KP pathway use, not evaluating whether treatments given were concordant with NCCN Guidelines. Treatments initiated outside the pathway may still be concordant with national guidelines. Measurement of pathway adherence is useful however to describe effective diagnostic and treatment pathway implementation across a large healthcare organization to facilitate the delivery of optimal care.

Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population.

Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.

Does pain duration and other variables measured at baseline predict re-referral of low back pain patients managed on an evidence-based pathway? A cohort study

ObjectiveTo explore the association between baseline pain duration and the likelihood of re-referral of patients with low back pain (LBP) managed on the evidence-based North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). Study designLongitudinal, observational cohort study. MethodsIn all, 12,509 adults with LBP were identified as having been discharged from the pathway, between May 2015 and December 2019. To quantify any association between baseline pain duration and the likelihood of re-referral, two statistical modelling approaches, were used: logistic regression models for odds ratios and generalised linear models with a binomial link function in order to quantify risk differences. ResultsTwenty-five percent of patients with LBP, who were discharged, re-referred for management over a 4.5-year period. A large difference in pain duration of 2 SD days was statistically associated with re-referral, with an odds ratio of 1.22 (95% CI: 1.03, 1.44) and a risk difference of 3.6% (95% CI: 0.6, 6.6). Nevertheless, the predictive value of an individual’s pain duration was found to be weak for re-referral. Higher baseline disability [odds ratio of 1.40 (95% CI: 1.07, 1.83)] and a younger age at baseline [odds ratio of 0.73 (95% CI 0.61, 0.86)] were also associated with an increased risk of re-referral. ConclusionsBaseline pain duration, disability and younger age are statistically associated with re-referral onto the NERBPP. However, the value of these variables for predicting an individual’s risk of re-referral is weak. Contribution of paper•The NERBPP is an evidence-based clinical pathway for low back pain and a forerunner to the National Back Pain Pathway.•Baseline pain duration, disability and younger participants have an association with re-referral onto the NERBPP, however, the predictive values of these variables are weak.•25% of patients with low back pain, who were discharged, re-referred for management over a four-and-a-half-year period, re-referral rates onto the NERBPP have not previously been published.

Effect of core versus enhanced implementation strategies on adherence to a clinical pathway for managing anxiety and depression in cancer patients in routine care: a cluster randomised controlled trial

BackgroundOptimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. We evaluated two implementation strategies (Core versus Enhanced) to facilitate implementation of a clinical pathway for the management of anxiety and depression in cancer patients (the ADAPT CP).MethodsTwelve cancer services in NSW Australia were cluster randomised, stratified by service size, to the Core versus Enhanced implementation strategy. Each strategy was in place for 12 months, facilitating uptake of the ADAPT CP (the intervention being implemented). The Core strategy included a lead team with champions, staff training and awareness campaigns prior to implementation, plus access to feedback reports and telephone or online support during implementation. The Enhanced strategy included all Core supports plus monthly lead team meetings, and proactive, ongoing advice on managing barriers, staff training and awareness campaigns throughout implementation. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Multi-level mixed-effect regression analyses examined the effect of Core versus Enhanced implementation strategy on adherence to the ADAPT CP (binary primary outcome: adherent ≥ 70% of key ADAPT CP components achieved versus non-adherent < 70%), with continuous adherence as a secondary outcome. Interaction between study arm and anxiety/depression severity step was also explored.ResultsOf 1280 registered patients, 696 (54%) completed at least one screening. As patients were encouraged to re-screen, there were in total 1323 screening events (883 in Core and 440 in Enhanced services). The main effect of implementation strategy on adherence was non-significant in both binary and continuous analyses. Anxiety/depression step was significant, with adherence being higher for step 1 than for other steps (p = 0.001, OR = 0.05, 95% CI 0.02–0.10). The interaction between study arm and anxiety/depression step was significant (p = 0.02) in the continuous adherence analysis only: adherence was significantly higher (by 7.6% points (95% CI 0.08–15.1%) for step 3 in the Enhanced arm (p = .048) and trending to significance for step 4.DiscussionThese results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services.Trial registrationANZCTR Registration: ACTRN12617000411347 (Trial registered 22/03/2017; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true)

Impact of Prior Authorization on Patient Access to Cancer Care.

Prior authorization (PA) is a type of utilization review that health insurers apply to control service delivery, payments, and reimbursements of health interventions. The original stated intent of PA was to ensure high-quality standards in treatment delivery while encouraging evidence-based and cost-effective therapeutic choices. However, as currently implemented in clinical practice, PA has been shown to affect the health workforce, adding administrative burden to authorize needed health interventions for patients and often requiring time-consuming peer-to-peer reviews to challenge initial denials. PA is presently required for a wide range of interventions, including supportive care medicines and other essential cancer care interventions. Patients who are denied coverage are commonly forced to receive second-choice options, including less effective or less tolerable options, or are exposed to financial toxicity because of substantial out-of-pocket expenditures, affecting patient-centric outcomes. The development of tools informed by national clinical guidelines to identify standard-of-care interventions for patients with specific cancer diagnoses and the implementation of evidence-based clinical pathways as part of quality improvement efforts of cancer centers have improved patient outcomes and may serve to establish new payment models for health insurers, thereby also reducing administrative burden and delays. The definition of a set of essential interventions and guidelines- or pathways-driven decisions could facilitate reimbursement decisions and thus reduce the need for PAs. Structural changes in how PA is applied and implemented, including a redefinition of its real need, are needed to optimize patient-centric outcomes and support high-quality care of patients with cancer.

A proposed clinical pathway for the patients with Borderline Personality Disorder presenting to Emergency Departments.

Emergency Department (ED) care of repeated self-injury, intensive affective lability, and interpersonal dysfunction associated with borderline personality disorder (BPD) is challenging. We propose an evidence-based acute clinical pathway for people with BPD. Our standardised evidence-based short-term acute hospital treatment pathway includes structured ED assessment, structured short-term hospital admission when clinically indicated, and immediate short-term (4-sessions) clinical follow-up. This approach could be adopted nationally to reduce iatrogenic harm, acute service overdependence and negative healthcare system impacts of BPD.

Management of Pain and Cachexia in Pancreatic Cancer: Protocol for Two Systematic Reviews, Network Meta-Analysis, Surveys, and Focus Groups

Approximately 75% of people with pancreatic cancer experience pain, and >50% of them have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding the management of these distressing symptoms. Our primary objectives are to compare the relative benefits and harms of different interventions for pain in people with unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews and network meta-analysis. Our secondary objectives are to develop an evidence-based clinical care pathway to manage pain and prevent and treat cachexia in people with pancreatic cancer through surveys and focus groups involving patients, carers, and health care professionals. We will perform 2 systematic reviews of the literature related to pain and cachexia in people with pancreatic cancer using searches from Cochrane Library, MEDLINE, Embase, Science Citation Index, and trial registries. Two researchers will independently screen for eligibility and identify randomized controlled trials (no language or publication status restriction), comparing interventions for pain or cachexia based on full-texts for articles shortlisted during screening. We will assess risk of bias in the trials using the Cochrane risk of bias tool (version 2.0) and obtain data related to baseline prognostic characteristics, potential effect modifiers and outcome data related to overall survival, health-related quality of life, treatment-related complications, and resource utilisation. We aim to conduct network meta-analysis on outcomes with multiple treatment comparisons where possible, otherwise, meta-analysis with direct comparisons, or narrative synthesis. We will perform various subgroup and sensitivity analyses. Using information obtained from both systematic reviews, we will conduct 2 surveys: one directed to patients or carers to assess acceptability of interventions, and the other to health care professionals to assess feasibility of delivery in the National Health Service. Four mixed focus groups will be conducted to evaluate findings and foster consensus in the development of the care pathway. Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022. Formal searches began thereafter. Approval by the University College London Research Ethics Committee (23563/001) was received in December 2022. Data collection began in January 2023; data analysis will begin in May 2023 (completion expected by October 2023). This study will comprehensively encompass major interventions for management of pain in people with unresectable pancreatic cancer, and prevention and treatment of cachexia in people with pancreatic cancer. Key stakeholders will facilitate the development of an evidence-based care pathway, ensuring both acceptability and feasibility. The project ends in April 2024 and published results are expected within 12 months of completion. We aim to present the findings through patient group websites, conferences, and publications, irrespective of the findings, in a peer-reviewed journal. DERR1-10.2196/46335.

Interpretation of the World Society of the Emergency Surgery/the Global Alliance for Infection in Surgery/the Surgical Infection Society-Europe/the World Surgical Infection Society/the American Association for the Surgery of Trauma global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAI) is common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The principles of IAI management included early diagnosis, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using critical care resources, combined with an optimal surgical approach. In order to facilitate clinical management, establish a global standard and provide guidance for clinicians, the World Society of Emergency Surgery (WSES), the Global Alliance for Infection in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) worked together to complete an international multi-society document, which provided the evidence-based clinical pathways. Herein, we made a comprehensive interpretation for the clinical pathways combined with the latest domestic and international research developments, aiming to provide evidence for domestic doctors on the diagnosis and treatment of IAI, and ultimately benefit patients.

Closing the Look in AI, EMR and Provider Partnerships: The Key to Improved Population Health Management?

The capabilities of and interest in artificial intelligence (AI) in healthcare, and more specifically, population health, has grown exponentially over the past decade. The vast volume of digital data or “big data” in the form of images generated by an aging population, with an ever-increasing demand for imaging, amassed by radiology departments, provides ample opportunity for AI application and has allowed radiology to become a service line leader of AI in the medical field. The screening and detection capabilities of AI make it a valuable tool in population health management, as organizations work to shift their services to early identification and intervention, especially as it relates to chronic disease. In this paper, the clinical, technological, and operational workflows that were developed and integrated within each other to support the adoption of AI algorithms aimed at detecting subclinical osteoporosis and coronary artery disease are described. The benefits of AI are reviewed and weighed against potential drawbacks within the context of population health management and risk contract arrangements. Mitigation tactics are discussed, as well as the anticipated outcomes in terms of cost-avoidance, physician use of evidence-based clinical pathways, and reduction in major patient events (e.g., stroke, hip fracture). The plan for data collection and analysis is also described for program evaluation.

Applying the behavior change wheel to design de-implementation strategies to reduce low-value statin prescription in primary prevention of cardiovascular disease in primary care.

IntroductionA substantial proportion of individuals with low cardiovascular risk receive inappropriate statin prescription for primary prevention of cardiovascular disease (CVD) instead of the evidence-based recommendations to promote healthy lifestyle behaviors. This study reports on the structured process performed to design targeted de-implementation strategies to reduce inappropriate prescription of statins and to increase healthy lifestyle promotion in low cardiovascular risk patients in Primary Care (PC).MethodsA formative study was conducted based on the Theoretical Domains Framework and the Behavior Change Wheel (BCW). It comprised semi-structured interviews with PC professionals to define the problem in behavioral terms; focus groups with Family Physicians and patients to identify the determinants (barriers and facilitators) of inappropriate statin prescription and of healthy lifestyle promotion practice; mapping of behavioral change interventions operationalized as de-implementation strategies for addressing identified determinants; and consensus techniques for prioritization of strategies based on perceived effectiveness, feasibility and acceptability.ResultsIdentified key determinants of statin prescription and healthy lifestyle promotion were: the lack of time and clinical inertia, external resources, patients' preferences and characteristics, limitation of available clinical tools and guidelines, social pressures, fears about negative consequences of not treating, and lack of skills and training of professionals. Fourteen potential de-implementation strategies were mapped to the identified determinants and the following were prioritized: 1) non-reflective decision assistance strategies based on reminders and decision support tools for helping clinical decision-making; 2) decision information strategies based on the principles of knowledge dissemination (e.g., corporative diffusion of evidence-based Clinical Practice Guidelines and Pathways for CVD primary prevention); 3) reflective decision-making restructuring strategies (i.e., audit and feedback provided along with intention formation interventions).ConclusionsThis study supports the usefulness of the BCW to guide the design and development of de-implementation strategies targeting the determinants of clinicians' decision-making processes to favor the abandonment of low-value practices and the uptake of those recommended for CVD primary prevention in low-risk patients. Further research to evaluate the feasibility and effectiveness of selected strategies is warranted.Clinical trial registrationSanchez A. De-implementation of Low-value Pharmacological Prescriptions (De-imFAR). ClinicalTrials.gov, Identifier: NCT04022850. Registered July 17, 2019. In: ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine (NLM). Available from: https://www.clinicaltrials.gov/ct2/show/NCT04022850.