Inform Quality Improvement Research Articles

USA dental health providers’ role in HPV vaccine communication and HPV-OPC protection: a systematic review

ABSTRACT Background. Improving human papilloma virus (HPV) vaccination coverage in the US will require healthcare providers to recommend the vaccine more effectively. To inform quality improvement efforts, we systematically reviewed studies of dental provider communication about HPV vaccination. Methods. We searched MEDLINE, CINAHL, ScienceDirect, PsycINFO and JSTOR in August 2018 to identify studies of dental provider knowledge, perceived role and communication about HPV, HPV vaccination and HPV-associated oropharyngeal cancer (HPV-OPC). Results. We identified 10 qualitative and quantitative studies. Results of the primarily descriptive studies showed that although there were some deficiencies in knowledge about HPV-related outcomes and its effect on the male population, most providers understand HPV as a sexually transmitted infection and know the HPV vaccine is available, yet many are not discussing the HPV-OPC link or recommending vaccination. Providers were less often to recommend HPV vaccination if they were uncomfortable discussing sex, perceived parents as hesitant, or believed patients to be low risk. Studies reported mixed results on providers’ perceived role in expanded HPV vaccination and HPV-OPC education, but indicated support for the role of professional organizations in promoting awareness. Conclusion. Interventions are needed to help dental providers perceive their role to deliver effective recommendations within the complex communication environment surrounding HPV vaccination and HPV-OPC education.

Assessing End-of-Life Care Quality Across Settings in an Integrated Healthcare Delivery System (TH310C)

•Describe the development and testing of a patient- and family-centered end-of-life care survey to strengthen the evaluation of quality of end-of-life care across a large and diverse integrated delivery system.•Discuss how insights from the survey can be used to promote and guide quality improvement. Kaiser Permanente has implemented programs aiming to improve care at the end of life. To better understand patient care experience, we adapted existing instruments to develop and test a survey assessing quality of end-of-life care (EOLC) across all care settings. To assess the feasibility and value of using the KP EOLC Survey across an integrated delivery system. Survey domains were prioritized through a key stakeholder consensus building process. We scanned relevant literature on EOLC quality measurement and adapted items from validated instruments that mapped to each prioritized domain, drawing primarily from the VA’s Bereaved Family Survey (BFS). We conducted cognitive testing of drafted instrument on next-of-kin (NOK) respondents of deceased KP members. The final survey was administered via mail and followed up by telephone outreach to NOK respondents six months after decedent’s death date. 2,701 surveys were completed (25.6% response rate). Respondents were similar to non-respondents in decedent’s age, gender, and clinical profile. Respondents were mostly family members (85%) and reported being familiar with decedents’ health issues and treatment decisions (88%) and had discussed EOLC preferences with decedents (84%). Overall care in the last month of life was rated “excellent” by 53% of respondents and varied across regions and care settings. Eighty-eight percent of respondents agreed that KP gave care and treatment concordant with decedent’s wishes and 78% reported decedent passed away in preferred setting. Regional leaders are using survey results to inform quality improvement. The KP EOLC Survey was acceptable to family members and yielded response rates comparable to those reported in the literature. It provided valuable patient-centered information about EOLC outcomes across settings. Further assessment of survey psychometrics is warranted, and strategies to incorporate regular administration of the KP EOLC Survey across the organization are under development.

Is future shareholder activism associated with current financial reporting quality? Evidence from the US

We examine whether future shareholder activism is associated with current financial reporting quality. Activism refers to actions taken by shareholders to change firm policies and practices. If issues are present in an investee’s financial reports, we expect shareholders to act to improve information quality and governance. Following prior literature, we adopt governance proposals as our measure of activism and a portfolio of measures as our proxies for financial reporting quality. Depending on specification, we find governance proposals are positively associated with abnormal audit fees, abnormal accruals, the use of a non-Big N auditor, internal control issues, and restatements.

Pomiar wybranych kryteriów jakości informacji na stronach WWW – studium przypadku

The paper presents the measurement of selected web indicators using the example of websites of the state higher vocational schools in Poland. The obtained indicators were used to assess specific criteria of information quality on websites. Based on the conducted study, it can be concluded that the web indicators can be used in the process of improving information quality on websites.

Integrating ICT-based Applications for Sustainable Tourism Development in Algeria

Information and Communication Technology (ICT) has inevitable impacts on different industries and their performances. The tourism industry, as the largest and fastest growing industry in the world, cannot be excluded from this technology and its huge impacts. ICT provides information about tourist attractions in different destinations before travelling and improves tourists’ satisfaction. Although Algeria has great tourism potentials, it still needs to be performed well in promoting its attractions to international tourists via ICT tools yet. This research explores the impact of ICT on foreign tourists’ satisfaction of the tourism industry and uses Algerian tourist agencies as a case study, and proposes a model for the impact of ICT on sustainable tourism. It proposes a model; namely, Al Djazaer Siyaha, for improving information quality and tourist services’ quality in the eTourism industry. Also, it is recommended that the tourism authorities should develop e-tourism infrastructures in order to keep up with the competitiveness of this field to enable the country to benefit from the global benefits of the tourism industry.

Multidisciplinary Quality Improvement Intervention to Achieve Sustained Improvement in Hand Hygiene Reliability in a Pediatric Intensive Care Unit.

Introduction:Suboptimal hand hygiene (HH) remains a significant modifiable cause of healthcare-associated infections in the intensive care unit. We report a single-center, quality improvement project aimed at improving adherence to optimal HH among physicians, nurse practitioners, and nursing staff, and to sustain any improvement over time.Methods:A key driver diagram was developed to identify 5 primary drivers of change: leadership support, education initiatives, patient-family engagement, increased audit frequency, and individual feedback to promote accountability. We examined HH compliance over 3 years in 3 phases (pre-intervention, intervention, and post-intervention). The intervention period involved a multimodal approach designed to influence unit culture as well as individual HH practice. HH screens were installed outside the patient rooms to provide just-in-time reminders and display of regularly updated HH adherence data for provider groups.Results:We recorded 6,563 HH opportunities, providers included nurses (66%), attendings (12%), fellow/resident (16%), and nurse practitioners (NP) (6%). All clinical groups demonstrated HH compliance >90% during the post-intervention period. The improvements in practice were sustained for a year after the intervention.Conclusion:Our report highlights modifiable factors that impact HH and may inform quality improvement interventions aimed at improving HH compliance at other centers.

Patient perspectives on a national multidisciplinary team meeting for a rare cancer.

Multidisciplinary team meetings (MDTM) provide a regular forum for cancer teams to convene and discuss the diagnostic and treatment aspects of patient care. For some rare cancers, MDTMs may also occur at national level to pool expertise and to ensure more consistent decision-making. One such national MDTM exists in the UK for patients with a diagnosis of Ewing's sarcoma of the bone-the National Ewing's MDT (NEMDT). This study explored the patient perspective of this rare cancer national MDTM using focus group and survey methodology. Study participants used their experience to provide several recommendations: that their views should always inform the decision-making process, these views should be presented by someone who has met them such as a specialist nurse, MDT recommendations should be provided to them in plain English, and tools to improve patient choice and enhance communication should be implemented. These patient-centred recommendations will be used to improve the NEMDT but may be valid to inform quality improvement processes for other similar national panels.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System.

The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the...

Establishing a denominator for palliative care quality metrics for patients with advanced cancer.

104 Background: Measurement and feedback of palliative care quality metrics for patients with advanced cancer is an important aspect of supporting a shared mental model for the early integration of palliative care within the oncology clinic. Accurately identifying the subset of advanced cancer patients within a population of cancer patients is critical to the development of quality improvement activities; however, there is not a methodology of identifying these patients in real time. Methods: We evaluated two main approaches to identifying patients with advanced cancer among active cancer patients defined as patients who were seen by an oncologist at least twice in the last 6 months and who had received chemotherapy or radiation at least once in the last two years. These approaches included: 1) Pattern matching of words indicating advanced cancer (e.g. metastatic, advanced) in oncology notes, radiology imaging and problem lists and 2) ICD-10 codes. To determine the final set of ICD-10 codes for the second approach, we used a conceptual model of the meaning of advanced cancer (evidence of distant metastasis and/or poor prognostic cancer with > 50% mortality rate at 5 years) and iterative chart review. In order to test our final definitions, we randomly selected 588 charts of patients with active cancer who see one of 64 oncologists in our health system. These charts were abstracted by an oncologist to establish a gold standard for advanced cancer. We evaluated the sensitivity and specificity of our approaches to identify advanced cancer patients compared to this gold standard. Results: We found that the methods used to identify patients using pattern matching had a specificity of 76% and a sensitivity of 80%. Using our final ICD-10 algorithm we achieved a specificity of 93% and a sensitivity of 68%. We improved our sensitivity to 74% while maintaining our specificity at 92% when we excluded oncologists who predominantly see hematological malignancies. Conclusions: We achieved high specificity and reasonable sensitivity for an advanced cancer quality metric denominator using an ICD-10 algorithm within an academic oncology practice. This will help inform quality improvement efforts locally and beyond.

Opportunities to improve measurement-based care practices in mental health care systems: A case example of electronic mental health screening and measurement.

Measurement-based care (MBC) involves the systematic collection of data to inform clinical decision-making and monitor treatment outcomes. In addition to benefitting patients and providers, data on MBC implementation can also be used to inform quality improvement efforts within existing health care systems. The method was retrospective chart review. We collected data on electronic mental health (MH) screens and symptom measures recorded by MH providers. Patients were 28,376 veterans who received MH services in a northeastern region. Although rates varied by MH condition and clinic type, screening for alcohol misuse, depression, and posttraumatic stress disorder appeared to occur with regularity. MH symptom measurement was less frequent than screening but included measures of alcohol and substance use, posttraumatic stress disorder, depression, and suicidal ideation. Patient demographics (e.g., age, military service era, sex, MH diagnosis) and frequency of clinic contact emerged as significant predictors of symptom measurement. In this article, we illustrate how data on MH screening and measurement can be organized, analyzed, and interpreted to identify opportunities to enhance MBC practices in MH care. We conclude with a discussion of how large data set analyses can contribute to programmatic MBC initiatives. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Micro ad-hoc Health Social Networks (uHSN). Design and evaluation of a social-based solution for patient support.

To contribute the design, development, and assessment of a new concept: Micro ad hoc Health Social Networks (uHSN), to create a social-based solution for supporting patients with chronic disease. After in-depth fieldwork and intensive co-design over a 4-year project following Community-Based Participatory Research (CBPR), this paper contributes a new paradigm of uHSN, defining two interaction areas (the "backstage", the sphere invisible to the final user, where processes that build services take place; and the "onstage", the visible part that includes the patients and relatives), and describes a new transversal concept, i.e., "network spaces segments," to provide timely interaction among all involved profiles and guaranteeing qualitative relationships. This proposal is applicable to any service design project and to all types of work areas; in the present work, it served as a social-based solution for supporting patients with chronic disease in two real-life health scenarios: a Parkinson disease patient association and a Stroke rehabilitation service in a hospital. These two scenarios included the following main features: thematic (related to the specific disease), private, and secure (only for the patient, relatives, healthcare professional, therapist, carer), with defined specific objectives (around patient support), small size (from tens to hundreds of users), ability to integrate innovative services (e.g., connection to hospital information service or to health sensors), supported by local therapeutic associations, and clustered with preconfigured relationships among users based in network groups. Using a mixed qualitative and quantitative approach for 6 months, the performance of the uHSN was assessed in the two environments: a hospital rehabilitation unit working with Stroke patients, and a Parkinson disease association providing physiotherapy, occupational therapy, psychological support, speech therapy, and social services. We describe the proposed methods for evaluating the uHSN quantitatively and qualitatively, and how the scientific community can replicate and/or integrate this contribution in its research. The uHSN overcomes the main limitations of traditional HSNs in the main areas recommended in the literature: privacy, security, transparency, system ecology, Quality of Service (QoS), and technology enhancement. The qualitative and quantitative research demonstrated its viability and replicability in four key points: user acceptance, productivity improvement, QoS enhancement, and fostering of social relations. It also meets the expectation of connecting health and social worlds, supporting distance rehabilitation, improving professionals' efficiency, expanding users' social capital, improving information quality and immediacy, and enhancing perceived peer/social/emotional support. The scientific contributions of the present paper are the first step not only in customizing health solutions that empower patients, their families, and healthcare professionals, but also in transferring this new paradigm to other scientific, professional, and social environments to create new opportunities.

2246. Assessment of Factors Impacting Cervical Cancer Screening Rates Among Urban Women Living with HIV/AIDS

BackgroundAlthough cervical cancer disproportionately affects women living with HIV, achieving high cervical cancer screening rates for this population continues to be a challenge. In our urban HIV clinic caring for ~700 women, the baseline annual on-site screening rate was only 68% in 2017. The goal of this study was to identify factors related to low rates of screening in order to inform quality improvement efforts.MethodsOver the time period of January 1, 2015 and June 30, 2017, we conducted a retrospective chart review of 185 randomly selected women with HIV. We collected data on cervical cancer screening adherence according to the screening guidelines provided by the Department of Health and Human Services. Correlations between clinical and demographic factors and patterns of cervical cancer screening were analyzed using chi square and logistic regression.ResultsDuring the review period, 68 (37%) patients completed two annual cervical cancer screenings, 96 (52%) completed 1, and 21 (11%) completed none. Of those completed, 22% were abnormal. When follow-up colposcopy was indicated, 18 of 42 (42%) women completed colposcopy within 6 months. Patients with screening rates lower than recommended were more likely to have substance use disorders and be uninsured (P < 0.05). Factors significantly associated with adherence to screening guidelines included history of an abnormal pap test, current antiretroviral therapy, and more than four HIV-related primary care visits per year. Age and HIV viral load between the groups were not significantly different.ConclusionIn this urban HIV clinic cohort, a high proportion of women completed at least one cervical cancer screening test over a 2-year period, a promising result in the setting of a recent change in cervical cancer screening guidelines recommending less frequent testing. However, a smaller proportion completed colposcopy when indicated. The strongest predictors of low adherence to the guidelines were substance use disorder and lack of insurance. The next phase of this project will include a review of cervical and anal cancer screening rates among women, as well as patient surveys to determine quality improvement strategies that may further enhance acceptability and access to cervical and anal cancer screening and prevention.Disclosures All authors: No reported disclosures.

Optimal Information Provision at Bottleneck Equilibrium with Risk-Averse Travelers

This paper aims to study the effects of travel information provision on risk-averse travelers when travel time is uncertain. A stochastic bottleneck model is examined with risk-averse commuters, in which the free-flow travel time is assumed to be uncertain and follows a uniform distribution. A mean-variance approach is adopted to measure the travel cost under risk. It is proven that the individual travel cost at bottleneck equilibrium monotonically increases with the risk-aversion level. With a higher risk-aversion level, the morning peak hour starts earlier, but the duration of the peak hour remains constant regardless of the risk-aversion level. If improvement in information quality can reduce the travel time uncertainty, risk-averse commuters will benefit from the higher quality of information. Nevertheless, when the cost of information provision is also considered, the optimal information provision strategy is derived to minimize the total system cost. The numerical examples demonstrate the information efficiency and provision strategy. The findings reveal the congestion patterns of a stochastic bottleneck with risk-averse travelers and will guide us to provide appropriate travel information.

Clinical pathway creation and adherence at a large hybrid cancer center.

298 Background: Clinical pathways are valuable in reducing treatment variation, improving outcomes, and reducing costs in an oncology setting. With input of clinical stakeholders at West Cancer Center, we created and implemented a melanoma clinical pathway to improve care and facilitate standardization between melanoma sub-specialists and general oncologists. Retrospective pathway adherence was assessed to inform quality improvement goals. Methods: Using national guidelines and expert literature review, we developed a pathway defining a center-wide algorithmic approach to treat melanoma. Prior adherence to the pathway was retrospectively assessed by evaluating treatment during 1 year across 8 metrics. All patients who received systemic melanoma therapy during the study period at a large cancer center ( &gt; 5000 new patients annually) were included in the assessment. Of the included patients, metric adherence was only measured when applicable. Adherence rates were described for predefined melanoma subspecialists versus predefined general oncologists without a declared subspecialty in melanoma. Significance was assessed with fisher exact test. Results: The following metrics were defined by the expert team as essential components of melanoma pathway; receipt of wide local excision; receipt of sentinel lymph node biopsy; presentation at multidisciplinary conference; molecular profiling before treatment of metastatic disease; treatment with preferred regimens in 1st line, 2nd line, and 3rd line; and clinical trial participation. Ninety patients were evaluated. Conclusions: Most differences in pathway adherence were found to be not significant. Clinical trial accrual was higher among melanoma subspecialists compared to general oncologists. Clinical pathways allow patients treated by general oncologists to benefit from the expertise of subspecialists and improve quality of care.[Table: see text]

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

BackgroundEnd-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.MethodsThis was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.ResultsThree quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.ConclusionsAcute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

154 Field Testing a Quality Measure for Treatment of Status Epilepticus in the Pediatric Emergency Department

Status epilepticus (SE) in children is a neurologic emergency. Although short-term mortality rates are low (3%), SE can lead to poor long term outcomes including disrupted neurodevelopment, increased risk of SE recurrence, and increased long term mortality. SE is “refractory” if seizures continue after first- and second-line therapy. Refractory status epilepticus (RSE) is associated with mortality rates as high as 32%. Expedient treatment of SE is essential for achieving good outcomes, however the average time to first-, second-, and third-line treatments are longer than guidelines recommend at US tertiary care hospitals. To address this issue, the American Academy of Neurology proposed as a quality measure, the proportion of pediatric patients receiving third-line treatment for convulsive RSE within 60 minutes. We field-tested this quality measure with the goal of determining whether it is feasible to measure and whether it actually reflects quality of care. Using the statistical programming language R, we developed a tool to automatically identify patients in RSE and calculate time to third-line treatment using data from electronic medical records. We tested the fidelity of our tool on a large cohort of patients using manual chart review as a gold standard. The cohort included all pediatric patients (age 0-21) admitted to both the pediatric ED and pediatric ICU at New York Presbyterian Cornell Hospital between 2012 and 2017 with ICD-9 and ICD-10 codes corresponding to epilepsy and recurrent seizures as well as convulsions not elsewhere specified and general symptoms. The tool identifies cases by searching for the term “status epilepticus” in radiation reports, EEG notes, and discharge summaries, as well as checking for ICD codes that correspond to status epilepticus. Any case that meets at least one of those conditions is next checked to see if a 2nd or 3rd line medication for SE, generally an IV antiepileptic drug (AED), was given while in the ED or within 3 hours of being transferred to the pediatric ICU. By manual chart review, we identified 62 episodes of convulsive SE out of a total of 665 patient visits. Of the 62 episodes of convulsive SE, 25 responded to first line treatment with benzodiazepines and 16 responded to second line treatment with an IV AED. In 6 cases, the patient was intubated and given paralytics after second line treatment - 2 were subsequently given a third line medication. Finally, there were 14 cases of convulsive RSE that required third line treatment for continued seizures. Our tool identified 15 of the 16 cases that received a 3rd line medication giving a sensitivity of 93.8% and a specificity of 94.9% for detection of convulsive RSE. We have designed a computable phenotype that identifies cases of convulsive RSE with a high degree of sensitivity and specificity. We’ve demonstrated that it is feasible to automate case detection for the quality measure: proportion of pediatric patients receiving third line treatment for convulsive RSE within 60 minutes. This will allow informed quality improvement as well as research into factors that influence quality care for convulsive RSE. Future directions of this work include validating the tool with data from other institutions, automating calculation of the quality measure, and ensuring the quality measure actually reflects quality of care.

Evidence from an Applied Research Health Question (AHRQ): Healthcare utilization of HIV patients before and after admission to Casey House, a specialized HIV hospital

IntroductionThe Applied Health Research Question (AHRQ) portfolio is an initiative funded by the Ontario Ministry of Health and Long-Term Care, leveraging the linked data and the scientific expertise at ICES to answer questions from Knowledge Users that have a direct impact on healthcare policy, planning or practice.&#x0D; Objectives and ApproachA request from Casey House, a specialty HIV hospital located in Toronto, ON, was reviewed and approved by the ICES AHRQ Team to evaluate patient healthcare utilization and costs. The purpose was to support the design of programs and services, improve transitions from healthcare settings to community services, and inform continuous quality improvement initiatives. Using inpatient records, hospital admissions to Casey House were identified in fiscal years 2009-2014. Inpatient, emergency, outpatient and home care visits were characterized before and after admission. Using the Ontario Drug Benefit Claims, antiretroviral (ARV) prescription fills were examined 7 days post discharge.&#x0D; ResultsBetween April 1, 2009 and March 31, 2015, 268 HIV patients had one or more hospital admissions to Casey House. The majority of Casey House patients had an Aggregated Diagnosis Group (ADG) ≥ 10 (79%) or Resource Utilization Band (RUB) = 5 (78%), indicating a high co-morbidity burden. Rate of emergency department usage declined from 4.61 to 2.46 per person-year, before and after Casey House admission (p &lt; 0.0001). Conversely, home care visits increased from 24.29 to 35.63 per person-year and family physician visits increased from 18.33 to 22.59 per person-year before and after Casey House admission (both p &lt; 0.0001). Interestingly, 89% did not fill an ARV prescription within 7 days of Casey House discharge, however 76% followed up with an outpatient HIV visit within 30 days.&#x0D; Conclusion/ImplicationsHealthcare utilization differed before and after admission to Casey House. Follow-up post-discharge warrants further examination to increase ARV prescription fills. Data from this AHRQ has facilitated future policy and programming changes. Results have been disseminated throughout the Toronto HIV research community to generate discussion on quality improvement in this population.

Association rule mining to identify potential under-coding of conditions in the problem list in primary care electronic medical records

IntroductionThe problem list of a patient’s primary care electronic medical record (EMR) generally reflects their important medical conditions. We will use association rule mining to assess between-provider and between-clinic variation in the coding of select conditions in the EMR problem list, in order to identify possible under-coding outliers.&#x0D; Objectives and ApproachEMR data from participating clinics in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) will be used, with a focus on three commonly-occurring conditions (hypertension, diabetes, and depression). Association rule mining will be used to develop association rules between these conditions and other clinical information available in the EMR, such as other diagnoses in the problem list, billing codes, medications, and laboratory results (e.g., a rule of “diabetic medication→diabetes” indicates that patients prescribed a diabetic medication are likely to have diabetes in the problem list). Under-coding outliers at the provider and clinic levels will be identified by comparing rule enforcement.&#x0D; ResultsResults from this work in progress will be presented at the conference. An estimated 270 clinics, 1340 providers, and 1.8 million patients will be included from the CPCSSN database. Rule ‘confidence’ will be used to identify outliers; the confidence of a rule X→Y is the proportion of individuals with X who also have Y (Pr(Y|X)). For example, we may find that on average 80% of patients prescribed a diabetic medication will also have a diagnosis of diabetes in the problem list (average confidence of 80%), but an outlier clinic may have a confidence of 40%; this low rule confidence may indicate under-coding of diabetes in the problem list. Confounding by patient demographics (e.g., age, sex, urban/rural) will be assessed and adjusted for, if necessary.&#x0D; Conclusion/ImplicationsThis work examines a novel method to identify potential under-coding in the EMR problem list. Providers/clinics could use this information to update patients’ problem list or inform quality improvement interventions. Researchers using primary care EMR data need to be aware of potential under-coding and take steps to mitigate the effects.

A nurse-led audit on the incidence and management of inadvertent hypothermia in an operating theatre department of an Irish hospital.

Inadvertent perioperative hypothermia (IPH) is a common problem associated with perioperative patients which can have significant consequences for them during surgery and in the immediate postoperative period. Recognising and managing IPH remains an important aspect of perioperative nursing and is a significant factor in maintaining patient safety, achieving positive surgical outcomes and patient satisfaction. A nurse-led clinical audit was undertaken in the operating theatre department of a major teaching hospital in Ireland to establish the incidence and management of IPH in the department. One hundred (n = 100) patients were included in the audit, both children and adults. Results of the audit were used to inform quality improvement initiatives, with the purpose of improving patient care standards in the operating theatre department in that hospital.