Audit Of Outcomes Research Articles

COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes.

Objectives:Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes.Materials and Methods:A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited.Results:Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%).Conclusion:Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

Audit of Clinical Outcomes with Dexamethasone in Patients Hospitalised with COVID-19

Audit of Clinical Outcomes with Dexamethasone in Patients Hospitalised with COVID-19

742 Transurethral LASER Ablation (TULA): A Safe and Well Tolerated Procedure for The Treatment of Bladder Tumours Up To 4cm In Diameter in An Outpatient Setting

Abstract Aim Traditionally the management of recurrent non-muscle invasive bladder cancer (NMIBC) involves rigid cystoscopy and bladder biopsies/tumour resection under general/regional anaesthesia. As a result, many frail patients endure frequent anaesthetics and therefore are at increased risk of adverse outcomes including cognitive decline. Discontinuation of anti-platelet/anti-coagulation is not required for TULA. An outpatient TULA service was recently started at our trust. We present a case series of our first 4 months data. Method All TULA cases (n = 39) performed between Aug-Dec 2020 were included. Data was gathered prospectively including patient demographics, co-morbidities, initial cancer diagnosis and number of subsequent recurrences, post-procedural complications, and patient procedural satisfaction. Results Median age was 82 years (range 34-96) and median number of co-morbidities were 4 (range 0-10). Previous bladder cancer diagnosis was present for 85% with the most common initial stage G2pTa (n = 11). Median number of recurrences was 1 (range 1-5). Median patient perceived pain score was 3 (range 1-7) with 100% of patients preferring TULA over TURBT. Reasons included reduced procedural time (n = 18) and enhanced recovery (n = 15). Only 1 patient was readmitted post-procedure due to haematuria, however urine was clear after catheterisation and the patient was discharged. Conclusions TULA is safe for all low risk NMIBC, particularly for frail patients. It is well tolerated and facilitates improved patient experience. It also alleviates demand on theatre capacity and inpatient beds which has a positive effect on surgical waiting lists. Further audit of clinical outcomes should continue as recommended by NICE.

832 Groin Hernia Should Remain A Clinical Diagnosis -- An Evidence-Based Study

Abstract Introduction British Hernia Society (BHS) 2013 guidelines1 suggest that groin hernia diagnostic investigation should not be done at the primary care level. Nevertheless, General Practitioners refer patients with a positive ultrasound finding of groin hernia to secondary care. As a result, patients have false hopes that their symptoms would resolve if the ultrasound finding is addressed. The study aims to find the positive predictive value (PPV) for groin ultrasound for hernia and should the primary care physicians request the scan before referral to secondary care. Method A retrospective audit of outcome of patients referred to a general surgical department for groin hernia treatment. The study looked at elective groin hernia referrals for the period between June and August 2019. Results 127 patients were electively treated for groin hernia in secondary care. 40% of the patients had ultrasounds before treatment. The GP requested 78% of the ultrasounds. A positive finding was the reason for the referral. Two patients (5%) in this group had negative operative findings. 24 herniograms over 57 months for patients referred with positive ultrasound and negative clinical findings showed only 2 had positive findings (8%). None of the negative patients returned to the same hospital for groin hernia treatment until date. Conclusions It is recommended that the diagnostic tests for groin hernia be requested by the operating surgeon as per the BHS guidelines. Patients should not be subjected to hernia operations based on ultrasound findings as the PPV for this investigation is very low for patients who have negative clinical findings.2

P117 Changes in prescription of home non-invasive ventilation (NIV) in Southern Adelaide Local Health Network (SALHN) from 2016 – 2020

Abstract Background Long term NIV is established therapy for patients with chronic type 2 respiratory failure (T2RF) due to neuromuscular disorders and obesity hypoventilation syndrome (OHS) without significant OSA. There is emerging evidence that COPD patients with T2RF also benefit from NIV. In our centre, there appears to be an increase in the prescription of long term NIV to patients over time, with 60% of all active long term NIV patients commencing therapy from 2017 onwards. In this study we will determine if (i) there has been increased provision of long term NIV to ward patients recovering from acute T2RF, (ii) there has been an increase in patients with COPD and T2RF commenced on long term NIV, (iii) there are patients with OHS and comorbid OSA who can be changed from NIV to CPAP and (iv) there is adequate follow up for patients who initiated NIV in the ward acutely. Methods Retrospective, observational study using a pre-existing database of all current and previous patients commenced on NIV from July 2016 to July 2020. Progress to date All active long term NIV patients have been identified and a database (n= 220) created containing all relevant information including date and place of NIV initiation and indication. Intended outcome and impact This audit will objectively assess the growth of our NIV service to facilitate better allocation of resources. It will also determine if our commencement and management of those on long term NIV is aligned with current evidence and best practice guidelines.

Keterbacaan Catatan Atas Laporan Keuangan dan Dampak Audit (Readability over Financial Reporting Footnotes and Audit Outcomes)

This study aims to find out the relationship of readability over financial reporting footnotes and audit outcomes. Audit outcomes are projected by audit fees and audit report lag. Researchers used data from the company's financial statements listed on IDX in 2015-2018. Researchers used purposive sampling. From the copying, researchers processed 184 company data. This study used the panel's data regression analysis method. Data processing uses Generalized - least - squares. This research proves that the worse the readability, the lower the audit fee. Meanwhile, the worse the readability, the more time it takes the auditor to carry out an examination of the financial statements. This phenomenon occurs because the condition of the readability of notes to financial statements in Indonesia is still at a low level.

OP02.08: A five‐year retrospective audit of pregnancy outcomes following transvaginal cervical cerclage at Liverpool Hospital

OP02.08: A five‐year retrospective audit of pregnancy outcomes following transvaginal cervical cerclage at Liverpool Hospital

Critical acute pancreatitis: A category with clinical relevance

Classifying the severity of acute pancreatitis is about defining the severity at any time point, monitoring severity over multiple time points or defining the worst severity during a disease episode [1]. In other words classification is about defining present or past severity and not about predicting future severity, although these are sometimes confused [1]. The classification of severity is important for communication between clinicians, monitoring of patients, allocation to clinical studies, auditing of clinical outcomes and comparison between centres [1].

Emergencies in freestanding ambulatory surgery centre.

Ambulatory surgery is increasing, more procedures as well as more complex procedures are transferred to ambulatory surgery. Patients of all ages including elderly and more fragile are nowadays scheduled for ambulatory surgery. Enhanced recovery after surgery (ERAS) protocols are now developed for further facilitating readily recovery, ambulation, and discharge. Thus, to secure safety, a vigilant planning and preparedness for adverse events and emergencies is mandatory. Proper preoperative assessment, preparation/optimization and collaboration between anaesthetist and surgeon to plan for the optimal perioperative handling has become basic to facilitate well tolerated perioperative course. Standard operating procedures for rare emergencies must be in place. These SOPs should be trained and retrained on a regular basis to secure safety. Check lists and cognitive aids are tools to help improving safety. Audit and analysis of adverse outcomes and deviations is likewise of importance to continuously analyse and implement corrective activity plans whenever needed. The present review will provide an oversight of aspects that needs to be acknowledged around planning handling of rare but serious emergencies to secure quality and safety of care in freestanding ambulatory settings.

Clinical audit of current Helicobacter pylori treatment outcomes in Singapore.

H. pylori eradication reduces the risk of gastric malignancies and peptic ulcer disease. First-line therapies include 14-day PAC (proton pump inhibitor [PPI], amoxicillin, clarithromycin) and PBMT (PPI, bismuth, metronidazole, tetracycline). Second-line therapies include 14-day PBMT and PAL (PPI, amoxicillin, levofloxacin). This clinical audit examined current treatment outcomes in Singapore. Clinical data of H. pylori-positive patientswho underwent empirical first- and second-line eradication therapies from 1 January 2017 to 31 December 2018 were reviewed. Treatment success was determined by 13C urea breath test performed at least 4 weeks after treatment and 2 weeks off PPI. A total of 963 patients (862 PAC, 36 PMC [PPI, metronidazole, clarithromycin], 18 PBMT, 13 PBAC [PAC with bismuth], 34 others) and 98 patients (62 PMBT, 15 PAL, 21 others) received first-and second-line therapies respectively. A 14-day treatment duration was appropriately prescribed for first- and second-line therapies in 65.2% and 82.7% of patients, respectively. First-line treatment success rates were noted for PAC (seven-day: 76.9%, ten-day: 88.3%, 14-day: 92.0%), PMC (seven-day: 0, ten-day: 75.0%, 14-day: 69.8%), PBMT (ten-day: 100%, 14-day: 87.5%) and PBAC (14-day: 100%). 14-day treatment was superior to seven-day treatment (90.8% vs. 71.4%; P = 0.028). PAC was superior to PMC (P < 0.001) but similar to PBMT (P = 0.518) and PBAC (P = 0.288) in 14-day therapies. 14-day second-line PAL and PBMT had similar efficacy (90.9% vs. 82.4%; P = 0.674). First-line empirical treatment using PAC, PBMT and PBAC for 14 days had similar efficacy. Success rates for second-line PBMT and PAL were similar.

Assessing audit outcomes of pre-determined objectives in a public institution (South Africa)

PurposeMany developing countries such as South Africa have been introducing measurement of results to improve public service delivery. The practice of development of performance measures in the public service emanates from pressure exerted by citizens who are calling for more efficiency and effectiveness in delivering services. This article examines the implementation of the audit of pre-determined objectives at the Department of Basic Education (DBE).Design/methodology/approachThis study is based on a qualitative case study approach. Secondary sources of data were used in order to analyse the DBE's challenges in managing performance information. Key secondary documents used include the AGSA annual audit reports as well as the DBE 2010/11–2014/15 Strategic Plan and Annual Performance Plans (APP) that provide the pre-determined objectives selected by the Department to measure performance for the five-year period.FindingsThe findings indicate that there are shortcomings in the processes of managing performance information. Based on the findings, it is incumbent upon the senior management of the DBE to strive towards understanding and improving their oversight roles and responsibilities in the management of pre-determined objectives.Originality/valueThe study generates a deeper understanding of what has been happening when pre-determined objectives were developed, reported or assessed in the DBE. This will assist the Department and similar public institutions to make further improvements in order to achieve pre-determined objectives.

Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes.

Magnetic resonance imaging (MRI) is often used in practice to investigate for cord or discoligamentous injury following blunt trauma and a normal computed tomography (CT). This study investigates the MRI findings and surgical outcomes of patients in this cohort. Retrospective analysis of patients following trauma with suspected cervical spine injury from 2016 to 2019. Inclusion criteria included patients receiving a normal CT of the cervical spine and subsequent MRI due to cervical spine injury symptomatology (persistent tenderness and/or neurology). Inclusion criteria included: age ≥16 years, alert and <72 h from CT to MRI. Mann-Whitney and χ2 statistical analysis techniques were employed. Two hundred and twenty-eight patients with persistent midline tenderness and/or persistent neurology following blunt trauma and negative CT report were included. One hundred and eighty-one patients received an MRI for persistent tenderness of which 35 revealed abnormal MRI findings. Twenty-one cases required no treatment, 14 cases were treated with a rigid collar with no patients requiring operative management. Forty-seven patients received an MRI for neurological symptoms following blunt trauma and negative CT, with 11 abnormal MRI findings. Management included no treatment (three cases), application of rigid collar (six cases) and operative management (two cases). No alert neurologically intact patient with 'persistent tenderness only' received operative management following a normal CT examination. While MRI is sensitive for detecting soft tissue injuries, the prevalence for detecting clinically significant cervical spine injury in blunt trauma patients in the absence of neurology is low. The utility of MRI in this cohort is questionable considering prolonged spinal immobilisation is not without harm.

Evaluation and outcomes of paediatric epilepsy surgery in Singapore: A single-centre audit

Background: Paediatric epilepsy surgery reduces seizure burden in drug-refractory epilepsy reducing long-term neurocognitive damage. Methods: Single-centre retrospective audit of pre-surgical evaluations and outcomes of the paediatric epilepsy and epilepsy surgery programme over eleven years at KK Women’s and Children’s Hospital, Singapore. Data were collected based on National Institute of Neurological Disorders and Stroke Common Data Elements guidelines. Outcome was categorized using Engel classification scale, and favourable outcome defined as greater than 50% decrease in seizure frequency or drop attacks. Results: Thirty-three children underwent epilepsy surgery, with mean follow-up 3.8±3.1 years. Median age at surgery was 10.9 years. Twenty-four children with focal epilepsy underwent resection of the epileptogenic focus, including lesionectomy (n=8), anterior temporal lobectomy (n=7), extratemporal lobectomy (n=7) and hemispherectomy (n=2). Nine children underwent corpus callosotomy for Lennox Gastaut Syndrome (n=8) and West Syndrome (n=1). Median hospital stay duration was ten days. All twenty-three focal epilepsy patients with minimum three-month follow-up achieved greater than 50% seizure reduction. Fifteen (65%) focal epilepsy patients achieved seizure-freedom (Engel Class IA) after first surgeries. Four patients required second surgeries, with two achieving seizure-freedom. Intraoperative MRI (iMRI) is beneficial. All nine corpus callosotomy patients (100%) achieved greater than 50% decrease in drop attacks. Number of antiepileptic drugs was weaned for 21/32 (66%) patients. Post-operative complications were low and some patients had anticipated neurological deficits. Outcomes were comparable to current literature. Conclusions: In well-selected candidates with tailored evaluation, paediatric epilepsy surgery is a safe therapeutic option with favourable outcomes and can be performed across the entire paediatric age range.

Investigating Internal Control Factors on Clean Audit Outcomes : A Case of Selected Departments in the Mpumalanga Province in South Africa

Investigating Internal Control Factors on Clean Audit Outcomes : A Case of Selected Departments in the Mpumalanga Province in South Africa

Do auditors’ early-life socioeconomic opportunities improve audit quality? Evidence from China

Prior research documents significant variation in audit outcomes based on individual auditors' demographic features, working experience, educational background, and social connections. This study examines whether individual auditors' early-life socioeconomic opportunities also affect audit practices. We expect that auditors from big cities have more access to socioeconomic opportunities and accumulate more human capital in early life, thus are more capable of providing high-quality audits after they start careers. Consistent with this hypothesis, we find that auditors from big cities make more audit adjustments to earnings compared with auditors from small towns. Additional tests suggest that this early-life effect on audit quality is moderated when auditors receive higher education or gain more auditing experience and is more pronounced in downward adjustments than in upward adjustments. We also find a fee premium for auditors from big cities. Overall, this paper provides evidence that auditors’ early-life socioeconomic opportunities have a far-reaching influence on audit quality.

Outliers from national audits: their analysis and use by the Care Quality Commission in quality assurance and regulation of healthcare services in England

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. As part of the intelligence-driven approach to regulation, the CQC works closely with national clinical audit bodies to identify key metrics which reflect quality of care and track the performance of providers against these metrics. Where outliers on national audits are identified that may reflect risks to patients, the CQC encourages the hospital to identify any learning points and implement changes to improve patient care.In this article, we describe the role of national audit outcomes in the regulatory process and how providers can use national audits to inform both quality assurance and quality improvement processes, with two illustrative case studies. We discuss the ongoing challenges with using audit data in the regulatory process and how these could be addressed.

Negotiating with the tax auditor: Determinants of tax auditors' negotiation strategy choice and the effect on firms’ tax adjustments

Using a survey of tax auditors, we investigate which factors determine tax auditors' choice of negotiation strategies during tax audits and analyze the effect of their chosen strategy on audit outcomes. The results show that, compared to a cooperative auditor negotiation strategy, a competitive auditor negotiation strategy is associated with significantly higher additional assessed taxes. However, the competitive strategy is associated with a lower probability that the negotiation partners will reach an agreement. These findings indicate an advantage of combining competitive and cooperative tactics (i.e., using a “mixed strategy”). We find that although this mixed strategy does not lead to significantly fewer additional taxes, it results in a higher agreement probability. Moreover, we show that the probability of using a mixed strategy increases with audit expertise and time pressure, whereas the use of a competitive (cooperative) strategy increases with the availability of higher authority (the quality of the taxpayer's financial accounting system) and a perceived competitive (cooperative or mixed) negotiation strategy of the tax advisor. In sum, our study provides new insights into how firms' tax burden is affected by negotiations between tax auditors and firms' tax advisors. The way these negotiations affect firms' tax burden is relevant for both tax policy and firms.

O-068 Training of clinicians: How to do it and how to best evaluate it

Abstract Training of clinicians: How to do it and how to best evaluate it? Anis Feki, Tatjana Motrenko, Roy Farquharson Many countries within Europe and EU do not have a specific national agency that provides the necessary structure or governance for appropriate training in Reproductive Medicine (RM). Therefore, The European Society of Human Reproduction and Embryology (ESHRE) has been the responsible agency for accreditation of RM training alongside its sister organization, the European Board and College of Obstetrics and Gynaecology (EBCOG). Both of these organizations are ultimately responsible to and approved by the Union of European Medical Specialties (UEMS), which represents the European Union (EU) governing body for medical practitioners’ education. The Reproductive Medicine subspecialist is a specialist in basic obstetrics and gynecology who has undergone theoretical and practical training in the medical and surgical management of infertility, including assisted reproductive techniques (ART). In general, the comprehensive management of these problems includes both diagnostic and therapeutic procedures allied to continuous audit of outcome. The global aim is to improve the care of patients with disorders of reproductive function. To reach this target, both ESHRE and EBCOG put in place a program that starts with accreditation of training centers in obstetrics and gynecology and more specifically, specialist training centers in reproductive medicine. Fellows must have a structured program of a minimum of 2 years after completing their basic obstetrics and gynecology syllabus and/or obtaining EFOG European Fellow of Obstetrics and Gynecology) diploma for non-European basic training. When a training fellow in RM has completed their logbook, the fellow will finish by assessing an individual’s knowledge and skills by passing an exit-training exam called the EFRM (ESHRE-EBCOG Fellow in Reproductive Medicine) diploma. The success of and the need for such certification has led ESHRE to structure the training also for reproductive surgeons, embryologists, as well as nurses and midwives. In addition, several countries within the EU already have a national compulsory specialist accreditation system for RM training. Recent proposals by the EU Commission to build European reference networks across all specialties, including RM may require the recognition of ESHRE/EBCOG–accreditation as an appropriate entry point for consideration of diagnostic and other interventions. Encouraging subspecialists and centers to apply for training accreditation may well prove to be an increasingly attractive option as educational needs across Europe become integrated and formalized through UEMS. ESHRE holds the view that accredited centers/subspecialists for training are beacons of excellence that often go hand in hand with high-quality research.

Improving the safety and quality of end-of-life in an Australian private hospital setting: An audit of documented end-of-life care.

This study reviewed the audit outcomes of the documented end-of-life care in a private hospital against the Australian Commission on Safety and Quality in Health Care's five recommended processes of care (Essential Elements (EE) 1-5). A retrospective database review of deaths over a three-year period was undertaken. This was followed by a sequential medical record audit (n=100) to evaluate the end-of-life care documented in the three days preceding death. There were 997 deaths from 2015 to 2017. The audit found communication to family the patient was dying (91%) and to the patient (36%) (EE1); evidence of specialist referral (68%) (EE2); assessment of the ability to eat/drink in the last 72hours (86%) (EE3); advance care directives (13%) and hospital resuscitation plans (92%) (EE4); and response to patient or family concerns (100%) (EE5). Components of the processes of care of the Essential Elements need to be addressed to improve patient-centred communication and shared decision-making.

The birth trauma psychological therapy service: An audit of outcomes

Objective: To evaluate routinely collected service data from a ‘Birth Trauma’ psychology clinic integrated into maternity services, in order to review effectiveness for women with symptoms of Post-Traumatic Stress Disorder (PTSD) following childbirth.Background: Prevalence of PTSD after child-birth has been estimated to be around 3% for women meeting full diagnostic criteria and up to 9% for sub-threshold symptoms. This can occur even in response to deliveries considered to be medically straightforward. NICE guidelines (2018) recommend psychological therapy as a first line treatment for symptoms of PTSD.Methods: The sample included 114 women referred post-natally for psychological assessment and intervention following a traumatic birth experience. Measures were routinely administered as part of initial assessment (T1) and at completion of intervention (T2). Data from these measures were collated and analyzed using a series of paired sample t tests. Following assessment 101 women were taken on for psychological intervention and of these, 74 completed both T1 and T2 measures.Results: There were highly significant reductions across all measures of PTSD, anxiety and negative mood symptoms. The treatment effect sizes were very large. Mean total score on a measure of PTSD symptomatology was no longer clinically significant following interventions.Conclusion: This evaluation suggests an integrated Birth Trauma psychology clinic using a small number of contact sessions is a highly efficient and effective model of care for women experiencing symptoms of PTSD following childbirth.