Clinical Quality Improvement Research Articles

Accurate, Robust, and Scalable Machine Abstraction of Mayo Endoscopic Subscores From Colonoscopy Reports.

The Mayo endoscopic subscore (MES) is an important quantitative measure of disease activity in ulcerative colitis. Colonoscopy reports in routine clinical care usually characterize ulcerative colitis disease activity using free text description, limiting their utility for clinical research and quality improvement. We sought to develop algorithms to classify colonoscopy reports according to their MES. We annotated 500 colonoscopy reports from 2 health systems. We trained and evaluated 4 classes of algorithms. Our primary outcome was accuracy in identifying scorable reports (binary) and assigning an MES (ordinal). Secondary outcomes included learning efficiency, generalizability, and fairness. Automated machine learning models achieved 98% and 97% accuracy on the binary and ordinal prediction tasks, outperforming other models. Binary models trained on the University of California, San Francisco data alone maintained accuracy (96%) on validation data from Zuckerberg San Francisco General. When using 80% of the training data, models remained accurate for the binary task (97% [n = 320]) but lost accuracy on the ordinal task (67% [n = 194]). We found no evidence of bias by gender (P = .65) or area deprivation index (P = .80). We derived a highly accurate pair of models capable of classifying reports by their MES and recognizing when to abstain from prediction. Our models were generalizable on outside institution validation. There was no evidence of algorithmic bias. Our methods have the potential to enable retrospective studies of treatment effectiveness, prospective identification of patients meeting study criteria, and quality improvement efforts in inflammatory bowel diseases.

Using Measurement-Based Care as a Precision Medicine Strategy for Substance Use Disorders.

Precision medicine prioritizes characterization of individual patient parameters to optimize care and this review evaluates measurement-based care (MBC) as a strategy for doing so in the treatment of substance use disorders (SUD). Measurement-based care refers to the systematic use of validated assessments to inform diagnosis and treatment planning, with varying frequency of assessments. Despite the seemingly obvious grounds for the use of MBC in treating SUD, systematic implementation to date has been limited. Thus, the goal of this review is to evaluate efforts to date and to stimulate greater consideration of MBC models in addictions programs. Data from two published randomized controlled trials and findings from pragmatic clinical research highlight the potential utility of MBC in the SUD treatment settings. Despite these findings, the existing literature indicates the high need for larger-scale clinical trials and quality improvement programs. Potential barriers to the implementation of MBC for SUD are outlined at the patient, provider, organization, and system levels, as well as the challenges associated with the use of MBC programs for clinical research. Critical thinking considerations and risk mitigation strategies are offered toward advancing MBC for SUD beyond the current nascent state. Collectively, the existing data confirm that MBC is a suitable and promising strategy for applying a precision medicine approach in SUD treatment, warranting further implementation efforts and scientific inquiry.

Implementing a Sodium-Glucose Cotransporter 2 Inhibitor Module With a Software Tool (Future Health Today): Qualitative Study.

Primary care plays a key role in the management of type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce hospitalization and cardiac and renal complications. Tools that optimize management, including appropriate prescribing, are a priority for treating chronic diseases. Future Health Today (FHT) is software that facilitates clinical decision support and quality improvement. FHT applies algorithms to data stored in electronic medical records in general practice to identify patients who are at risk of a chronic disease or who have a chronic disease that may benefit from intensification of management. The platform continues to evolve because of rigorous evaluation, continuous improvement, and expansion of the conditions hosted on the platform. FHT currently displays recommendations for the identification and management of chronic kidney disease, cardiovascular disease, type 2 diabetes, and cancer risk. A new module will be introduced to FHT focusing on SGLT2 inhibitors in patients with type 2 diabetes who have chronic kidney diseases, cardiovascular diseases, or risk factors for cardiovascular disease. The study aims to explore the barriers and enablers to the implementation of an SGLT2 inhibitor module within the Future Health Today software. Clinic staff were recruited to participate in interviews on their experience in their use of a tool to improve prescribing behavior for SGLT2 inhibitors. Thematic analysis was guided by Clinical Performance Feedback Intervention Theory. In total, 16 interviews were completed. Identified enablers of use included workflow alignment, clinical appropriateness, and active delivery of the module. Key barriers to use were competing priorities, staff engagement, and knowledge of the clinical topic. There is a recognized benefit to the use of a clinical decision support tool to support type 2 diabetes management, but barriers were identified that impeded the usability and actionability of the module. Successful and effective implementation of this tool could support the optimization of patient management of type 2 diabetes in primary care.

Cost-effectiveness of quality improvement intervention to reduce time between CT-detection and ureteroscopic laser fragmentation in acute symptomatic ureteric stones management

ObjectiveTo prospectively assess clinical and cost effectiveness of emergency ureteroscopic laser fragmentation of urinary stones causing symptoms or obstruction.Patients and methods100 consecutive patients with an average (median) age 55.6 (57.5) years and average (median) stone size of 8.2 mm (± 7 mm) between October 2018 and December 2021 who underwent emergency ureteroscopy and laser fragmentation formed the study cohort as part of a clinical service quality improvement. Primary outcome was single procedure stone-free rate and cost-effectiveness. The secondary outcomes were complications, re-admission and re-intervention. A decision analysis model was constructed to compare the cost-effectiveness of emergency ureteroscopy with laser fragmentation (EUL) and emergency temporary stenting followed by delayed ureteroscopy with laser fragmentation (DUL) using our results and success rates for modelling.ResultsSingle procedure stone-free rates (SFR) for EUL and DUL were 85%. The re-intervention rate, re-admission and complication rates of the study cohort (EUL) were 9%, 18%, and 4%, respectively, compared to 15%, 20%, and 5%, respectively for the control cohort (DUL). The decision analysis modelling demonstrated that the EUL treatment option was more cost-efficient, averting £2868 (€3260) per patient for the UK health sector. Total cost of delayed intervention was £7783 (€8847) for DUL in contrast to £4915 (€5580) for EUL.ConclusionsImplementation of quality improvement project based on a reduction in CT detection-to-laser fragmentation time interval in acute ureteric obstruction or symptoms caused by stones had similar clinical effectiveness compared to delayed ureteroscopic management, but more cost-effective.

Development and Evaluation of a Serious Game on Pressure Injury Prevention for the Training of Patient Relatives: A Quasi-Experimental Study

Background In recent years, serious games have been used as an educational method in various fields such as economy, marketing, military, education, and health as a training method. Pressure injuries (PIs) are a significant health problem and clinical quality improvement issue throughout the world. Implementation of prevention strategies has gained importance in all healthcare settings due to the negative effects of PIs. Educating patient relatives on PI prevention is essential. Aims This study aimed to develop a serious game for the training of patient relatives on PI prevention and evaluate the game in terms of knowledge acquisition and its features. Methods The study was carried out as a single-group quasi-experimental pre-test and post-test design in three stages between August 1, 2020-April 30, 2022. In the first stage educational content, knowledge assessment test, and game evaluation questionnaire were prepared. A web-based serious game (PreSore: Pressure Injury Prevention Game) was developed in the second stage. The participants played the game in the third stage, and data was collected. The study sample consisted of patient relatives (n=55). A knowledge assessment test (pre-test, post-test, and re-test) and a game evaluation questionnaire were administered for the data collection. Results It was determined that there was a significant increase in knowledge scores after the PreSore game implementation ( p < .001). Most of the participants indicated that the information in the game was easy to understand (98.2%), they wanted to share their educational experience with others with the digital game method (96.4%), and they found the game was authentic (94.5%). Conclusions The study revealed that the PreSore game is a method that could be used to train patient relatives on PI prevention. Integrating the PreSore into daily practice in healthcare institutions and conducting prospective studies are recommended.

The Role of Clinical Audits in Advancing Quality and Safety in Healthcare Services: A Multiproject Analysis From a Jordanian Hospital.

Introduction Clinical audits have become essential instruments for evaluating and improving the standard of patient care in healthcare services. While individual clinical audits focus on particular aspects of care, multiple clinical audits across various domains, specialties, or departments provide a more comprehensive understanding of clinical practice and encourage systemic improvements. Methodology This study employed a mixed-methods approach to review and assess various clinical audits and quality improvement initiatives conducted at Al-Karak Governmental Hospital in southern Jordan. The study aimed to identify obstacles and possibilities of conducting clinical audits and provide suggestions for enhancing audit procedures and results. Data were collected from both retrospective and prospective sources and analyzed using descriptive and inferential statistics. Results The study comprised 11 audits conducted in three medical departments, namely surgery, obstetrics and gynecology (OB/GYN), and pediatrics, with a total of 618 participants. The improvements in adherence to guidelines after the second loop of all the audits were significantandshowed significant improvements in adherence to guidelines, demonstrating the efficacy of clinical audits in improving clinical practice and outcomes. Conclusions Clinical audits are essential for maintaining and improving quality and safety in healthcare services, particularly in developing nations where emergency obstetric care is lacking. Multiple clinical audits provide a comprehensive understanding of clinical practice and encourage systemic improvements. The findings of our study suggest that clinical audits can lead to significant improvements in adherence to guidelines and better clinical outcomes. Future research should focus on identifying best practices for conducting clinical audits and evaluating their long-term viability and expandability.

Perspectives of Certified Nurse-Midwives and Physicians on the Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in the San Francisco Bay Area.

Black birthing people in the United States disproportionately endure inequitable experiences and outcomes during pregnancy and childbirth via structural, interpersonal, and obstetric racism. In this study, the researchers explore provider perspectives of how racism is perpetuated in institutional perinatal and reproductive health care. Critical Race Theory, Reproductive Justice, and midwifery theory were operationalized through secondary thematic analysis of existing qualitative data from the Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Twenty-four perinatal providers (certified nurse-midwives [n = 7] and physicians [n = 17]) voluntarily participated in interviews. A comparative approach was used to determine how professional identity and model of care influence physicians' and certified nurse-midwives' perceptions of equity. Thematic analysis produced 5 themes: racism as a comorbidity, health care systems' inability to address the needs of Black birthing people, health care systems prioritizing providers over patients are failed systems, patients are the experts in the optimal health care model, and benefits of interprofessional teams grounded in Reproductive Justice. Additionally, both physicians and midwives expressed a need for a new care model. With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift the experience and outcomes of perinatal and reproductive health care and reduce mortality. Using a human rights approach to care, a Reproductive Justice-Public Health Critical Race praxis-informed midwifery model may be operationalized by all perinatal and reproductive health care providers. This novel model reflects an iterative process that may offer institutions and providers methods to build on past research supporting midwifery-centered care for improving outcomes for all patients by specifically focusing on improving care of Black birthing people. The implications of this work offer broad application in current clinical practice, quality improvement, research, technology, and patient resources.

Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo.

In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.

Abstract TP70: EHR Based System Improves Stroke Alerting Process in the Emergency Department

Background and Issues: Treatment decisions for patients experiencing acute ischemic stroke require complex imaging and evaluation. Specialized teams including Neurologists, pharmacists and CT technicians are alerted to the ED when a patient presents with signs or symptoms of acute ischemic stroke (AIS) to carry out these evaluations. At our facility, these alerts were delivered via a de-identified text message, preventing the collection of data needed for clinical effectiveness and quality improvement work. Purpose: This project's purpose was to improve the Stroke Alert process using Computerized Physician Order Entry (CPOE) to initiate the alert via a HIPAA Compliant Group Messaging (HCGM) application called Haiku. Methods: Haiku is an application available in the hospital’s electronic health record, which allows for retrieval of data unavailable when utilizing the de-identified alerting method. Data on 70 consecutive Stroke Alerts from 6 weeks prior to implementation of the Haiku Stroke Alert were compared to 80 consecutive Stroke Alerts 6 weeks after implementation. A comparison of Door to CT and Door to Needle times in those periods were also compared to ensure the new process did not cause any delays in these metrics. Results: Results showed the CPOE based Haiku Stroke Alert process was easily adopted and allowed for access to data necessary for clinical effectiveness and quality improvement work without causing delays in Door to CT (DTCT) or Door to Needle (DTN) times. Conclusions: In conclusion, this quality improvement project addressed the lack of data available to assess the Stroke Alert process. A new CPOE based alert process utilizing the HCGM app Haiku proved feasible, received positive feed-back from ED team who initiates the alert and the Neurology resident team who receives the alert. The Haiku alert did not appreciably add time to the DTCT or DTN times. This process allows access to comprehensive data that can be used to explore other avenues to improve the hyperacute phase of AIS triage and treatment. The availability of robust Stroke Alert data was the missing foundational element allowing for clinical effectiveness and quality improvement work.

Abstract TP77: Stroke Rank Order Correlation but Moderate Absolute Value Drift Between Early Day 2/4 and Day 90 Stroke Outcome Scales: mRS, BI, and NIHSS

Background: In acute stroke trials, the three most commonly used outcome scales are the modified Rankin Scale (mRS) to assess global disability, the Barthel Index (BI) to assess instrumental activities of daily living, and the National Institutes of Health Stroke Scale (NIHSS) to assess neurologic deficit severity. The value of early scale assessments to forecast 3-month disability outcomes has not been formally investigated. Methods: In this cohort study of patients with acute ischemic stroke (AIS) in the NIH Field Administration of Stroke Therapy- Magnesium (FAST-MAG) Phase 3 trial, we assessed the performance of day 2, 4, and 30, BI, and NIHSS to forecast their day 90 counterparts using correlation coefficients and absolute differences. Results: Among 1041 with AIS, mRS on d2 (r=0.67) and d4 (r=0.72) showed strong correlation and mRS on d30 (r=0.89) very strong correlation with d90 mRS. However, value shifts were common. For example, d4 mRS exactly matched d90 mRS in only 35.8%, while 40.2 % had better and 24 % had worse outcomes. D4 BI exactly matched d90 BI in only 41.2%, while 48.5% had better and 11.2% had worse outcomes. For NIHSS, d4 exactly matched d90 value in only 20.5%, while 57.9% had better and 22.6% had worse outcomes. (Figure) Conclusions: mRS, BI, and NIHSS outcomes as early as days 2 and 4 post-stroke correlate strongly with their longterm, 3m outcome rank ordering but only moderately with their absolute values. Delineation of this outcome trajectory provides a foundation for imputing final patient disability, ADL, and deficit outcomes in clinical trials and quality improvement programs.

Clinical Knowledge Model for the Prevention of Healthcare-Associated Venous Thromboembolism.

Knowledge models inform organizational behavior through the logical association of documentation processes, definitions, data elements, and value sets. The development of a well-designed knowledge model allows for the reuse of electronic health record data to promote efficiency in practice, data interoperability, and the extensibility of data to new capabilities or functionality such as clinical decision support, quality improvement, and research. The purpose of this article is to describe the development and validation of a knowledge model for healthcare-associated venous thromboembolism prevention. The team used FloMap, an Internet-based survey resource, to compare metadata from six healthcare organizations to an initial draft model. The team used consensus decision-making over time to compare survey results. The resulting model included seven panels, 41 questions, and 231 values. A second validation step included completion of an Internet-based survey with 26 staff nurse respondents representing 15 healthcare organizations, two electronic health record vendors, and one academic institution. The final knowledge model contained nine Logical Observation Identifiers Names and Codes panels, 32 concepts, and 195 values representing an additional six panels (groupings), 15 concepts (questions), and the specification of 195 values (answers). The final model is useful for consistent documentation to demonstrate the contribution of nursing practice to the prevention of venous thromboembolism.

Adopting the Klein Triple Path Model of Insight for Clinical Quality Improvement.

Adopting the Klein Triple Path Model of Insight for Clinical Quality Improvement.

1770 Assessment of lying and standing blood pressure; an audit leading to an improved clinical effectiveness and quality improvement

Abstract Introduction Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme). Method It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021 Results During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions. Conclusions Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.

Endovascular treatment of chronic ilio-femoral vein obstruction with extension below the inguinal ligament in patients with post-thrombotic syndrome

ObjectiveThis study aimed to evaluate postoperative outcomes of patients with chronic iliofemoral venous outflow obstruction and post-thrombotic syndrome (PTS) who underwent endovascular recanalization and stenting across the inguinal ligament. MethodsAll consecutive patients with chronic iliofemoral venous outflow obstruction and PTS were included in the analysis, from January 2018 and February 2022. Preoperative, intraoperative, and postoperative outcomes were assessed. Primary endpoints analyzed were major adverse events (MAEs) at 30 days and primary patency rate at 2 years of follow-up. Secondary endpoints assessed were secondary patency rate, target vessel revascularization, and clinical improvement evaluated with the Venous Clinical Severity Score (VCSS) classification, Villalta scale, and visual analog scale (VAS), respectively. ResultsA total of 63 patients (mean age, 48.1 ± 15.5 years; female, 61.9%) were evaluated. No intraoperative and 30-day postoperative complications were documented. The technical success rate was achieved at 100%. Overall, one in-stent occlusion and five in-stent restenosis were detected during follow-up. The primary patency rate was 93.7% (95% confidence interval [CI], 87.8%-99.9%) and 92.1% (95% CI, 85.6%-99%), at 1- and 2-year follow-up, respectively (Kaplan-Meier analysis). Target vessel revascularization was conducted in two cases, resulting in a secondary patency of 98.4% (95% CI, 95.4%-100%) at 2 years of follow-up. Stent fracture and/or migration were not observed during follow-up. A significant clinical improvement in the patient’s quality of life was documented. The median improvement of VCSS and Villalta scores were 4 (interquartile range, 2-7; P = .001), and 3 (interquartile range, 1.5-5; P = .001) vs baseline at the last follow-up. Overall, pain reduction of 17 mm on the VAS scale was documented at 2 years of follow-up. At multivariate analysis, presence of trabeculation into the femoral vein and deep femoral vein (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043), and Villalta scale >15 points at admission (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043) were predictive for in-stent occlusion during the follow-up. ConclusionsThe use of a dedicated venous stent across the inguinal ligament was safe and effective for the treatment of symptomatic iliofemoral venous disease with acceptable primary and secondary patency rates at 2 years of follow-up.

Artificial intelligence in pediatric surgery

Artificial intelligence (AI) is rapidly changing the landscape of medicine and is already being utilized in conjunction with medical diagnostics and imaging analysis. We hereby explore AI applications in surgery and examine its relevance to pediatric surgery, covering its evolution, current state, and promising future. The various fields of AI are explored including machine learning and applications to predictive analytics and decision support in surgery, computer vision and image analysis in preoperative planning, image segmentation, surgical navigation, and finally, natural language processing assist in expediting clinical documentation, identification of clinical indications, quality improvement, outcome research, and other types of automated data extraction. The purpose of this review is to familiarize the pediatric surgical community with the rise of AI and highlight the ongoing advancements and challenges in its adoption, including data privacy, regulatory considerations, and the imperative for interdisciplinary collaboration. We hope this review serves as a comprehensive guide to AI's transformative influence on surgery, demonstrating its potential to enhance pediatric surgical patient outcomes, improve precision, and usher in a new era of surgical excellence.

P22 Exploration of specialist AMS nursing roles across the UK and Ireland

Abstract Background There is increasing interest in the work undertaken by nurses employed as antimicrobial stewardship (AMS) specialists across the UK and Ireland but scarce evidence describing their roles, characteristics and career trajectory is available. Objectives To investigate the characteristics of the current specialist AMS nursing workforce in the UK and Ireland to inform progression and support. Specifically, to (i) describe the background, roles and professional development opportunities of specialist AMS nurses; and (ii) identify barriers and enablers in delivering the specialist AMS nursing role. Methods An online survey was circulated among purposefully selected members of the AMS Nursing Group and Scottish Antimicrobial Nursing Group (SANG). Survey development was informed by the literature1 and included closed questions (n=23) alongside free text, with expert validation of content and access. Consent was assumed on survey completion, responses were anonymized. Results Twelve registered and one non-registered nurse completed the survey (100% completion rate), AfC band 5 to 8 or equivalent, from England (n=8), Scotland (n=3), Wales (n=1) and Ireland (n=1). All respondents were directly involved in clinical audit, education and quality improvement projects (n=13), alongside contributing to IV to oral switch initiatives (n=12), AMS ward rounds (n=9) and the clinical management of infection (n=7). Most respondents capture the impact of these interventions with process measures, clinical outcomes or feedback (n=11). Respondents work closely with microbiology/infectious diseases teams (n=13), infection prevention and control (n=12), ward teams (n=11) and pharmacy colleagues (n=9). Ambition to progress in current roles was noted, including development as clinical academic, nurse consultant/ANP or within regional or national teams (n=6). Opportunity to access further formal qualifications to support AMS roles including degree, masters or postgraduate modules can be limited (n=5). Free text responses revealed both barriers and facilitating factors to delivering the specialist AMS nursing role. Challenges included dual role commitments, being part of a pilot project and lack of understanding of the nursing role in AMS. Enablers included support from multi-professional colleagues and autonomous working. Conclusions AMS programmes are currently being supported by specialist AMS nurses. This survey revealed that there are commonalties and variations, as well as barriers and challenges to delivering the role. Interprofessional collaborative working and learning was evident, reflecting the multi-professional nature of AMS. These roles are therefore in a position to influence nursing clinical practice and behaviours2 in collaboration with other specialist teams.3 Opportunities exist to formalize the AMS nursing role and ensure inclusion as a core member of the AMS team within UK and Ireland. This should be part of an integral strategy to support the largest workforce within the NHS and requires recognition and commitment at team, trust and national level.

Effectiveness, quality of life, and safety of secukinumab versus conventional systemic therapy in patients with erythrodermic psoriasis: a comparative study.

Erythrodermic psoriasis (EP) is a rare but life-threatening variant of psoriasis less responsive to conventional systemic therapies (CST). Limited research exists on the management of EP with secukinumab. To compare the effectiveness, quality-of-life effects and safety of secukinumab versus CST in patients with EP. EP patients treated with either secukinumab or CST between August 2020 and October 2022 were identified using the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID) database encompassing 962 healthcare organizations. Propensity score matching (PSM) was performed to balance the cohorts based on demographic and clinical characteristics. The primary outcomes assessed were Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA), and Dermatology Life Quality Index (DLQI) scales at 4 weeks, 10-14 weeks, and 22-24 weeks. The study included 311 patients (160 receiving secukinumab and 151 receiving CST), among them, 101 matched pairs were generated by propensity score matching (PSM). Secukinumab recipients displayed a notably accelerated response compared to those receiving CST, evidenced by significantly higher rates of achieving PASI50 (before PSM: 73.8% vs. 61.6%, after PSM: 76.2% vs. 63.4%), PASI90 (before PSM: 36.9% vs. 25.8%, after PSM: 40.6% vs. 25.7%), and BSA50 (before PSM: 64.4% vs. 50.3%, after PSM: 68.3% vs. 51.5%) at week 4 (p < 0.05). However, before PSM, secukinumab showed significantly higher DLQI0/1 rates at weeks 4 (41.3% vs. 29.8%) and 12 (63.8% vs. 44.8%). After PSM, statistically significant differences were observed at week 12 for PASI and BSA scores, and at week 4 for DLQI scores (p < 0.05). Similar efficacy trends were observed in other outcomes at week 0 up to week 24, but no statistical differences were noted. Compared to the CST, secukinumab tend to offer a more rapid response and achieve greater improvements in clinical symptoms and quality of life for EP patients.

Clinical outcomes and direct cost analysis of rotator cuff repair surgery.

The purpose of this study was to evaluate the clinical and functional outcomes in patients who underwent surgical treatment for rotator cuff tears using open and arthroscopic techniques, and to evaluate the direct costs involved. Retrospective cohort study with analysis of the data of patients who were referred to two private hospitals in Sao Paulo, Brazil for surgical repair of the rotator cuff from January 2018 to September 2019. Clinical outcomes were assessed using functional scores (SPADI and QuickDASH) and a quality of life questionnaire (EuroQoL). Procedure costs were calculated relative to each hospital's costliest procedure. Data from 362 patients were analyzed. The mean patient age was 57 years (SD= 10.46), with a slight male predominance (53.9%). Arthroscopic procedures were more common than open procedures (95.6% versus 4.4%). Significant clinical improvement was reported in 84.8% of the patients. The factors associated with increased surgery costs were arthroscopic technique (increase of 29.2%), age (increase of 0.6% per year), and length of stay (increase of 18.9% per day of hospitalization). Rotator cuff repair surgery is a highly effective procedure, associated with favorable clinical outcomes and improvement in life quality, and low rates of complications. Arthroscopic surgery tends to be costlier than open surgery.

Effect of interventional health educational program on clinical improvement in a sample of Egyptian school-age asthmatic children

Background/aim Asthma is one of the most widespread chronic disorders. To achieve better control over the disease, health intervention education programs could be applied to manage asthma and its consequences effectively to have a better quality of life. This study aimed to evaluate the impact of interventional health education programs on asthma symptoms and the quality of life of Egyptian asthmatic children. Patients and methods This study was conducted as an interventional study on asthmatic children and patients aged 6–16 years. Potential asthmatics according to GINA guidelines were enrolled in the study. Pulmonary function tests were applied including forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio. 97 asthmatic cases were evaluated by asthma scoring, asthma control, and pediatric asthma quality of life questionnaire. All the study procedures were conducted at the start of the study and after applying the educational intervention program. Results The present results reported marked significant improvement (P&lt;0.05) in the respiratory symptoms after the application of the intervention education program including cough, night symptoms, dyspnea, and chest pain. In addition significant improvement (P&lt;0.05) occurred in the posteducational pulmonary function tests, including FEV1, prebronchodilator and postbronchodilators while there is no significant difference pre and postbronchodilator, FVC compared with the pre-educational pulmonary function tests. Conclusion The interventional health education program has been useful for the improvement of clinical symptoms, pulmonary function, and quality of life of Egyptian school-age asthmatic patients and the performance of their families.

Measuring continuity in primary care: how it is done and why it matters.

Continuity of care (COC) is a foundational element of primary care and is associated with improved patient satisfaction and health outcomes and decreased total cost of care. The patient-physician relationship is highly valued by both parties and is often the reason providers choose to specialize in primary care. In some settings, such as outpatient residency clinics, however, patients may only see their primary care provider (PCP) 50% or less of the time. Considering the many benefits of COC for patients and providers, there is a clear need for us in primary care to understand how to compare different COC measures across studies and how to choose the best COC measure when conducting quality improvement efforts. However, at least 32 different measures have been used to evaluate COC. The manifold variations for measuring COC arise from data source restrictions, purpose (research or clinical use), perspective (patient or provider), and patient visit frequency/type. Key factors distinguishing common COC formulas are data source (e.g. claims data or electronic medical records), and whether a PCP is identifiable. There is no "right" formula, so understanding the nuances of COC measurement is essential for primary care research and clinical quality improvement. While the full complexity of COC cannot be captured by formulas and indices, they provide an important measure of how consistently patients are interacting with the same provider.