Variation In Clinical Practice Research Articles

Pregnancy outcomes after implementation of an induction of labor care pathway

BackgroundInduction of labor is common, however the optimum clinical strategy for induction is less clear. Variation in clinical practices related to labor induction may lead to increased complications and longer induction times. ObjectiveThe objective of this study was to analyze whether implementation of an evidence-based standardized care pathway improved clinical outcomes associated with induction of labor. Study DesignThis was an approved quality improvement project implementing a clinical care pathway for induction of labor. We conducted a retrospective cohort study of inductions for 5 months before (January through May 2018) and 14 months after pathway implementation (August 2018 through September 2019). The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. Secondary outcomes included chorioamnionitis, endometritis, NICU admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, NICU admissions, cesarean delivery, and postpartum hemorrhage). Pathway adherence was also analyzed. Outcomes were analyzed with two tailed t-tests for continuous data, and Fisher's Exact Test and Chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates. ResultsWe reviewed a total of 1,471 inductions, 392 before and 1,079 after pathway implementation. The pathway was associated with a non-significant reduction in time from admission to delivery by 1.2 hours (23.4 hours to 22.2 hours, p=0.08). There was a non-significant increase in time to cesarean delivery before (28.2 hours) and after protocol implementation (28.8 hours), p = 0.71. There was a significant decrease in time to delivery by 1.7 hours for vaginal deliveries, from 22.2 hours to 20.5 hours after protocol implementation, p = 0.02. There was a significant decrease in chorioamnionitis (12.5% to 6%, OR 0.44, 0.29-0.67), a significant decrease in endometritis (6.9% to 2.6%, OR 0.36, 0.2-0.65), and a significant decrease in composite unanticipated outcomes (56.9% to 36.6%, OR 0.46, 0.34-0.56) following pathway implementation. There were no significant differences in postpartum hemorrhage (7.9% to 6.1%, OR 0.76, 0.48-1.22), NICU admissions (18.1% to 14%, OR 0.74, 0.54-1.02) or cesarean deliveries (19.6% to 20.1%, OR 1.03, 0.76-1.4) following pathway implementation. Pathway adherence varied, ranging from 50% to 89%. ConclusionsIntroduction of a standardized induction of labor pathway is associated with a non-significant reduction in time from admission to delivery by 1.2 hours, and improved pregnancy outcomes including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.

Managing unwarranted variation in hospital care – findings from a regional audit in Norway

Background/AimThere has been increasing focus and research over the past decades on defining, identifying, visualizing and reducing unwarranted clinical variation in clinical practice. Both clinician-driven initiatives such as the US based “Choosing Wisely” campaign and the top-down driven “Evidence-based intervention programme (EBI)” launched by NHS UK to improve quality of care by reducing unnecessary interventions have shown marginal results. We present the findings from a mixed-methods audit performed to evaluate the compliance by senior hospital leaders of a new regional strategy to reduce unwarranted variation in outcomes and utilization rates.MethodsSeventy-five mid- to senior-division and department leaders from eight hospital trusts in South-Eastern Norway Regional Trust (HSO) were invited to participate in evaluating the response and compliance of the regional leadership strategy for reducing unwarranted variation in patient outcomes and service utilization rates.ResultsThe audit revealed that the aim of reducing unwanted variation was not clearly communicated by senior HSO management. There was varying use of data from the national quality registers and health atlases for quality improvement. One third of the clinical leaders reported a lack of scrutiny of their work and were insufficiently aware of the HSO’s top-management and the hospital’s Boards strategic expectations about the importance of reducing unwarranted variation in their hospital utilization.ConclusionsWe found that the strategic aim of reducing unwanted clinical variation was not clearly communicated by senior HSO management to hospital boards and senior management.The hospitals could benefit from a better understanding of causes of variation by strengthening their efforts to reduce unwarranted variation in utilization rates as a key element in improving health care quality and patient safety. The findings of the audit are relevant for other healthcare organizations trying to improve their quality and reduce unnecessary variation.

Results from Multisite Implementation of Electronic Health Record Tools for Clinical Pre-Test Probability of Pulmonary Embolism in the Emergency Department

Introduction: Use of validated risk stratification tools for work up of suspected pulmonary embolism (PE) is an endorsed recommendation of the American Society of Hematology and the American College of Emergency Physicians. Due to variations in clinical practice, electronic health record (EHR) systems, and medical provider trainings, the use, documentation, and implementation of these tools vary widely. Current processes do not allow for electronic capture and quality reporting at most institutions. Methods: We sought to design and implement clinical pre-test probability (PTP) tools at three large healthcare institutions for use in emergency departments (ED). At each site, a hematologist partnered with ED physician leadership and local information technology experts to design and implement PTP tools in clinical workflows. Overall, 38 EDs (high volume tertiary EDs and smaller regional EDs) located in the United States along the East Coast and Midwest regions were involved. A major goal of implementation was integration into clinical workflow and automatic documentation. After design and implementation, awareness and education of the new EHR tool was distributed electronically to ED providers. After implementation, use of PTP tools was analyzed between September 12, 2022 and January 11, 2023. PTP use was examined as percent of visits for which patients underwent CT pulmonary angiography (CTPA). Results: Each institution chose the 3 tier Wells' Score for implementation while one site designed an integrated Wells'/PERC or YEARS score calculator. Two sites implemented the tool as an optional flowsheet and one site implemented the tool as mandatory parameters within the orders for PE imaging studies. The mandatory tool could be bypassed with prespecified selections or if a D-dimer existed within 48 hours . Complete details of the site-specific implementation are shown in Table 1. Over the 4-month evaluation timeframe, there was a total of 270,214 ED encounters. Uptake and utilization of the PTP tools are shown in Table 2. Use of PTP was highest at the site with forced PTP documentation which ranged from 49-53% of ordered CTPAs, compared to Site 2 where use was 2-3%, and Site 1 where use ranged from 1-3%. At Site 1, use of PTP increased slightly over the study period with signs that PE yield on imaging was increasing as well (3.4% to 5.9%). At Site 2, PE yield on imaging was overall high (9-10%), and remained similar with similar use of PTP tools over the study period. Use of PTP and PE yield (6-8%) on imaging also remained similar throughout the study at Site 3. Conclusion: Forced use of PTP within the orders for CTPA led to the highest use of PTP (Site 3) but this did not result in meaningfully higher PE yield on CTPA compared to the other sites. PE yield at each site was at or above the 5% yield for PE on CTPA which has been previously reported. Given that PTP uptake was relatively stable over the measurement period at Site 2 and 3, this indicates the process had mostly stabilized and that other strategies are needed to improve uptake of PTP, reduce utilization of CTPA, and further increase yield on CTPA. Increasing PTP use and rising PE yield at Site 1 demonstrated ongoing potential for improvements past this study timeframe.

Prevalence of Axillary Artery Variants and Their Clinical Significance: A Scoping Review.

Axillary artery (AA) variants occurred quite commonly, presenting clinical implications. A literature search yielded 523 resultsfrom which 13 parameters were extracted. Some of the AA variants found were the fusion of two or more branches into common trunks, like the fusion of anterior and posterior circumflex humeral arteries. Moreover, several branches were found to emerge from different points than expected, like the lateral thoracic artery's origin from the subscapular artery instead of the second part of the AA. The importance of the knowledge of the AA variations in clinical practice is undeniable and very useful when planning interventional procedures, as in the case of AA aneurysm treatment or in cases of fracture of the surgical neck of the humerus. The heterogeneity of data limited the possibility of a quantitative summary of data. Therefore, a more systemic study of AA variants based on the origin, course, and branching pattern is suggested. The aim of the current review is to summarize current data literatureregarding the AA typical anatomy and its variants, with a focus on their prevalence and possible clinical implications.

Multidisciplinary Management of Phyllodes Tumours and Breast Sarcoma: A Cross-sectional Survey of Clinical Practice across the UK and Ireland

AimsPhyllodes tumours and breast sarcomas are uncommon tumours and their rarity poses significant challenges in diagnosis and management. This cross-sectional study was conducted to evaluate the multidisciplinary clinical practice for these tumours across the UK and Ireland, with the aim of identifying gaps in knowledge and providing direction for establishing national guidelines. Materials and methodsAn international survey was adapted and circulated to breast and/or sarcoma surgeons and oncologists in the UK and Ireland through national organisations. Multidisciplinary team (MDT) responses were analysed anonymously. ResultsTwenty-eight MDTs participated in this study, predominately from high-volume units (85.5%). Although only 43% of the surveyed units were part of a trust that holds a sarcoma MDT, 68% of units managed malignant phyllodes and angiosarcoma, whereas 64.5% managed soft-tissue sarcoma of the breast. Across all subtypes, axillary surgery was recommended by 14–21% of the MDTs and the most recommended resection margins for breast surgery were ‘no tumour on ink’ in benign phyllodes (39%) and 10 mm in the remaining subtypes (25–29%). Immediate breast reconstruction was supported by 11–18% of MDTs for breast sarcoma subtypes, whereas 36% and 32% advocated this approach in benign and borderline phyllodes tumours, respectively. Adjuvant radiotherapy and chemotherapy were recommended by up to 29% and 11% of the MDTs, respectively. ConclusionThe results of this study demonstrate a wide variation in clinical practice across the surveyed MDTs. As only 28 MDTs participated in our study, with under-representation from low-volume units, our results might be an underestimation of the variability in practice across the UK and Ireland. This multi-institutional study sheds light on controversial aspects in the management of phyllodes tumours and breast sarcoma, identifies the need for national guidelines to inform best practice, and calls for the centralisation of the management of breast sarcoma within specialist centres.

Child-to-adult transition: a survey of current practices within the European Reference Network for Rare Neurological Diseases (ERN-RND).

Transition from child-centered to adult-centered healthcare is a gradual process that addresses the medical, psychological, and educational needs of young people in the management of their autonomy in making decisions about their health and their future clinical assistance. This transfer is challenging across all chronic diseases but can be particularly arduous in rare neurological conditions. To describe the current practice on the transition process for young patients in centers participating in the European Reference Network for Rare Neurological Diseases (ERN-RND). Members of the ERN-RND working group developed a questionnaire considering child-to-adult transition issues and procedures in current clinical practice. The questionnaire included 20 questions and was sent to members of the health care providers (HCPs) participating in the network. Twenty ERN-RND members (75% adult neurologists; 25% pediatricians; 5% nurses or study coordinators) responded to the survey, representing 10 European countries. Transition usually occurs between 16 and 18years of age, but 55% of pediatric HCPs continue to care for their patients until they reach 40years of age or older. In 5/20 ERN-RND centers, a standardized procedure managing transition is currently adopted, whereas in the remaining centers, the transition from youth to adult service is usually assisted by pediatricians as part of their clinical practice. This survey demonstrated significant variations in clinical practice between different centers within the ERN-RND network. It provided valuable data on existing transition programs and highlighted key challenges in managing transitions for patients with rare neurological disorders.

Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes

Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC. In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations. Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation. Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.

Regional Variation in the Clinical Practice and Prognosis in Patients With Heart Failure With Reduced Ejection Fraction in Japan - A Report From the Japanese Registry of Acute Decompensated Heart Failure (JROADHF).

The present study aimed to clarify the regional variations in clinical practice and the prognosis of patients with heart failure with reduced ejection fraction (HFrEF) in Japan using the Japanese Registry of Acute Decompensated Heart Failure (JROADHF). We recruited data of hospitalized patients with HFrEF (n=4,329) from the JROADHF. The patients were divided into 6 groups based on the region of Japan where they were hospitalized: Hokkaido-Tohoku (n=504), Kanto (n=958), Chubu (n=779), Kinki (n=902), Chugoku-Shikoku (n=446), and Kyushu (n=740). We compared the patients' characteristics, including etiology of HF and prognosis after discharge. The age of the patients was lowest in the Kanto and Kinki regions. In contrast, there were no differences in the prevalence of comorbidities, levels of B-type natriuretic peptide, or left ventricular EF among the 6 groups. Post-discharge cardiospecific prognosis, specifically, the composite of cardiac death or HF hospitalization, cardiac death, and HF hospitalization, was comparable among the 6 regions. There were no differences in cardiospecific prognosis in patients with HFrEF among the 6 regions in Japan.

Remdesivir Reduced Mortality in Immunocompromised Patients Hospitalized for COVID-19 Across Variant Waves: Findings From Routine Clinical Practice.

Immunocompromised patients are at high risk of severe coronavirus disease 2019 (COVID-19) and death, yet treatment strategies for immunocompromised patients hospitalized for COVID-19 reflect variations in clinical practice. In this comparative effectiveness study, we investigated the effect of remdesivir treatment on inpatient mortality among immunocompromised patients hospitalized for COVID-19 across all variants of concern (VOC) periods. Data for immunocompromised patients hospitalized for COVID-19 between December 2020 and April 2022 were extracted from the US PINC AITM Healthcare Database. Patients who received remdesivir within 2 days of hospitalization were matched 1:1 using propensity score matching to patients who did not receive remdesivir. Additional matching criteria included admission month, age group, and hospital. Cox proportional hazards models were used to examine the effect of remdesivir on risk of 14- and 28-day mortality during VOC periods. A total of 19 184 remdesivir patients were matched to 11 213 non-remdesivir patients. Overall, 11.1% and 17.7% of remdesivir patients died within 14 and 28 days, respectively, compared with 15.4% and 22.4% of non-remdesivir patients. Remdesivir was associated with a reduction in mortality at 14 (hazard ratio [HR], 0.70; 95% confidence interval, .62-.78) and 28 days (HR, 0.75; 95% CI, .68-.83). The survival benefit remained significant during the pre-Delta, Delta, and Omicron periods. Prompt initiation of remdesivir in immunocompromised patients hospitalized for COVID-19 is associated with significant survival benefit across all variant waves. These findings provide much-needed evidence relating to the effectiveness of a foundational treatment for hospitalized COVID-19 patients among a high-risk population.

Establishing a regional registry for neonatal encephalopathy: impact on identification of gaps in practice.

Neonatal encephalopathy (NE) continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of a malpractice insurance patient safety organization. A NE registry was also established to include 14 centers representing around 50% of deliveries in the state of Massachusetts. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects. This manuscript reports on the establishment of the registry and the primary findings to date. From 2018 to 2020, 502 newborns with NE were evaluated for Therapeutic Hypothermia (TH), of which 246 (49%) received TH, representing a mean of 2.91 per 1000 live births. The study reports on prenatal characteristics, delivery room resuscitation, TH eligibility screening, and post-natal management of newborns with NE who did and did not receive TH. The registry has allowed for the identification of areas of variation in clinical practices, which have guided ongoing quality improvement projects. The authors advocate for the establishment of local and regional registries to standardize and improve NE patient care. They have made the registry data collection tools freely available for other centers to replicate this work. Malpractice insurance companies can take an active role in supporting clinicians in establishing clinical practice guidelines and regional registries. Establishing a collaborative regional neonatal encephalopathy (NE) registry is feasible. Data Collection tools for a NE registry have been made publicly available to be adopted and replicated by other groups. Establishing a regional NE registry allowed for the identification of gaps in knowledge, variations in practice, and the opportunity to advance care through quality improvement projects.

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

DP01 Survey on the management of dysplastic naevus

Abstract Although dysplastic naevus (DN) is a frequent diagnosis, there is significant controversy on its definition and gradation and its relationship to melanoma risk. Therefore, there is no consensus over optimal management, and surveys from Australia, Canada and the USA have shown variation in clinical practice. Dysplastic naevus with involved histological margins has not been shown to progress to melanoma. To assess UK management of DN depending on the grade of atypia and reported excision margin, we circulated a questionnaire via email to dermatologists in Scotland, north Wales, Liverpool and Manchester. Seventy-two responded, of whom 46 (64%) were consultants. The cohort was generally highly experienced, with 10 (14%) responders with 1–5 years’ dermatology experience, 15 (21%) with 6–10 years, 27 (37%) with 11–20 years and 20 (28%) with > 20 years’ experience. Management of DN varied greatly. For mild DN excised with < 1-mm margin, 59 (82%) agreed that no further management was required. Opinions were divided when margins were involved in mild DN, with 14 (19%) agreeing that no further management was required, 42 (58%) choosing to re-excise and six (8%) to re-excising only any residual pigmentation. Most dermatologists reassured patients with moderately DN with margins < 1 mm (49, 68%); 18 (25%) preferred to re-excise. For moderate DN with involved margins, six respondents (8%) felt that no further management was necessary and 54 (75%) would re-excise. For severe DN with margins > 1 mm, 16 (22%) would still re-excise and six (8%) would agree management in the multidisciplinary team meeting (MDT). For severe DN with margins < 1 mm, 41 (57%) would re-excise and seven (10%) would agree management in the MDT. Lastly, for severe DN with involved margins, 62 (86%) would re-excise and seven (10%) would agree management in the MDT. This study has shown comparable results with those from Australia and the USA, whereby most dermatologists would re-excise moderate and severe DN with involved margins. Significant numbers indicated that they would re-excise in the case of close histological margins: this is unnecessary, and more standardized management may reduce expenditure. Limitations of the study include the usual potential sources of bias in a questionnaire survey; it should be noted that reported behaviour may differ from actual practice. However, this is the first UK study on this common clinical scenario. The move to report DN as low- or high-grade may help to reduce variation, but our survey suggests that some patients are currently undergoing unnecessary procedures.

Independent Validation of a Unifying Prognostic Model for Intracranial and Extracranial Metastasis-directed Radiotherapy.

The aim of this study was to analyze the validity of a unifying prognostic model, originally developed by Kowalchuk et al., because relevant variations in clinical practice and observed survival may impact on the performance of predictive tools. Retrospectively, data from a single institution were analyzed. The study included 253 patients managed with radiotherapy for spine and/or brain metastases. The Kowalchuk et al. score [3 parameters including performance status, number of organ systems involved with disease outside of the organ system of the treatment target, and treatment of intracranial target(s)] was assigned and the resulting prognostic strata compared. The decision tool developed by Kowalchuk et al. performed well, e.g., in terms of 2-year survival. Complementary information could be obtained by analyses of blood test results such as hemoglobin, albumin, and C-reactive protein. The new unifying score emerged as a valid prognostic model in our external validation database.

Variation in Hemodynamic Assessment and Interpretation: A Call to Standardize the Right Heart Catheterization

BackgroundInvasive hemodynamic measurement via right heart catheterization has shown divergent data in its role in the treatment of patients with heart failure (HF) and cardiogenic shock. We hypothesized that variation in data acquisition technique and interpretation might contribute to these observations. We sought to assess differences in hemodynamic acquisition and interpretation by operator subspecialty as well as level of experience. Methods and ResultsIndividual-level responses to how physicians both collect and interpret hemodynamic data at the time of right heart catheterization was solicited via a survey distributed to international professional societies in HF and interventional cardiology. Data were stratified both by operator subspecialty (HF specialists or interventional cardiologists [IC]) and operator experience (early career [≤10 years from training] or late career [>10 years from training]) to determine variations in clinical practice. For the sensitivity analysis, we also look at differences in each subgroup. A total of 261 responses were received. There were 141 clinicians (52%) who self-identified as HF specialists, 99 (38%) identified as IC, and 20 (8%) identified as other. There were 142 early career providers (54%) and late career providers (119 [46%]). When recording hemodynamic values, there was considerable variation in practice patterns, regardless of subspecialty or level of experience for the majority of the intracardiac variables. There was no agreement or mild agreement among HF and IC as to when to record right atrial pressures or pulmonary capillary wedge pressures. HF cardiologists were more likely to routinely measure both Fick and thermodilution cardiac output compared with IC (51% vs 29%, P < .001), something mirrored in early career vs later career cardiologists. ConclusionsSignificant variation exists between the acquisition and interpretation of right heart catheterization measurements between HF and IC, as well as those early and late in their careers. With the growth of the heart team approach to management of patients in cardiogenic shock, standardization of both assessment and management practices is needed.

P-285 Analysis, including morphokinetic data, of IVF/ICSI cycles with oocytes containing aggregates of smooth endoplasmic reticulum (SER)

Abstract Study question Is there a difference in ART outcomes and morphokinetic parameters for SER+ and SER- cycles and oocytes? Summary answer Fertilisation and blastulation rates are lower in the SER+ group but no difference was seen in pregnancy or live birth rates. What is known already The SER is an organelle found in eukaryotic cells, including oocytes. SERs synthesize lipids and steroids, and store and metabolise calcium ions, needed for fertilization and early embryonic development. SERs can aggregate in the oocyte, forming an intracytoplasmic dimorphism, thought to interfere with reproductive outcomes. It is suggested that SER aggregates in an oocyte may negatively effect embryo development and implantation. Oocytes without SERs, but which arise from the same oocyte cohort as SER+ oocytes may also affect outcomes. Evidence around the safety and use of these SER+ and SER- oocytes is conflicting, with widespread variations in clinical practice. Study design, size, duration A retrospective review was conducted of all IVF/ICSI[MW1] cycles between January 2019 and December 2020 at Merrion Fertility Clinic, Dublin. Cycles containing SER+ oocytes were identified, and their outcomes were compared with those of a matched control group of SER- cycles. Within the SER+ group, results were compared for SER+ and SER- oocytes within the same cohort. Participants/materials, setting, methods Once participants had been identified, a chart review was undertaken noting demographics, IVF protocol used, duration of stimulation, ART and neonatal outcomes and morphokinetic parameters in the embryoscope. Statistical analysis was performed using PRISM. Main results and the role of chance There were 77 SER+ cycles with a total of 135 SER+ oocytes and 645 SER- oocytes, accounting for 8% of total cycles for the study period. These were matched to 64 control cycles with 528 SER- oocytes. 12 embryo transfers occured using blastocysts derived from SER+ oocytes. SER+ cycles had a higher mean oocyte number than controls (9.3 vs 7.3) and 92% of oocytes were mature compared to 88% of the control group. Fertilisation rates were significantly lower in the study group (60% SER+cycle; 68% in SER-cycle), related to the SER+ oocytes in that cohort. Good/top quality blastocyst rates differed (SER+ cycle 28%, SER- cycle 36%) but pregnancy(SER+ cycle 53%, SER- cycle 51%) and livebirth (SER+31%, SER- 32% ) rates were similar, even when blastocysts derived from SER+ oocytes were transferred. 5 morphokinetic variables were studied – time to 2-cell (t2), 3 cell (t3) 4 cell (t4), 5 cell (t5) and time to blastulation (tB). T5 appears to be shorter in embryos derived from SER+ oocytes than in controls, with the other parameters being comparable. In terms of neonatal outcomes there were no congenital malformations reported in the SER+ groups and one case of upper limb amelia in the control group. Limitations, reasons for caution This study is limited by its retrospective nature. We only have embryoscope data on 46 out of 77 patients with SERs, limiting numbers. Embryos transferred which derived from SER+ve oocytes were limited by the clinic policy to only transfer these embryos if no other embryos available. PGT was not performed. Wider implications of the findings This preliminary study shows that, while SER+ cycles have lower fertilisation rates than SER- cycles, pregnancy rates and live birth rates are comparable. Neonatal outcomes are reassuring. Initial analysis of morphokinetic data shows little effect. Larger numbers and further analysis are needed to fully understand the importance of these aggregates. Trial registration number n/a

Facilitators and barriers of appropriate and timely initial fluid administration in sepsis: A qualitative study

BackgroundSepsis is a medical emergency requiring prompt recognition, and early administration of intravenous fluids and antibiotics. While compliance with appropriate and timely administration of intravenous fluids has been found to be poor, the reasons are not well understood. Therefore, we have explored the experiences and perceptions of emergency nurses and medical officers from four hospitals to identify the associated facilitators and barriers. MethodsQualitative design incorporating six focus group discussions and thematic analysis of data. A hybrid approach using both inductive and deductive reasoning was used. FindingsFour key themes were developed: 1. Overcrowding and understaffing threaten appropriate fluid management in sepsis; 2. Variations in clinical practice results in suboptimal fluid management; 3. Challenges with clinical recognition of sepsis impedes timely fluid administration; 4. Top-down approach is necessary to improve fluid management. ConclusionThemes highlighted the specific challenges associated with fluid administration in sepsis in the emergency department setting providing potential strategies to be implemented to improve practice and ultimately patient outcomes.

Perceived barriers to a career in pain medicine in the Republic of Ireland.

As the population ages, musculoskeletal disorders are a prominent contributory factor to loss of mobility and autonomy. Pain is a predictor of disability and worsening frailty and the role of the chronic pain specialist in the management of this cohort cannot be overstated. With growing requirements for pain specialists, we sought to identify barriers to recruitment within this specialty. Establish baseline attitudes and perceived barriers towards a career in pain medicine among Irish anaesthesiology trainees. Suggest a framework to improve recruitment to the specialty. Ethical approval was obtained. A web-based questionnaire was sent to all anaesthesiologists in training in the Republic of Ireland. Data was analyzed using SPSS. Two hundred forty-eight trainees received the questionnaire, 59 responded. 54.2% male, 45.8% female. 79.7% had previous clinical exposure to pain medicine, most of whom had spent over one month with a service. Only 10.2% of respondents were considering a career in pain medicine. Factors that attracted trainees to the subspeciality included: interventional practice (81%), variation in clinical practice (66.7%), autonomy of practice (61.9%) and perceived good work-life balance (42.9%). Deterrents from the subspecialty included a psychologically challenging patient cohort (69.5%), frequency of clinics (50.8%), and additional exams (32.2%). When asked how to improve engagement with the speciality, 62% suggested earlier exposure to the speciality and 32.2% suggested increased frequency of formal teaching and workshops. Increased exposure of trainees to the specialty during early stages of training may improve future recruitment to the subspecialty in Ireland.

Discontinuation of contraception in perimenopausal women – variations in clinical practice

Discontinuation of contraception in perimenopausal women – variations in clinical practice

Timing of Kidney Replacement Therapy among Children and Young Adults.

No randomized trials exist to guide the timing of the initiation of KRT in children. We sought to define trends and predictors of the eGFR at initiation of KRT, center-related clinical practice variation, and any association with patient survival. Children and young adults (1-25 years) commencing KRT (dialysis or kidney transplantation) between 1995 and 2018 were included using data from the Australia and New Zealand Dialysis and Transplant Registry. The associations between eGFR on commencing KRT and covariates were estimated using quantile regression. Cox regression was used to estimate the association between eGFR and patient survival. Logistic regression, categorizing eGFR about a value of 10 ml/min per 1.73 m 2 , was used in conjunction with a random effect by center to quantify clinical practice variation. Overall, 2274 participants were included. The median eGFR at KRT initiation increased from 7 to 9 ml/min per 1.73 m 2 over the study period and the 90th centile from 11 to 17 ml/min per 1.73 m 2 . The effect of era on median eGFR was modified by modality, with a greater increase among those receiving a preemptive kidney transplant (1.0 ml/min per 1.73 m 2 per 5 years; 95% confidence interval [CI], 0.6 to 1.5) or peritoneal dialysis (0.7 ml/min per 1.73 m 2 per 5 years; 95% CI, 0.4 to 0.9) compared with hemodialysis (0.1 ml/min per 1.73 m 2 per 5 years; 95% CI, -0.1 to 0.3). There were 252 deaths (median follow-up 8.5 years, interquartile range 3.7-14.2) and no association between eGFR and survival (hazard ratio, 1.01 per ml/min per 1.73 m 2 ; 95% CI, 0.98 to 1.04). Center variation explained 6% of the total variance in the odds of initiating KRT earlier. This rose to over 10% when comparing pediatric centers alone. Children and young adults progressively commenced KRT earlier. This change was more pronounced for children starting peritoneal dialysis or receiving a preemptive kidney transplant. Earlier initiation of KRT was not associated with any difference in patient survival. A substantial proportion of clinical practice variation was due to center variation alone. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_08_08_CJN0000000000000204.mp3.

ID: 208462 Medial Branch Radiofrequency Denervation Improves Pain, Quality-of-Life, and Disability in Patients With Chronic Spinal Pain

Facet joints are clinically important spinal pain generators in 15%-45% of patients with chronic low back pain, 48% with thoracic pain, and 54%-67% with chronic neck pain.1 Radiofrequency (RF) denervation is a minimally invasive procedure that conventionally uses heat generated by radio waves to target peripheral nerves; specifically, the medial branches of the dorsal rami for facetogenic pain. The benefit of RF procedures in the management of chronic low back pain has recently been questioned.2 Broad variations in clinical practice, however, underlined the need for standardization.3 The aim of this abstract is to affirm the role of these techniques in managing chronic spinal pain.