Challenges of customizing electrocardiography alarms in intensive care units: A mixed methods study

Background

Customizing monitor alarm settings to individual patients can reduce alarm fatigue in intensive care units (ICUs), but has not been widely studied.

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers

Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.     

HIV Testing and Care in Canadian Aboriginal Youth: A community based mixed methods study

Background  

HIV infection is a serious concern in the Canadian Aboriginal population, particularly among youth; however, there is limited attention to this issue in research literature. The purpose of this national study was to explore HIV testing and care decisions of Canadian Aboriginal youth.     

Exploring the effect of the hospital gown on wellbeing: a mixed methods study

BackgroundThe importance of personalised and dignified care is increasingly being recognised in health-care policy and practice. Despite the known effect of clothing on social identity, few studies have considered the effect of hospital clothing on patient wellbeing. Although clothing can empower the wearer, it can also induce psychological distress, feelings of disempowerment, and lowered self-esteem. Despite drives to empower patients with person centred health-care provisions, the institutionalised acceptance of the hospital gown persists. Research has yet to explore the effect of wearing the hospital gown on patients’ wellbeing.MethodsRecruitment for both studies commenced on Nov 1, 2018 and ended on the Aug 31, 2019. Two studies were carried out to consider the effect of the hospital gown on wellbeing of adults with and without chronic health conditions. The first study consisted of doing in-depth, semi-structured interviews with adults living with life-long chronic health conditions, which were audio recorded and transcribed, and thematic analysis was used to identify themes from the qualitative data. The second study was a cross-sectional, online survey exploring adults’ views and experiences of wearing the hospital gown. Ethical approval was sought and granted from the Psychological Sciences in Health Ethics Committee.FindingsTen people participated in the interviews. 928 people completed the survey, aged 18–80 years (mean age 43 [SD 12]). Participants were predominantly female (79%), white, living in the UK (86%), with 46% identifying as having a long-term health condition. Qualitative analysis identified the four master themes: loss of healthy identity; symbolic embodiment of the sick role; relinquishing control to medical professionals; and vulnerability, disempowerment, and embarrassment. Quantitative analysis of the online survey data indicated that 542 (58%) of 928 adults reported wearing the hospital gown despite feeling uncertain that it was a medical necessity. The gown's design was considered to be not fit for purpose, with 573 (61%) of 928 adults reporting that they struggled to put it on or required assistance, and 623 (67%) of 928 reported that they did not think that the gown fitted them. From the 928 adults, 670 reported feeling exposed (72%), 554 (60%) felt self-conscious, and 530 (57%) felt uncomfortable while wearing the hospital gown.InterpretationThese findings suggest that hospital gowns might contribute towards patients experiencing an increased sense of exposure, discomfort, disempowerment, and embarrassment at a time of potential vulnerability while undergoing medical intervention, emphasising the importance of challenging cultural norms in health care. Dehumanising aspects of care, as symbolically represented by the hospital gown, might adversely affect patient wellbeing and increase distress.FundingNone.     

Children on losing end of access to new drugs

Only five of the fourteen approved AIDS drugs have been tested in children, and there are no approved protease inhibitors for pediatric use. Eighty percent of the drugs on the market have never been tested in children. As a result, physicians are forced to prescribe AIDS medication for off-label use. Further development of pediatric AIDS drugs has decreased, largely due to the effectiveness of AZT in preventing perinatal transmission. A proposed White House rule would require pharmaceutical companies to test more drugs in children and to submit pediatric test data to the Food and Drug Administration (FDA) at the same time or shortly after a drug is approved for adults. The AIDS Policy Center and other groups are concerned that loopholes in the proposal will give manufacturers a way to avoid pediatric testing. The International Association for Physicians in AIDS Care (IAPAC) has launched a demonstration project in several States that will work to create resources and structures to provide HIV-positive children with access to all HIV drugs within three years. In 1998, the group will meet with drug companies, clinicians, and government health officials to set an agenda for pediatric HIV treatment research and to develop a pediatric HIV mentor program. Four areas for pediatric research improvement are cited: develop drug formulations, undertake combination therapy clinical trials, distribute pediatric treatment information to clinicians, and guarantee access to approved drugs, regardless of ability to pay.     

Cancer risk in primary biliary cirrhosis: a study in northern England

BACKGROUND: Suggestions that breast cancer may be more common in patients with primary biliary cirrhosis (PBC) have been challenged. It has recently been proposed that total cancer rates may be higher in patients with PBC, as well as liver cancers. AIMS: To investigate these proposals on a strictly defined case series. SUBJECTS: A total of 769 prevalent or incident PBC patients with "definite" or "probable" disease detected in a defined area of the north-east of England during 1987-94. METHODS: Cancer events and deaths were identified by obtaining information from one or more of the following sources: Office for National Statistics (ONS) Central Registers, Regional Cancer Registry, and clinical case records. Standardised cancer incidence (SIR) and mortality ratios (SMR) were calculated using the local region as the standard population. RESULTS: There were 97 cancer events during 1987-96. SIR from cancer registrations for all cancers was 1.7 (95% confidence interval (CI) 1.3 to 2.2), for liver cancer was 74 (95% CI 32 to 146), and for breast cancer was 1.1 (95% CI 0.4 to 2.4). SMR for all cancers was 1. 8 (95% CI 1.4 to 2.4), for liver cancer was 39 (95% CI 20 to 68), and for breast cancer was 0.4 (95% 0.1 to 1.6). The results were similar after excluding the first year of follow up after PBC diagnosis. CONCLUSIONS: There was some evidence of a small increase in overall cancer incidence and mortality in PBC patients. With the exception of liver cancer, it is unlikely that there is a high excess incidence for PBC patients from any cancer at a particular site, and specifically breast cancer.     

Delays in lung cancer management pathways between rural and urban patients in North Queensland: a mixed methods study

Background

Despite advances in medical therapies, disparity in outcome between rural and urban patients remain in Australia and many Western countries.

Aims

To examine time delays in lung cancer referral pathways in North Queensland (NQ), Australia, and explore patients’ perspective of factors causing these delays.

Methods

Prospective study of patients attending three cancer centres in Townsville, Cairns and Mackay in NQ from 2009 to 2012. Times along referral pathway were divided as follows: Onset of symptoms to treatment (T1), symptoms to general practitioner (GP) (T2), GP to specialist (T3) and Specialist to treatment (T4). Quantitative and qualitative methods were used for analysis.

Results

In total, 252 patients were participated. T1 was influenced by remoteness (125 days in Townsville vs 170 days for remote, P = 0.01), T2 by level of education (91 days for primary education vs 61 days for secondary vs 23 days for tertiary/Technical and Further Education (TAFE), P = 0.006), and age group (14 days for 31–50 years, 61 days for 51–70 years, 45 days for >71 years, P = 0.026), T3 by remoteness (15 days for Townville and 29.5 days for remote, P = 0.02) and T4 by stage of disease (21 days for Stage I, 11 days for Stage II, 34 days for Stage III 18 days for Stage IV, P = 0.041). Competing priorities of family and work and cost and inconvenience of travel were perceived as rural barriers.

Conclusion

Remoteness, age and level of education were related to delays in various time lines in lung cancer referral pathways in NQ. Provision of specialist services closer to home may decrease delays by alleviating burden of cost and inconvenience of travel.     

Experiences of adult extracorporeal membrane oxygenation patients following discharge: A mixed methods study

BackgroundSurvival and discharge rates after extracorporeal membrane oxygenation are gradually increasing. More research is warranted to investigate extracorporeal membrane oxygenation patients’ post-discharge experiences, problems and quality of life.ObjectiveThe aim of this study was to determine adult extracorporeal membrane oxygenation patients’ experiences, problems and quality of life following discharge.MethodsA mixed methods research was used. Study sample consisted of 11 adult extracorporeal membrane oxygenation patients discharged at least one month prior to study entry. In-depth interviews were conducted. Participants' quality of life was assessed using the EuroQol 5 Dimension 5 Level questionnaire.ResultsTwo categories (pre- and post-discharge), 7 themes and 16 sub-themes were developed based on in-depth interviews. According to the EuroQol 5 Dimension 5 Level, participants had high perceptions of health.ConclusionExtracorporeal membrane oxygenation patients should be provided with comprehensive post-discharge education, exercise programs, social support and regular home visits for post-discharge assessment and follow-up care.     

Pancreatic cancer incidence and survival and the role of specialist centres in resection rates in England, 2000 to 2014: A population-based study

BackgroundThe aim was to compare population-based survival for exocrine pancreatic cancer in England in the 23 regions covered by specialist centres. The centres were initiated in 2001, covering populations of 2–4 million.MethodsWe examined incidence for adults diagnosed with a pancreatic exocrine cancer during 1995–2014 and age-standardised net survival up to five years after diagnosis for patients diagnosed during 2000–2013. We examined variation in regional resection rates and survival for patients diagnosed during 2010–2013. The data were extracted from the National Cancer Registration and Analysis Service.ResultsAge-standardised annual incidence rates of exocrine pancreatic cancer increased from 17.1 per 100,000 during 1995–1999 to 18.7 during 2010–2014. Age-standardised one-year and five-year net survival increased from 17.9% and 3.6%, respectively, for 2000–2009, to 21.6% and 4.2% during 2010–2013. There were 2086 (8.9%) resections among 23,415 patients diagnosed with an exocrine tumour in 2010–2013. The proportion ranged from 5.1% to 19.6% between centres. Among resected patients, survival was 73.0% at one year and 20.2% at five years. Of the total 2118 resected patients, 18 (0.9%) were at stage 1; 34 (1.6%) at stage 2; 791 (37.3%) at stage 3 and 140 (6.6%) at stage 4, although 53.6% of stage information was missing. Five-year survival was 2.1% for those who were not resected. The number of resections performed in each centre was not correlated with one-year survival.ConclusionsDespite improvements in the management of pancreatic cancer in England with the introduction of specialist centres, resection rates remain relatively low, and survival remains lower than in comparably wealthy countries.     

Reducing overuse of antibiotics at discharge home: A single-center mixed methods pilot study

BackgroundAntibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge.MethodsFrom May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (eg, duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre versus postintervention antibiotic use at discharge in intervention versus control groups was assessed using logistic regression models controlling for patient characteristics.ResultsPharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention.ConclusionsA pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.     

Developing a composite outcome tool to measure response to treatment in ANCA-associated vasculitis: A mixed methods study from OMERACT 2020

ObjectiveThe Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group aims to develop composite response criteria for ANCA-Associated Vasculitis (AAV).MethodsThe project follows the OMERACT approach for composite measures: (i) choose relevant domains; (ii) define high-quality instruments; (iii) decide on a scoring system approach; (iv) put through the OMERACT Filter 2.1 for validation.ResultsA systematic literature review of outcome measures used in clinical trials in AAV and an international Delphi exercise among patients with AAV and clinician-investigators with expertise in AAV have been completed to inform the candidate domains/instruments for the composite response criteria, which are the first two steps in the OMERACT approach for developing composite measures. Results of the systematic literature review and Delphi were presented at the OMERACT 2020 virtual workshop, and feedback was received on the next steps of the project, including the development of a scoring system approach.ConclusionThe ultimate goal of this project is to develop validated composite response criteria for use in clinical trials of AAV.     

OMERACT consensus-based operational definition of contextual factors in rheumatology clinical trials: A mixed methods study

ObjectivesTo develop an operational definition of contextual factors (CF) [1].MethodsBased on previously conducted interviews, we presented three CF types in a Delphi survey; Effect Modifying -, Outcome Influencing - and Measurement Affecting CFs. Subsequently, a virtual Special Interest Group (SIG) session was held for in depth discussion of Effect Modifying CFs.ResultsOf 161 Delphi participants, 129 (80%) completed both rounds. After two rounds, we reached consensus (≥70% agreeing) for all but two statements. The 45 SIG participants were broadly supportive.ConclusionThrough consensus we developed an operational definition of CFs, which was well received by OMERACT members.     

A mixed methods study of symptom perception in patients with chronic heart failure

Background

Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF.