The Active Risk Control (ARC) toolkit: A new approach to designing risk control interventions

Current practice in healthcare risk management is supported by many tools for risk assessment (understanding problems), but none for risk control (solving problems). The results: a failure to improve safety, and a waste of the investment made in risk assessment. The Active Risk Control (ARC) Toolkit, available for free, fills this void with a systematic, structured approach to risk control.     

Polygenetic-Risk Scores Related to Crystallin Metabolism Are Associated with Age-Related Cataract Formation and Interact with Hyperglycemia,Hypertension, Western-Style Diet,and Na Intake

Age-related cataract (ARC) development is associated with loss of crystalline lens transparency related to interactions between genetic and environmental factors. We hypothesized that polygenetic risk scores (PRS) of the selected genetic variants among the ARC-related genes might reveal significant genetic impacts on ARC risk, and the PRS might have gene–gene and gene–lifestyle interactions. We examined the hypothesis in 1972 and 39,095 subjects aged ≥50 years with and without ARC, respectively, in a large-scale hospital-based cohort study conducted from 2004 to 2013. Single nucleotide polymorphisms (SNPs) of the genes related to ARC risk were identified, and polygenetic risk scores (PRS) were generated based on the results of a generalized multifactor dimensionality reduction analysis. Lifestyle interactions with PRS were evaluated. The PRS derived from the best model included the following six SNPs related to crystallin metabolism: ULK4_rs1417380362, CRYAB_rs2070894, ACCN1_rs55785344, SSTR2_rs879419608, PTN_rs322348, and ICA1_rs200053781. The risk of ARC in the high-PRS group was 2.47-fold higher than in the low-PRS group after adjusting for confounders. Age, blood pressure, and glycemia interacted with PRS to influence the risk of ARC: the incidence of ARC was much higher in the elderly (≥65 years) and individuals with hypertension or hyperglycemia. The impact of PRS on ARC risk was greatest in middle-aged individuals with hypertension or hyperglycemia. Na, coffee, and a Western-style diet intake also interacted with PRS to influence ARC risk. ARC risk was higher in the high-PRS group than in the low-PRS group, and high Na intake, Western-style diet, and low coffee intake elevated its risk. In conclusion, ARC risk had a positive association with PRS related to crystallin metabolism. The genetic impact was greatest among those with high Na intake or hypertension. These results can be applied to precision nutrition interventions to prevent ARC.     

Rebalancing risk management—Part 1: The Process for Active Risk Control (PARC)

Risk assessment, by itself, does nothing to reduce risk or improve safety. It can only change outcomes by informing the design and management of effective risk control interventions. But current practice in healthcare risk management suffers from an almost complete lack of support for risk control. This first installment of a 2‐part series on rebalancing risk management describes a new framework to guide risk control practice: The Process for Active Risk Control.     

Using prospective hazard analysis to assess an active shooter emergency operations plan

Most risk management activity in the healthcare sector is retrospective, based on learning from experience. This is feasible where the risks are routine, but emergency operations plans (EOP) guide the response to events that are both high risk and rare. Under these circumstances, it is important to get the response right the first time, but learning from experience is usually not an option. This case study presents the rationale for taking a proactive approach to improving healthcare organizations' EOP. It demonstrates how the Prospective Hazard Analysis (PHA) Toolkit can drive organizational learning and argues that this toolkit may lead to more efficient improvement than drills and exercises.     

Epidemiological aspects of HTLV-III infection in Italy

An epidemiological survey on the presence of serum antibodies to human T lymphotropic retrovirus III (HTLV-III) is reported. The study was carried out on people living in large as well as small cities in different Italian regions. Serum samples of 21 patients with AIDS, 402 with ARCS, and 920 from individuals at risk for these diseases were analyzed. The percentage of positive sera varied from 81% in AIDS, to 100% –33.3% in ARC according to the different geographical areas and/or the various categories of people with ARC. The percentage of positive sera in individuals at risk for AIDS or ARC varied from 11.9% in homosexuals, to 21% in drug abusers and 23.1% in haemophiliacs. No positive sera were observed among 660 normal individuals, relatives of patients with AIDS or ARC and in 114 patients suffering from immunological or infectious disease and among people at risk living in small cities. Sera were also negative in patients with classical Kaposi's sarcoma or T-cell chronic lymphocytic leukemia. Since none of the 660 unselected normal adults were positive while a significant percentage of people at risk for AIDS showed antibodies to HTLV-III, we may presume that this infection is prevalent in the Italian categories in which AIDS and ARC are most likely to develop.Corresponding author.     

Margins of safety provided by COSHH Essentials and the ILO Chemical Control Toolkit

COSHH Essentials, developed by the UK Health and Safety Executive, and the Chemical Control Toolkit (Toolkit) proposed by the International Labor Organization, are 'control banding' approaches to workplace risk management intended for use by proprietors of small and medium-sized businesses. Both systems group chemical substances into hazard bands based on toxicological endpoint and potency. COSSH Essentials uses the European Union's Risk-phrases (R-phrases), whereas the Toolkit uses R-phrases and the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. Each hazard band is associated with a range of airborne concentrations, termed exposure bands, which are to be attained by the implementation of recommended control technologies. Here we analyze the margin of safety afforded by the systems and, for each hazard band, define the minimal margin as the ratio of the minimum airborne concentration that produced the toxicological endpoint of interest in experimental animals to the maximum concentration in workplace air permitted by the exposure band. We found that the minimal margins were always <100, with some ranging to <1, and inversely related to molecular weight. The Toolkit-GHS system generally produced margins equal to or larger than COSHH Essentials, suggesting that the Toolkit-GHS system is more protective of worker health. Although, these systems predict exposures comparable with current occupational exposure limits, we argue that the minimal margins are better indicators of health protection. Further, given the small margins observed, we feel it is important that revisions of these systems provide the exposure bands to users, so as to permit evaluation of control technology capture efficiency.     

Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National Home Care Assessment Database of Older Adults

ObjectivesEvaluate the influence of social factors on admission to aged residential care (ARC) facilities using a national comprehensive geriatric assessment database in New Zealand.DesignTime-to-event analysis of a continuously recruited national cohort.Participants and settingAn anonymized data extract from a large national database for home care assessments (June 2012–December 2015) was matched with data on mortality and admissions into ARC.MethodsFour key components of psychosocial risk in relation to ARC admission were used for analysis: living alone, negative social interactions, perceived loneliness, and carer stress. Exploratory data analysis was conducted for each of the variables of interest and demographics. Unadjusted and adjusted competing risk regressions were then performed with admission into ARC being the primary outcome, death the competing risk, and remaining at home the survival case.ResultsAfter data cleaning, matching, and applying exclusions, the study population consisted of 54,345 eligible participants. Mean age of participants was 81.9 years (standard deviation 7.4), 62.1% were female, and 88.7% identified as European ethnicity. In the adjusted model, all 4 social factors remained significantly associated with ARC admission, namely: living alone [subhazard ratio (SHR) = 1.43 95% confidence interval (CI) 1.37–1.50]; negative social interactions (SHR = 1.22, 95% CI 1.15–1.30); perceived loneliness (SHR = 1.18, 95% CI 1.13–1.24); and carer stress (SHR = 1.28, 95% CI 1.23–1.34).Conclusions and implicationsInterventions targeted at social factors in the context of delaying ARC admission merit further development and evaluation.     

Predictors of Residential Care Admission in Community-Dwelling Older People With Dementia

ObjectivesThe objectives of this study were to identify variables associated with dementia and entry into aged residential care (ARC) and derive and validate a risk prediction model for dementia and entry into ARC.DesignThis was an observational study of prospectively collected Home Care International Residential Assessment Instrument (interRAI-HC) assessment data.Setting and ParticipantsParticipants included all people age ≥65 years who had completed an interRAI-HC assessment between July 1, 2012 and June 30, 2018. Exclusion criteria included death or entry into ARC within 30 days of assessment and not living at home at the time of the assessment.MeasuresInterRAI data from 94,202 older New Zealanders were evaluated for presence or absence of dementia. A multivariable competing-risks model for entry into ARC with death as the competing event was used to estimate subdistribution hazard ratios (SHR).ResultsIn total, there were 18,672 (19.8%) persons with dementia (PWD). PWD were almost twice as likely to enter ARC as persons without dementia [42.8% vs 25.3%; difference 17.5% (95% confidence interval 16.7%‒18.2%)]. PWD at highest risk of entering ARC were those where there was a desire to live elsewhere (SHR 1.44), depression (indicated, SHR 1.15), poor cognitive performance (Cognitive Performance Scale minimal SHR 1.32 and severe plus SHR 1.91), and wandering (SHR 1.19). Factors associated with reduced risks of PWD entering ARC were living with a child or relative, alcohol consumption, and comorbidities.Conclusions and ImplicationsA desire to live elsewhere, social isolation, independent activities of daily living, and depression were independently associated with entry into ARC. Supporting caregivers may improve outcomes for PWD that delay entry into ARC. Future revisions of the interRAI questionnaire could provide more insight on this matter.     

Physician partnerships: The value of clinical effectiveness resource management

Once perceived as a hospital‐only process, risk management is now recognized as an important part of clinical decision‐making and hospital operations. The greatest opportunities exist where risk management programs can be integrated into the development and implementation of guidelines, protocols and order sets that encourage adherence to valid clinical evidence and reduce unwarranted clinical variation in patient care. The limiting factors in this approach are providing the data needed to demonstrate the need for change and engaging administrators and clinicians in the development and implementation of those changes. This article describes a process for the development of hospital‐specific data that can be used to evaluate the cost impact of various decisions about patterns of care — the Clinical Effectiveness Initiative? — in this case used to demonstrate the cost impact of a choice between two medications used to prevent and treat a common disorder, venous thrombosis. It also describes how this data can be used to engage clinicians and administrators in a partnership focused on improving outcomes and patient safety by considering the full complement of factors — clinical, operational and risk management‐related — that contribute to those costs and outcomes. This process is clinical effectiveness resource management.     

Identifying risks in the realm of enterprise risk management

An enterprise risk management (ERM) discipline is comprehensive and organization‐wide. The effectiveness of ERM is governed in part by the strength and breadth of its practices and processes. An essential element in decision making is a thorough process by which organizational risks and value opportunities can be identified. This article will offer identification techniques that go beyond those used in traditional risk management programs and demonstrate how these techniques can be used to identify risks and opportunity in the ERM environment.     

Aids in sicily: Prevalence of antibodies to human immunodeficiency virus (HIV) in low and high risk groups

A seroepidemiological survey, carried out to evaluate the prevalence of antibodies to HIV in patients with ARC and in healthy individuals at risk for AIDS, showed the infection to be widespread in the groups at risk, namely in drug abusers and hemophiliacs.However, remarkable difference existed between the prevalence of antibodies to HIV in drug abusers of the city of Palermo and those of other Sicilian provinces. Spread of the virus among Sicilian thalassemics, however, was very low and quite similar in all geographic areas. Antibodies were found very rarely (0.06)% in unpaid voluntary blood donors. The spread of the virus is still confined in high risk groups, and the major part of the seropositive blood donors were identified a posteriori as drug abusers.     

Sleep patterns in relation to dietary patterns and cardio‐metabolic risk: An update from Drummond Pump Priming Award recipients

This article provides an update on the project ‘Sleep patterns in relation to dietary patterns and cardio‐metabolic risk’, which received funding from the British Nutrition Foundation (BNF) Drummond Pump Priming Award. Studying the relationship between sleep, the biological clock, timing of eating and nutrition is part of a new research area termed chrono‐nutrition. With the help of the BNF award, a PhD project was set up to investigate the effects of sleep duration and quality on energy balance, dietary intake and quality, and cardio‐metabolic risk factors. The project included three studies: (1) a systematic review and meta‐analysis investigating whether partial sleep deprivation results in positive energy balance; (2) a cross‐sectional study exploring associations between energy balance, dietary intake and quality, chrono‐nutrition and cardio‐metabolic risk factors; and (3) a randomised controlled intervention feasibility study investigating whether sleep extension in participants with chronic mild sleep deprivation can improve energy balance, diet quality, body composition and cardio‐metabolic risk profile. The systematic review showed that partial sleep deprivation results in a net positive energy balance arising from a significantly higher energy intake of 385 kcal/day, with no compensatory effect on energy expenditure. Results from the cross‐sectional and randomised controlled feasibility studies are expected later this year. Overall, the project will help to establish whether sleep extension can be used in combination with existing weight management strategies to reduce the burden of obesity and metabolic dysregulation, which are major public health threats.     

Risks,dangers and competing clinical decisions on venous thromboembolism prophylaxis in hospital care

Drawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision‐making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in‐patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions about VTE risks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision‐making in four hospitals in one NHS region. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision‐making. The implementation of NICE guidelines for VTE prevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the new VTE risk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care.     

The factors associated with care‐related quality of life of adults with intellectual disabilities in England: implications for policy and practice

Over the last three decades, quality of life (QoL) has been advocated as an indicator of social care outcomes for adults with intellectual disabilities. In England, the Adult Social Care Survey (ASCS) is conducted annually by local authorities to contribute to the evidence base of the care‐related QoL of people receiving publicly funded adult social care. This study explores relationships between QoL and non‐care‐related factors to identify relationships that could inform social care policy and practice. Cross‐sectional data collected from 13,642 adults who participated in the 2011 and 2012 ASCS were analysed using regression to explore the factors associated with QoL measured using the Adult Social Care Outcomes Toolkit (ASCOT). Self‐rated health, rating of the suitability of home design and anxiety/depression were all found to be significantly associated with ASCOT. Other individual and survey completion factors were also found to have weak significant relationships with ASCOT. The models also indicate that there was an increase in overall ASCOT‐QoL and in five of the eight ASCOT domains (Personal comfort and cleanliness, Safety, Social participation, Occupation and Dignity) between 2011 and 2012. These findings demonstrate the potential value of QoL data for informing policy for people with intellectual disabilities by identifying key factors associated with QoL, the characteristics of those at risk of lower QoL, and QoL domains that could be targeted for improvement over time. Future research should establish causal relationships and explore the risk adjustment of scores to account for variation outside of the control of social care support.     

Co-morbidities as predictors of mortality in Clostridium difficile infection and derivation of the ARC predictive score

Clostridium difficile associated diarrhoea (CDAD) has increased significantly in the last 15 years, but predictors of outcome are inadequately understood. This was a cohort study of 2761 patients in North East England between 2002 and 2009, with the end-point of mortality at 30 days. The role of age, gender and co-morbidities was examined by binary logistic regression. Rounded odds ratios were used to develop a predictive score. A predictive score based on age, renal disease and cancer (ARC score) differentiated groups with differing risk of 30-day mortality (risk for score of 0-3 was 9-21%, score of 4-7 was 31-48% and score of 8 was 66%). Co-morbidities were shown to be important predictors of outcome in CDAD, and can be combined with age in the ARC score to assess the likelihood of survival. This requires further validation in other populations, but has important implications for clinical and research practice.     

Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy

The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration > 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance > 149 mL/min/1.73 m². Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%; p = 0.004), had traumatic brain injury (33% vs. 9%; p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12; p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years; p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL; p = 0.001) and were more catabolic (nitrogen balance of −10.8 ± 13.0 vs. −6.2 ± 9.2 g/d; p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.     

Nephrologists’ perspectives on ambulatory care of patients with non‐dialysis chronic kidney disease ‐ A qualitative study

Little is known on the perspectives of nephrologists on managing non‐dialysis patients with chronic kidney disease (CKD). The purpose of this qualitative study was to explore the experiences and perspectives of nephrologists regarding the interface with general practitioners (GP) and GPs’ management of patients with non‐dialysis CKD, so that barriers to cooperation and need for improved management can be identified. Twenty semi‐structured interviews were conducted for this qualitative study. The interviews were audio‐recorded and coded to be analysed. The concept of knowledge systems served as a sensitising concept. Optimising underlying diseases, medication adaptation and patient awareness of CKD were regarded as the most important treatment measures in CKD management. Differing views exist on who should be responsible for lifestyle interventions, patient education and timing of referral. Nephrologists generally preferred the referral of patients with high progression risk and co‐treatment models in which daily care was performed by GP, but some preferred referral of all patients with early CKD and some nephrologists stated that patient care should be in the hands of nephrologists entirely in case of CKD. Doctor–patient communication predominantly remained within the medical‐scientific knowledge system whereas patients’ everyday knowledge systems were rarely considered. While stressing optimisation of laboratory values, diabetes and hypertension, patients’ perspectives and shared decision‐making to identify and prioritise patients’ individual health goals were rarely considered by nephrologists. Instead, most nephrologists regarded educating patients and GPs as an important part of their professional role. Defining the interface between GPs and nephrologists, with specific recommendations on when to refer and which tasks each professional group should perform can lead to standardisation and improved interdisciplinary management of CKD patients. Addressing patients' everyday knowledge systems can be valuable in formulating and prioritising health goals with patients.     

体重指数及腰臀比与年龄相关白内障关系

[目的]探讨中老年人体重指数(BMI)、腰臀比(WHR)与年龄相关白内障(ARC)的关系。[方法]采取以医院为基础的病例对照研究。病例为因视力下降接受手术治疗,术后经病理证实为晶状体混浊的260例ARC患者,对照为因患其他非白内障及其他眼部疾病而入住与病例相同医院的同期患者260例。采用标准调查表对研究对象进行面对面调查,同时对身高、体重、腰围、臀围进行测量,并计算BMI及WHR。采用多元Logistic回归分析对研究对象的BMI、WHR与临床ARC的比值比(OR值)及其95%的可信区间(CI)进行估计。[结果]与正常体型者(男性WHR﹤0.9;女性﹤0.88)相比,向心性肥胖者(男性WHR≥0.9;女性及≥0.88)发生ARC的危险性增加(OR值分别为2.105和1.821,95%CI分别为1.796～3.238和1.483～2.845),二者间差异有统计学意义(P﹤0.05)。在调整了年龄和性别后,与正常BMI(18.50～23.99)者相比较,无论是超重(BMI24.0～27.99),还是肥胖(BMI≥28.00),发生ARC的危险性均明显升高(超重者OR=1.624,95%CI:1.025～1.986,P=0.015;肥胖者OR=1.745,95%CI:1.321～2.394,P=0.022),而体重过低者(BMI﹤18.50)发生ARC的危险性亦增加(OR=1.370,95%CI:1.103～1.684,P=0.017)。[结论]向心性肥胖是发生ARC的一个重要的危险因素,超重和肥胖的人群,发生ARC的危脸性明显增加,维持正常体重可能是ARC发病的保护因素。     

Troublesome times demand more effective practices

The intensifying financial pressures bearing down on the American government and taxpayers due to egregious corporate mismanagement will focus increasing and unprecedented scrutiny on the business world. The risk management community believes a paradigm shift is at hand. Organizations of every kind will feel pressure to do more than they have in the past to understand the risks they face, expose and challenge every assumption they make, and take steps to quantify and appropriately mitigate the exposures they identify. This will not be an easy transition. Just as the healthcare community has struggled over the past 25 years with the paradigm shift from the unsystematic clinical experience to a more analytical, evidence‐based approach, the corporate world will have to move from a traditional silo‐centric risk management system to a more formalized, analytical, enterprise‐wide risk management competency.     

Value‐driven ERM: Making ERM an engine for simultaneous value creation and value protection

Enterprise risk management (ERM) began as an effort to integrate the historically disparate silos of risk management in organizations. More recently, as recognition has grown of the need to cover the upside risks in value creation (financial and otherwise), organizations and practitioners have been searching for the means to do this. Existing tools such as heat maps and risk registers are not adequate for this task. Instead, a conceptually new value‐driven framework is needed to realize the promise of enterprise‐wide coverage of all risks, for both value protection and value creation. The methodology of decision analysis provides the means of capturing systemic, correlated, and value‐creation risks on the same basis as value protection risks and has been integrated into the value‐driven approach to ERM described in this article. Stanford Hospital and Clinics Risk Consulting and Strategic Decisions Group have been working to apply this value‐driven ERM at Stanford University Medical Center.