Opportunities For Quality Improvement Research Articles

Quantifying air quality co-benefits to industrial decarbonization: the local Air Emissions Tracking Atlas

IntroductionMany decarbonization technologies have the added co-benefit of reducing short-lived climate pollutants, such as particulate matter (PM), nitrogen oxides (NOx), and sulfur dioxide (SO2), creating a unique opportunity for identifying strategies that promote both climate change solutions and opportunities for air quality improvement. However, stakeholders and decision-makers may struggle to quantify how these co-benefits will impact public health for the communities most affected by industrial air pollution.MethodsTo address this problem, the LOCal Air Emissions Tracking Atlas (LOCAETA) fills a data availability and analysis gap by providing estimated air quality benefits from industrial decarbonization options, such as carbon capture and storage (CCS). These co-benefits are calculated using an algorithm that connects disparate datasets that separately report greenhouse gas emissions and other pollutants at U.S. industrial facilities.ResultsVersion 1.0 of LOCAETA displays the estimated primary PM2.5 emission reduction co-benefits from additional pretreatment equipment for CCS on industrial and power facilities across the state of Louisiana, as well as the potential for VOC and NH3 generation. The emission reductions are presented in the tool alongside facility pollutant emissions information and relevant air quality, environmental, demographic, and public health datasets, such as air toxics cancer risk, satellite and in situ pollutant measurements, and population vulnerability metrics.DiscussionLOCAETA enables regulators, policymakers, environmental justice communities, and industrial and commercial users to compare and contrast quantifiable public health benefits due to air quality impacts from various climate change mitigation strategies using a free and publicly-available tool. Additional pollutant reductions can be calculated using the same methodology and will be available in future versions of the tool.

Increasing Referral Acceptance for Women’s Health Services Among Hispanic Women

ObjectiveTo evaluate the effect of an individualized educational intervention on women’s health referral acceptance rates among Hispanic women. DesignQuality improvement (QI) project. Setting/Local ProblemBarriers to cervical cancer screening among Hispanic women include a lack of access to women’s health services and a lack of knowledge related to cervical cancer risk factors. Primary care providers at two medical clinics in eastern Pennsylvania did not routinely discuss cervical cancer risk factors, provide well-woman care, or perform cervical cancer screening during office visits. This gap in preventive care provided an opportunity for quality improvement. ParticipantsA convenience sample of 65 self-identified Hispanic women presenting for primary care office visits. Intervention/MeasurementsEach consenting participant received a one-on-one education session lasting 5 to 10 minutes regarding individual risk factors for cervical cancer. Each woman was offered a referral for a well-woman examination, with or without cervical cancer screening. Data collection included the participant’s response to the offered referral. ResultsThe majority of participants who received the educational intervention (96.9%, n = 63) accepted referrals for women’s health services. ConclusionAn educational intervention discussing individual cervical cancer risk factors was associated with increased women’s health referral acceptance rates among Hispanic women.

Artificial Intelligence-Based Quality Assessment of Histopathology Whole-Slide Images within a Clinical Workflow: Assessment of 'PathProfiler' in a Diagnostic Pathology Setting.

Digital pathology continues to gain momentum, with the promise of artificial intelligence to aid diagnosis and for assessment of features which may impact prognosis and clinical management. Successful adoption of these technologies depends upon the quality of digitised whole-slide images (WSI); however, current quality control largely depends upon manual assessment, which is inefficient and subjective. We previously developed PathProfiler, an automated image quality assessment tool, and in this feasibility study we investigate its potential for incorporation into a diagnostic clinical pathology setting in real-time. A total of 1254 genitourinary WSI were analysed by PathProfiler. PathProfiler was developed and trained on prostate tissue and, of the prostate biopsy WSI, representing 46% of the WSI analysed, 4.5% were flagged as potentially being of suboptimal quality for diagnosis. All had concordant subjective issues, mainly focus-related, 54% severe enough to warrant remedial action which resulted in improved image quality. PathProfiler was less reliable in assessment of non-prostate surgical resection-type cases, on which it had not been trained. PathProfiler shows potential for incorporation into a digitised clinical pathology workflow, with opportunity for image quality improvement. Whilst its reliability in the current form appears greatest for assessment of prostate specimens, other specimen types, particularly biopsies, also showed benefit.

Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement

BackgroundDespite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use...

Clinical Practice Guideline: Age-Related Hearing Loss.

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition. The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantationcandidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Clinical Practice Guideline: Age-Related Hearing Loss Executive Summary.

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition. The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with an explanation of the support in the literature, the evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the Guideline Development Group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life. (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related quality of life at a subsequent health care encounter or within 1 year. The GDG offered the following KASas an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Plain Language Summary: Age-Related Hearing Loss.

The plain language summary explains age-related hearing loss to patients, families, and care partners. The summary is for any patient aged 50 years and older, families, and care partners. It is based on the 2024 "Clinical Practice Guideline: Age-Related Hearing Loss." This plain language summary is a companion publication to the full guideline, which provides greater detail for clinicians. Guidelines and their recommendations may not apply to every patient, but they can be used to find best practices and quality improvement opportunities.

Implementation of the 2015 American Thyroid Association guideline changes across a health system: A quality improvement opportunity

BackgroundWith the release of the 2015 management guidelines, the American Thyroid Association narrowed the indications for postoperative radioactive iodine (RAI) in well-differentiated thyroid cancer. However, the adoption of new guidelines varies between healthcare entities. The goal of this study was to characterize the appropriateness of RAI use within our health system, before and after the 2015 guideline changes. MethodsIn this retrospective cohort study, we identified patients who were treated for well-differentiated thyroid cancer between 2011–2020. Patients were characterized as “undertreated,” “appropriately treated,” or “overtreated” with RAI. Variation in RAI use was assessed using interrupted time series and multivariable logistic regression analyses. ResultsAmong 6310 patients, the mean age was 50 ± 15 years, and 74% were female. There was an immediate drop in the likelihood of receiving RAI after the release of the 2015 guidelines (p = 0.016), and the likelihood of receiving RAI therapy continued to significantly decline over time (OR 0.83, p < 0.001). Despite this trend in the absolute rate of RAI use, there was a significant increase in overtreatment with RAI after the release of the 2015 guidelines (p < 0.001), indicating imperfect uptake of the new criteria. Two hospitals within the health system were identified as disproportionate contributors to overtreatment (Hospital 4: OR 6.50, p < 0.001; Hospital 6: OR 8.63, p < 0.001). ConclusionsWhile the use of postoperative RAI was largely appropriate across our health system, rates of guideline adherence differed between hospitals. Efforts to standardize treatment protocols systemwide may enable more rapid and consistent uptake of new management guidelines.

530 Understanding Strengths and Weaknesses of Clinical Research Operations in Regional Settings

OBJECTIVES/GOALS: An environmental scansoughtto understand research processes, areas for improvement, and opportunities for collaborative quality improvement (QI)across the Northwest Participant and Clinical Interactions Network (NW PCI). METHODS/STUDY POPULATION: NW PCI site champions were invited for semi-structured single and group Zoom-based interviews. Interviewers asked participants about local research processes, strengths and weaknesses, existing infrastructure to support QI, and interest in collaborative QI across the Network. Audio transcripts were coded using Dedoose and analyzed with deductive and inductive coding. RESULTS/ANTICIPATED RESULTS: Between February and April 2023, 10 interviews collected data from 7 research decision makers and 7 staff members across 7 sites. Most participants (n=13, 92%) agreed the diagram shown during the interview was representative of the local process. Organizations consistently identified strengths and weaknesses within the domains of study start-up, recruitment, budgets, and compliance. QI infrastructure was inconsistent (n=5, 36%) and all (n=14, 100%) saw potential for success in multisite QI initiatives to enhance efficiency. DISCUSSION/SIGNIFICANCE: NW PCI sites use similar processes, share common strengths and weaknesses, and universally reported interest in collaborating on QI. Study startup was reported as both a strength and weakness within the same organization, requiring unpacking of key elements before pursuing QI initiatives.

The entwined circles of quality improvement & advocacy

Health policy and quality improvement initiatives exist symbiotically. Quality projects can be spurred by policy decisions, such as the creation of financial incentives for high-value care. Then, advocacy can streamline high-value care, offering opportunities for quality improvement scholars to create projects consistent with evidenced-based care. Thirdly, as pediatrics and neonatology reconcile with value-based payment structures, successful quality initiatives may serve as demonstration projects, illustrating to policy-makers how best to allocate and incentivize resources that optimize newborn health. And finally, quality improvement (QI) can provide an essential link between broad reaching advocacy principles and boots-on-the-ground local or regional efforts to implement good ideas in ways that work practically in particular environments. In this paper, we provide examples of how national legislation elevated the importance of QI, by penalizing hospitals for low quality care. Using Medicaid coverage of pasteurized human donor milk as an example, we discuss how advocacy improved cost-effectiveness of treatments used as tools for quality projects related to reduction of necrotizing enterocolitis and improved growth. We discuss how the future of QI work will assist in informing the agenda as neonatology transitions to value-based care. Finally, we consider how important local and regional QI work is in bringing good ideas to the bedside and the community.

Quality improvement lessons from Canadian thyroid and parathyroid surgery legal decisions

BackgroundThis is the first study of Canadian thyroid and parathyroid surgery legal decisions, and the first study of surgical malpractice using the Canadian Legal Information Institute (CanLII) database. The objective was to identify quality improvement opportunities in surgical practice, to increase patient safety and satisfaction. MethodsLegal decisions relating to thyroid and parathyroid surgery in the CanLII database were screened. Cases were included if a surgeon was listed as applicant or respondent; they related to pre-, intra-, or post-operative management of thyroid or parathyroid disease; and malpractice was alleged. Cases were excluded if surgery was mentioned incidentally or for non-surgical focus. ResultsOf the 347 unique legal decisions screened, 14 met inclusion and exclusion criteria. Surgeries occurred between 1976 and 2012, with 13 thyroid surgeries, 1 parathyroidectomy, and 4 mortalities. ConclusionsQuality improvement lessons include communication, pre-operative patient education and documentation of risks discussed, and in-person assessment of complications.

Hospice providers serving assisted living residents: Association of higher volume with lower quality.

Assisted living (AL) community caregivers are known to report lower quality of hospice care. However, little is known about hospice providers serving AL residents and factors that may contribute to, and explain, differences in quality. We examined the association between hospice providers' AL patient-day volume and their quality ratings based on Hospice Item Set (HIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Surveys. This cross-sectional study employed information from the Medicare Compare website and Medicare claims data. Medicare-eligible AL residents were identified using previously validated methods and merged with hospice claims. Linear probability models adjusting for county fixed effects were used to examine the association between hospice provider AL volume, measured as the share of annual hospice patient days from AL residents, and quality measures obtained from HIS and CAHPS. Models controlled for hospice providers' profit status and daily patient census. Higher AL-volume hospice providers were 7 percentage points more likely to have caregivers reporting lower median scores on domains of pain assessment, dyspnea treatment, and emotional support. Their caregivers also reported lower scores in team communications and training family to provide care. Higher AL-volume hospice providers also were 5 percentage points less likely to get higher aggregated scores from all CAHPS domains and 7 percentage points less likely to have higher HIS composite scores. Hospice providers serving higher volumes of AL patient days had lower quality scores. In order to identify targeted opportunities for quality improvement, research is needed to understand why lower quality providers are concentrated in the AL market.

Abstract 1307: Community-driven support platform BlueHQ: An innovative solution to address the needs of patients with colorectal cancer

Abstract Background: Colorectal cancer (CRC) is the third-most commonly diagnosed cancer and the second-leading cause of cancer death in men and women combined in the United States. To manage the disease, patients and caregivers turn to various tools and resources for financial assistance, information dissemination, emotional and peer support, and treatment planning, among other critical issues and needs they face. The Colorectal Cancer Alliance (the Alliance) created BlueHQ to provide patients and caregivers with a resource solution encompassing all potential areas of need. Methods: A survey aimed at understanding needs, barriers, and quality improvement opportunities was disseminated via the Alliance's Blue Hope Nation community for two weeks and by email. One hundred sixty-seven colorectal cancer patients and forty caregivers of colorectal cancer patients completed the survey. Results: Patients and caregiver respondents report reliance on external tools and resources to manage disease and support information. Of the support methods, patient respondents reported using social media (46.11%); notebooks, journals, and planners (45.41%); online articles (44.91%); the Blue Hope Nation Facebook group (41.32%); cancer discussion boards (35.33%); and spiritual or religious advice (29.94%). Patients sought financial assistance, local peer support and groups, and mental health help to minimize diagnosis-related stressors. To provide more efficient care and limit stress, the community suggested financial help, communication and support from other patients and caregivers, and informational resources. Conclusions: These survey results are consistent with other published learnings about patient and caregiver reliance on support tools and highlight the myriad resources that patients and caregivers currently use for managing CRC. BlueHQ is a support solution that provides patients and caregivers with access to information and resources tailored to users’ specified profiles, including molecular characteristics of the tumor. Users can also store documents and information from healthcare encounters, creating a longitudinal record and tracking disease progression. In the age of precision oncology, BlueHQ ensures patients and users are presented with personalized educational materials and multimedia resources to help manage their disease and bridge the gaps in patient support. BlueHQ was explicitly designed to connect the CRC community to the latest therapeutic and clinical research resources to improve outcomes and quality of life for all CRC patients. Citation Format: Kimberly Lynn Newcomer. Community-driven support platform BlueHQ: An innovative solution to address the needs of patients with colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1307.

Impact of AI-Based Post-Processing on Image Quality of Non-Contrast Computed Tomography of the Chest and Abdomen.

Non-contrast computed tomography (CT) is commonly used for the evaluation of various pathologies including pulmonary infections or urolithiasis but, especially in low-dose protocols, image quality is reduced. To improve this, deep learning-based post-processing approaches are being developed. Therefore, we aimed to compare the objective and subjective image quality of different reconstruction techniques and a deep learning-based software on non-contrast chest and low-dose abdominal CTs. In this retrospective study, non-contrast chest CTs of patients suspected of COVID-19 pneumonia and low-dose abdominal CTs suspected of urolithiasis were analysed. All images were reconstructed using filtered back-projection (FBP) and were post-processed using an artificial intelligence (AI)-based commercial software (PixelShine (PS)). Additional iterative reconstruction (IR) was performed for abdominal CTs. Objective and subjective image quality were evaluated. AI-based post-processing led to an overall significant noise reduction independent of the protocol (chest or abdomen) while maintaining image information (max. difference in SNR 2.59 ± 2.9 and CNR 15.92 ± 8.9, p < 0.001). Post-processing of FBP-reconstructed abdominal images was even superior to IR alone (max. difference in SNR 0.76 ± 0.5, p ≤ 0.001). Subjective assessments verified these results, partly suggesting benefits, especially in soft-tissue imaging (p < 0.001). All in all, the deep learning-based denoising-which was non-inferior to IR-offers an opportunity for image quality improvement especially in institutions using older scanners without IR availability. Further studies are necessary to evaluate potential effects on dose reduction benefits.

Patient and Family Satisfaction with Intensive Care in a Mega University Hospital: An exploratory study

Background: Being admitted to the ICU is stressful for both patients and families, in addition to being very costly. Therefore, the ICU was chosen for conducting the study in this university hospital, the New Kasr Al-Ainy Hospital (NKHICU). This was the first such study. Objective: Identify NKHICU patient and family satisfaction to prioritize opportunities for quality improvement. Methods: This was health-system research, exploratory design. Work began by providing training for selected NKHICU administrative staff to help with data collection activities. Next, a well-prepared checklist was used to observe some quality dimensions. Finally, satisfaction was identified using two ICU-designed interview questionnaires for patients and family members who matched the eligibility criteria. Quantitative and qualitative findings were analyzed independently and combined in the discussion. The mean % satisfaction scores of the participants were calculated. The reliability of questionnaires was measured using Cronbach's Alpha. Results: The observation revealed 'excellent' results, except for some inconvenient conditions in the family waiting areas. The highest mean % score of patient and family satisfaction was for the neat appearance of NKHICU staff (96.4%, and 97.1%, respectively) and the continuous availability of nurses to respond to patient needs (94.7%, and 94.3%, respectively). The least mean % score of patient and family satisfaction was for the shortage of required drugs/supplies (51.5%, and 40.7%, respectively). The top suggestions raised by the participants were increasing the availability of medications/supplies and reduction in hospital bills. Conclusion: The provision of adequate drugs/supplies, reduction in bills, and addressing patients' and families' concerns will improve their satisfaction with services.

A Survey Study of Motivators for Pediatric Hospitalists to Work in the Community.

The loss of pediatric beds in the community has contributed to decreased access to pediatric inpatient and emergency services. Community pediatric hospitalist programs could reduce the overhead of inpatient care, promoting the financial feasibility of caring for hospitalized children closer to home. This study aims to determine which career motivators are the most important for pediatric hospitalists to begin working in, remain in, and leave the community setting. A survey was sent to a convenience sample of 269 community hospitalists from 31 different sites. Sites were invited if the program director was known to the authors. Responses were evaluated and χ-square or Fisher's exact test were used to compare the differences. One hundred twenty six community pediatric hospitalists completed the survey (response rate 49.1%). The 3 most important motivators for pediatric hospitalists to begin working in the community were work-life integration (80%), geographic location (75%), and flexible hours (71%). Pediatric hospitalists who planned to leave the community setting were more likely to cite mentoring and teaching opportunities (76% vs 32%, P = .0002), opportunities for research and quality improvement (29% vs 10%, P = .021), and paid time for nonclinical interests (52% vs 26%, P = .02) as very important. This study demonstrates key motivators for pediatric hospitalists to work in the community and elucidates motivators for transitioning to larger pediatric centers. This knowledge may be used to guide community pediatric hospital medicine recruitment and program development that could lead to improved retention.

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020.

Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact. In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance. The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.

Clinical Practice Guideline: Immunotherapy for Inhalant Allergy.

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AITis administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm.The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients'symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy.

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AITis administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. The guideline development group made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The guideline development group made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitization, (2)reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The guideline development group offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.