Patient engagement in the inpatient setting: a systematic review

Objective

To systematically review existing literature regarding patient engagement technologies used in the inpatient setting.

Methods

PubMed, Association for Computing Machinery (ACM) Digital Library, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and Cochrane databases were searched for studies that discussed patient engagement (‘self-efficacy’, ‘patient empowerment’, ‘patient activation’, or ‘patient engagement’), (2) involved health information technology (‘technology’, ‘games’, ‘electronic health record’, ‘electronic medical record’, or ‘personal health record’), and (3) took place in the inpatient setting (‘inpatient’ or ‘hospital’). Only English language studies were reviewed.

Results

17 articles were identified describing the topic of inpatient patient engagement. A few articles identified design requirements for inpatient engagement technology. The remainder described interventions, which we grouped into five categories: entertainment, generic health information delivery, patient-specific information delivery, advanced communication tools, and personalized decision support.

Conclusions

Examination of the current literature shows there are considerable gaps in knowledge regarding patient engagement in the hospital setting and inconsistent use of terminology regarding patient engagement overall. Research on inpatient engagement technologies has been limited, especially concerning the impact on health outcomes and cost-effectiveness.     

Artificial intelligence in breast cancer screening: primary care provider preferences

BackgroundArtificial intelligence (AI) is increasingly being proposed for use in medicine, including breast cancer screening (BCS). Little is known, however, about referring primary care providers’ (PCPs’) preferences for this technology.MethodsWe identified the most important attributes of AI BCS for ordering PCPs using qualitative interviews: sensitivity, specificity, radiologist involvement, understandability of AI decision-making, supporting evidence, and diversity of training data. We invited US-based PCPs to participate in an internet-based experiment designed to force participants to trade off among the attributes of hypothetical AI BCS products. Responses were analyzed with random parameters logit and latent class models to assess how different attributes affect the choice to recommend AI-enhanced screening.ResultsNinety-one PCPs participated. Sensitivity was most important, and most PCPs viewed radiologist participation in mammography interpretation as important. Other important attributes were specificity, understandability of AI decision-making, and diversity of data. We identified 3 classes of respondents: “Sensitivity First” (41%) found sensitivity to be more than twice as important as other attributes; “Against AI Autonomy” (24%) wanted radiologists to confirm every image; “Uncertain Trade-Offs” (35%) viewed most attributes as having similar importance. A majority (76%) accepted the use of AI in a “triage” role that would allow it to filter out likely negatives without radiologist confirmation.Conclusions and RelevanceSensitivity was the most important attribute overall, but other key attributes should be addressed to produce clinically acceptable products. We also found that most PCPs accept the use of AI to make determinations about likely negative mammograms without radiologist confirmation.     

Can we understand population healthcare needs using electronic medical records?

INTRODUCTIONThe identification of population-level healthcare needs using hospital electronic medical records (EMRs) is a promising approach for the evaluation and development of tailored healthcare services. Population segmentation based on healthcare needs may be possible using information on health and social service needs from EMRs. However, it is currently unknown if EMRs from restructured hospitals in Singapore provide information of sufficient quality for this purpose. We compared the inter-rater reliability between a population segment that was assigned prospectively and one that was assigned retrospectively based on EMR review.METHODS200 non-critical patients aged ≥ 55 years were prospectively evaluated by clinicians for their healthcare needs in the emergency department at Singapore General Hospital, Singapore. Trained clinician raters with no prior knowledge of these patients subsequently accessed the EMR up to the prospective rating date. A similar healthcare needs evaluation was conducted using the EMR. The inter-rater reliability between the two rating sets was evaluated using Cohen’s Kappa and the incidence of missing information was tabulated.RESULTSThe inter-rater reliability for the medical ‘global impression’ rating was 0.37 for doctors and 0.35 for nurses. The inter-rater reliability for the same variable, retrospectively rated by two doctors, was 0.75. Variables with a higher incidence of missing EMR information such as ‘social support in case of need’ and ‘patient activation’ had poorer inter-rater reliability.CONCLUSIONPre-existing EMR systems may not capture sufficient information for reliable determination of healthcare needs. Thus, we should consider integrating policy-relevant healthcare need variables into EMRs.     

Beyond return of spontaneous circulation: update on post-cardiac arrest management in the intensive care unit

A well-functioning chain of survival is critical for good outcomes following out-of-hospital cardiac arrest, a major public health concern in Singapore. While the percentage of survivors to hospital admission has increased over the years, the percentage of survivors to hospital discharge and the number of patients with good neurological recovery can be greatly improved. This underscores the urgent need to focus on ‘post-cardiac arrest care’, the fifth link in the chain of survival, to improve the outcomes of patients who are admitted to the intensive care unit (ICU) after return of spontaneous circulation. This review builds on earlier recommendations of the Singapore National Targeted Temperature Management Workgroup in 2017 to provide a focused update on post-cardiac arrest management and a practical guide for physicians managing resuscitated patients with cardiac arrest in the ICU.     

Prognostic factors in the rehabilitation of patients with spinal problems

One hundred patients undergoing intensive rehabilitation for painful spinal lesions were studied. They were divided into three groups in relation to result, these being ‘good’, ‘moderate’ or ‘poor’. Seventy-eight per cent were regarded as ‘good’ or ‘moderate’. The ‘poor’ group showed significantly raised neuroticism scores measured by the Middlesex Hospital Questionnaire, particularly sub-scores for ‘depression’ and ‘somatic concomitants of anxiety’ in women and ‘free floating anxiety’, ‘depression’ and ‘obsessionality’ in men. Other factors associated with poor outcome were long history, multiple operations and a nonspecific diagnosis of ‘low back pain’. It is suggested that this group can be identified early and might benefit from a combined physical rehabilitation and psychotherapy programme. A controlled study to test this is planned.     

The use of facemasks to prevent respiratory infection: a literature review in the context of the Health Belief Model

INTRODUCTION

Acute respiratory infections are prevalent and pose a constant threat to society. While the use of facemasks has proven to be an effective barrier to curb the aerosol spread of such diseases, its use in the local community is uncommon, resulting in doubts being cast on its effectiveness in preventing airborne infections during epidemics. We thus aimed to conduct a literature review to determine the factors that influence the use of facemasks as a primary preventive health measure in the community.

METHODS

A search for publications relating to facemask usage was performed on Medline, PubMed, Google, World Health Organization and Singapore government agencies’ websites, using search terms such as ‘facemask’, ‘mask’, ‘influenza’, ‘respiratory infection’, ‘personal protective equipment’, ‘disease prevention’, ‘compliance’ and ‘adherence’. Findings were framed under five components of the Health Belief Model perceived susceptibility, perceived benefits, perceived severity, perceived barriers and cues to action.

RESULTS

We found that individuals are more likely to wear facemasks due to the perceived susceptibility and perceived severity of being afflicted with life-threatening diseases. Although perceived susceptibility appeared to be the most significant factor determining compliance, perceived benefits of mask-wearing was found to have significant effects on mask-wearing compliance as well. Perceived barriers include experience or perception of personal discomfort and sense of embarrassment. Media blitz and public health promotion activities supported by government agencies provide cues to increase the public’s usage of facemasks.

CONCLUSION

Complex interventions that use multipronged approaches targeting the five components of the Health Belief Model, especially perceived susceptibility, are needed to increase the use of facemasks in the community. Further studies are required to evaluate the effectiveness of implemented interventions.     

Current state of reflective learning in anaesthesiology residents: a call for ‘reflection-on-action’ training in Singapore

INTRODUCTIONReflective learning is the cognitive process whereby information from new experiences is integrated into existing knowledge structures and mental models. In our complex healthcare system, reflective learning (specifically ‘reflection on action’) is important for postgraduate learners. We observed that our anaesthesiology residents were not building on their competence through deliberate experiential and reflective practice. This qualitative study explored the current state and challenges of reflective learning in anaesthesia training in Singapore.METHODSThis study was conducted at KK Women’s and Children’s Hospital, Singapore, from 1 January 2018 to 31 October 2018. A semi-structured interview format was used in focus groups. Information collection continued until data saturation was reached. The interviews were coded and analysed, and themes were identified. Seven focus group interviews involving 19 participants were conducted.RESULTSReflective learning was found to be poor. It was of concern that the stimuli for reflection and reflective learning emerged from medical errors, critical incidents and poor patient outcomes. Challenges identified were: (a) lack of an experiential learning framework; (b) need for reflective training; (c) quality of experiential triggers; (d) clinical pressures; and (e) poor learner articulation and feedback. We described some strategies to frame, teach and stimulate reflective learning.CONCLUSIONThis study described the state and challenges of reflective learning in anaesthesia training. We advocate the implementation of reflective training strategies in postgraduate training programmes in Singapore. Research is warranted to integrate patient feedback and outcomes into reflective practice.     

Research and applications: Breast cancer survivability prediction using labeled,unlabeled, and pseudo-labeled patient data

Background

Prognostic studies of breast cancer survivability have been aided by machine learning algorithms, which can predict the survival of a particular patient based on historical patient data. However, it is not easy to collect labeled patient records. It takes at least 5 years to label a patient record as ‘survived’ or ‘not survived’. Unguided trials of numerous types of oncology therapies are also very expensive. Confidentiality agreements with doctors and patients are also required to obtain labeled patient records.

Proposed method

These difficulties in the collection of labeled patient data have led researchers to consider semi-supervised learning (SSL), a recent machine learning algorithm, because it is also capable of utilizing unlabeled patient data, which is relatively easier to collect. Therefore, it is regarded as an algorithm that could circumvent the known difficulties. However, the fact is yet valid even on SSL that more labeled data lead to better prediction. To compensate for the lack of labeled patient data, we may consider the concept of tagging virtual labels to unlabeled patient data, that is, ‘pseudo-labels,’ and treating them as if they were labeled.

Results

Our proposed algorithm, ‘SSL Co-training’, implements this concept based on SSL. SSL Co-training was tested using the surveillance, epidemiology, and end results database for breast cancer and it delivered a mean accuracy of 76% and a mean area under the curve of 0.81.     

Clinical teaching and learning: from theory and research to application

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.     

Using nursing notes to improve clinical outcome prediction in intensive care patients: A retrospective cohort study

ObjectiveElectronic health record documentation by intensive care unit (ICU) clinicians may predict patient outcomes. However, it is unclear whether physician and nursing notes differ in their ability to predict short-term ICU prognosis. We aimed to investigate and compare the ability of physician and nursing notes, written in the first 48 hours of admission, to predict ICU length of stay and mortality using 3 analytical methods.Materials and MethodsThis was a retrospective cohort study with split sampling for model training and testing. We included patients ≥18 years of age admitted to the ICU at Beth Israel Deaconess Medical Center in Boston, Massachusetts, from 2008 to 2012. Physician or nursing notes generated within the first 48 hours of admission were used with standard machine learning methods to predict outcomes.ResultsFor the primary outcome of composite score of ICU length of stay ≥7 days or in-hospital mortality, the gradient boosting model had better performance than the logistic regression and random forest models. Nursing and physician notes achieved area under the curves (AUCs) of 0.826 and 0.796, respectively, with even better predictive power when combined (AUC, 0.839).DiscussionModels using only nursing notes more accurately predicted short-term prognosis than did models using only physician notes, but in combination, the models achieved the greatest accuracy in prediction. ConclusionsOur findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Physicians’ and nurses’ notes are both uniquely important in mortality prediction and combining these notes can produce a better predictive model.     

Simplified instructional phrasing in dispatcher-assisted cardiopulmonary resuscitation – when ‘less is more’

INTRODUCTIONIn our national emergency dispatch centre, the standard protocol for dispatcher-assisted cardiopulmonary resuscitation (DACPR) in out-of-hospital cardiac arrests (OHCAs) involves the instruction ‘push 100 times a minute 5 cm deep’. As part of quality improvement, the instruction was simplified to ‘push hard and fast’.METHODSWe analysed all dispatcher-diagnosed OHCAs over four months in 2018: January to February (‘push 100 times a minute 5 cm deep’) and August to September (‘push hard and fast’). We also performed secondary per-protocol analysis based on the protocol used: (a) standard (n = 48); (b) simplified (n = 227); and (c) own words (n = 231).RESULTSA total of 506 cases were included: 282 in the ‘before’ group and 224 in the ‘after’ group. Adherence to the protocol was 15.2% in the ‘before’ phase and 72.8% in the ‘after’ phase (p < 0.001). The mean time between instruction and first compression for the ‘before’ and ‘after’ groups was 34.36 seconds and 26.83 seconds, respectively (p < 0.001). Time to first compression was 238.62 seconds and 218.83 seconds in the ‘before’ and ‘after’ groups, respectively (p = 0.016). In the per-protocol analysis, the interval between instruction and compression was 37.19 seconds, 28.31 seconds and 32.40 seconds in the standard protocol, simplified protocol and ‘own words’ groups, respectively (p = 0.005). The need for paraphrasing was 60.4% in the standard protocol group and 81.5% in the simplified group (p < 0.001).CONCLUSIONSimplified instructions were associated with a shorter interval between instruction and first compression. Efforts should be directed at simplifying DACPR instructions.     

Integrating advance care planning as part of comprehensive geriatric assessment for hospitalised frail elderly patients: findings of a cross-sectional study

INTRODUCTION:The integration of advance care planning (ACP) as part of the comprehensive geriatric assessment (CGA) of hospitalised frail elderly patients, together with the clinical and demographic factors that determine successful ACP discussion, has not been previously explored.METHODS:A cross-sectional study on patients and family caregivers admitted under the geriatric medicine department of a tertiary hospital was conducted from October 2015 to December 2016.RESULTS:Among 311 eligible patients, 116 (37.3%) patients completed ACP discussion while 166 (53.4%) patients declined, with 62 (37.3%) of the decliners providing reasons for refusal. Univariate logistic regression analysis showed that older age, higher Charlson Comorbidity Index, poorer functional status and cognitive impairment had statistically significant associations with agreeing to ACP discussion (p < 0.05). On multivariate logistic regression analysis, only poorer functional status was significantly associated (odds ratio 2.22 [95% confidence interval 1.27–3.87]; p = 0.005). Among those who completed ACP discussion, a majority declined cardiopulmonary resuscitation (79.3%), preferred limited medical intervention or comfort care (82.8%), and opted for blood transfusion (62.9%), antibiotics (73.3%) and intravenous fluid (74.1%) but declined haemodialysis (50.9%). Decision-making was divided for enteral feeding. Among decliners, the main reasons for refusal were ‘not keen’ (33.9%), ‘deferring to doctors’ decision’ (11.3%) and ‘lack of ACP awareness’ (11.3%).CONCLUSION:The feasibility and utility of integrating ACP as part of CGA has been demonstrated. Poorer functional status is significantly associated with successful ACP discussion. Greater public education on end-of-life care choices (besides cardiopulmonary resuscitation) and follow-up with decliners are recommended.     

Caregiver burden and its prevalence,measurement scales,predictive factors and impact: a review with an Asian perspective

Caregiver burden is a well-recognised global phenomenon. The primary aim of this review is to summarise the prevalence of caregiver burden and its measurement scales, predictive factors and impact in Singapore. PubMed® and Scopus® databases were searched using the key terms ‘caregiver’, ‘burden’, ‘stress’, ‘strain’ and ‘Singapore’. A total of 206 papers were retrieved and 20 were included. This review showed that a significant proportion of caregivers in Singapore experience caregiver burden. Caregiving experiences and outcomes are affected by cultural, behavioural and socioeconomic factors. Being a Malay caregiver appears to be a protective factor for caregiver burden, whereas having negative coping strategies and care recipients with functional, cognitive and behavioural impairments are positive risk factors. As for outcomes, caregiver burden is associated with poorer self-rated health and reduced quality of life. Multiple instruments have been used to measure caregiver burden, and the Zarit Burden Interview is the most widely used.     

Surgeons' attitudes to some aspects of day case surgery

The level of day case surgery is much lower in Northern Ireland than in England. A questionnaire was sent to all 55 consultant general surgeons in Northern Ireland to assess attitudes to this form of care and 51 (93%) replied. They were asked about the suitability of five procedures for day surgery. The three minor procedures of vasectomy, cystoscopy and gastroscopy were regarded as suitable or very suitable by 50 (98% of those who replied), 48 (94%) and 48 (94%) respectively. For the two intermediate procedures, 25 (49%) regarded the repair of inguinal hernia as suitable for day case surgery and 22 (43%) ligation of varicose veins. When asked about eight factors limiting their use of day surgery for inguinal hernia repair, the two most frequently rated as important were ‘home conditions’ and ‘level of provision of domiciliary care’ (both by 44 (86%) of the surgeons). Of factors which might promote their use of day surgery for this operation the two most important were ‘more efficient use of health service resources’ (71%) and the ‘ability to convalesce at home’ (67%). The problem of under-reporting of day cases and the importance of accurate statistics are considered.     

Why common carrier and network neutrality principles apply to the Nationwide Health Information Network (NWHIN)

The Office of the National Coordinator will be defining the architecture of the Nationwide Health Information Network (NWHIN) together with the proposed HealtheWay public/private partnership as a development and funding strategy. There are a number of open questions—for example, what is the best way to realize the benefits of health information exchange? How valuable are regional health information organizations in comparison with a more direct approach? What is the role of the carriers in delivering this service? The NWHIN is to exist for the public good, and thus shares many traits of the common law notion of ‘common carriage’ or ‘public calling,’ the modern term for which is network neutrality. Recent policy debates in Congress and resulting potential regulation have implications for key stakeholders within healthcare that use or provide services, and for those who exchange information. To date, there has been little policy debate or discussion about the implications of a neutral NWHIN. This paper frames the discussion for future policy debate in healthcare by providing a brief education and summary of the modern version of common carriage, of the key stakeholder positions in healthcare, and of the potential implications of the network neutrality debate within healthcare.     

Understanding patients’ perspective of statin therapy: can we design a better approach to the management of dyslipidaemia? A literature review

INTRODUCTION

Dyslipidaemia leads to atherosclerosis and is a major risk factor for cardiovascular diseases. In clinical trials, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been shown to effectively reduce dyslipidaemia. Despite the availability and accessibility of statins, myocardial infarctions and cerebrovascular accidents remain among the top causes of mortality in developed countries, including Singapore. This enigma could be attributed to suboptimal adherence to statin therapy. The present literature review aimed to evaluate patients’ perceptions of statin therapy.

METHODS

We searched PubMed and other databases for articles published in English from October 1991 to May 2012 containing keywords such as ‘patient’, ‘views’, ‘perceptions’, ‘adherence’, ‘statin’ and ‘dyslipidaemia’. Of the 122 eligible studies retrieved, 58 were reviewed. The findings were categorised and framed in accordance with the Health Belief Model.

RESULTS

Patients with dyslipidaemia appeared to underestimate their susceptibility to dyslipidaemia-related complications, partly due to their demographic profiles. Failure to appreciate the severity of potential complications was a major hindrance toward adherence to statin therapy. Other factors that affected a patient’s adherence included lack of perceived benefits, perceived side effects, the cost of statins, poor physician-patient relationship, and overestimation of the effectiveness of diet control as a treatment modality.

CONCLUSION

Existing evidence suggests that the cause of poor adherence to statin therapy is multifactorial. The use of the Health Belief Model to present the results of our literature review provides a systematic framework that could be used to design a patient-centric approach for enhancing adherence to statin therapy.     

Response-oriented measuring inequalities in Tehran: second round of UrbanHealth Equity Assessment and Response Tool (Urban HEART-2), concepts and framework

Background

Current evidence consistently confirm inequalities in health status among socioeconomic none, gender,ethnicity, geographical area and other social determinants of health (SDH), which adversely influence health ofthe population. SDH refer to a wide range of factors not limited to social component, but also involve economic, cultural,educational, political or environmental problems. Measuring inequalities, improving daily living conditions, andtackling inequitable distribution of resources are highly recommended by international SDH commissioners in recentyears to ‘close the gaps within a generation’. To measure inequalities in socio-economic determinants and core healthindicators in Tehran, the second round of Urban Health Equity Assessment and Response Tool (Urban HEART-2)was conducted in November 2011, within the main framework of WHO Centre for Health Development (Kobe Centre).

Method

For ‘assessment’ part of the project, 65 indicators in six policy domains namely ‘physical and infrastructure’,‘human and social’, ‘economic’, ‘governance’, ‘health and nutrition’, and also ‘cultural’ domain were targetedeither through a population based survey or using routine system. Survey was conducted in a multistage random sampling,disaggregated to 22 districts and 368 neighborhoods of Tehran, where data of almost 35000 households(118000 individuals) were collected. For ‘response’ part of the project, widespread community based development(CBD) projects were organized in all 368 neighborhoods, which are being undertaken throughout 2013.

Conclusion

Following the first round of Urban HEART project in 2008, the second round was conducted to trackchanges over time, to institutionalize inequality assessment within the local government, to build up community participationin ‘assessment’ and ‘response’ parts of the project, and to implement appropriate and evidence-based actionsto reduce health inequalities within all neighborhoods of Tehran.     

Incipient non-arteritic anterior ischaemic optic neuropathy: a distinct clinical entity,the Singapore scene 3

We report five cases of non-arteritic anterior ischaemic optic neuropathy (NA-AION) where spontaneous resolution of the optic disc swelling occurred, and all relevant visual modalities were normal at presentation and remained so until resolution of the process after a median time of 9.6 weeks. This condition, which can be termed ‘incipient NA-AION’ or ‘threatened NA-AION’, should be recognised so that unnecessary investigations for other and more serious causes of optic disc swelling can be prevented.     

Clinical and biochemical findings in ten patients with benign myalgic encephalomyelitis

Ten patients in whom the clinical findings were consistent with the syndrome variously described as ‘benign myalgic encephalomyelitis’, ‘epidemic neuromyasthenia’, ‘Royal Free disease’ and ‘Icelandic disease’ were investigated for blood levels of myoglobin and various enzymes. Although there is no clinical resemblance between the two diseases, the biochemical pattern bears a close similarity to that found in Duchenne muscular dystrophy (DMD) though differing sharply in that no rise in creatinine kinase levels was found. These findings are discussed with particular reference to recent suggestions that the permeability of cell membranes may be impaired by changes in intracellular energy mechanisms.