Patient-level glucose reporting: averages,episodes, or something in between?

The article by Van Herpe and colleagues in the previous issue of Critical Care describes the glycemic penalty index (GPI), which weights both hyperglycemic and hypoglycemic blood glucose measurements commensurate to their clinically significant difference from target. Although certain adverse consequences result from isolated severe hyperglycemic episodes, several specific outcomes depend upon overall hyperglycemia. In contrast, although mortality has been related epidemiologically to overall low blood glucose, specific negative outcomes may depend upon isolated episodes. Capturing both hypoglycemia and hyperglycemia in a single index will be shown to be useful if the GPI enables us to better define insulin strategies, outcomes, and targets.     

Bringing to light the health needs of African-American men: the Overtown Men's Health Study

Background

The harsh intersections of racism and sexism in US society have contorted roles for African-American men and damaged their social ties, thereby contributing to excess morbidity and mortality in communities of color. The Overtown Men's Health Study is used here as a case study to examine the health needs of African-American men.

Methods

Men aged 18 years and older who resided in the neighborhood of Overtown within Miami, Florida, USA completed an in-person survey administered at 15 community sites: 3 housing complexes, 3 rooming houses, 3 commercial sites, 2 abandoned buildings, 1 large and 1 small public park, 1 union hall, and 1 community center.

Results

The vast majority of respondents (n = 129) were identified as Black/African-American (95.3%). Just 9.3% of the men surveyed were currently married, yet over half were fathers (59.7%). Nearly two-thirds (62.8%) of the men in Overtown reported drinking alcohol, and almost half (47.3%) reported smoking cigarettes. Only one of three (33.3%) Overtown men reported having a primary care physician or health practitioner, and only one of five (20.2%) had received dental care in the previous 12 months. A remarkable one of four (25.6%) Overtown men reported having been a victim of police violence, and nearly two-thirds (65.9%) reported having been incarcerated.

Conclusions

These findings are a call to action issuing from Overtown to other distressed neighborhoods of color within central cities through the USA. Urgent pursuit of measures for reducing social disparities in health for African-American men is ethically compulsory.     

Ruptured abdominal aortic aneurysm: endovascular repair does not confer any long-term survival advantage over open repair

Recent studies have suggested that endovascular aneurysm repair (EVAR) may reduce the perioperative mortality of ruptured abdominal aortic aneurysm (AAA). Whether EVAR confers any long-term survival advantage over published results for open repair of ruptured AAA has not been established. We conducted a single-center retrospective study over a 10-year period (1994-2004) examining the long-term outcome of patients who have undergone endovascular repair of ruptured AAA. Fifty-four patients underwent endovascular repair of a ruptured AAA. The median age was 75 years (interquartile range 69.5-79.5 years); 42 (78%) patients were male. The perioperative mortality rate was 37%. During a median follow-up of 32 months (range 14-48 months), there were 5 aneurysm-related and 13 non-aneurysm-related deaths. Overall, the 3- and 5-year survival rates were 36% and 26%, respectively. EVAR does not appear to confer any overall survival advantage in the mid- to long term compared with the published results for open repair. The reasons for this remain unclear. Further, larger studies are required to confirm these results.     

Adenovirus E1b-58 kD antigen binds to p53 during infection of rodent cells: evidence for an N-terminal binding site on p53.

We show using mild extraction procedures that the p53 proto-oncogene forms a complex with adenovirus 5 E1b-58 kD during infection. These complexes are detected as coimmunoprecipitates from radiolabeled extracts of adenovirus infected cells on SDS-PAGE. Furthermore, adenovirus mutants with defects in E1b-58 kD fail to form complexes, whereas mutants in other early region genes still show evidence of complex. Using a panel of monoclonal antibodies to mouse p53, we show that antibodies reacting with N-terminal epitopes on p53, displace E1b-58 kD. This result suggests that E1b-58 kD binds to an N-terminal region of mouse p53. In addition, in a transient transfection assay in monkey COS cells, we show that an N-terminal deletion mutant of mouse p53 does not bind to E1b-58 kD but wild-type mouse p53 does bind. This result again suggests that E1b-58 kD binds an N-terminal determinant on p53.     

Multimethod Evaluation of Information and Communication Technologies in Health in the Context of Wicked Problems and Sociotechnical Theory

Objective

Few research designs look at the deep structure of complex social systems. We report the design and implementation of a multimethod evaluation model to assess the impact of computerized order entry systems on both the technical and social systems within a health care organization.

Design

We designed a multimethod evaluation model informed by sociotechnical theory and an appreciation of the nature of wicked problems. We mobilized this model to assess the impact of an electronic medication management system via a three-year program of research at a major academic hospital.

Measurements

Model components include measurements relating to three dimensions of system impact: safety and quality, organizational culture, and work and communication patterns.

Results

Application of the evaluation model required the development and testing of purpose-built measurement tools such as software to collect multidimensional work measurement data. The model applied established research methods including medication error audits and social network analysis. Design features of these tools and techniques are described, along with the practical challenges of their implementation. The distinctiveness of doing research within a unique paradigm of complex systems, explicating the wickedness and the dimensionality of sociotechnical theory, is articulated.

Conclusion

Designing an effective evaluation model requires a deep understanding of the nature and complexity of the problems that information technology interventions in health care are trying to address. Adopting a sociotechnical perspective for model generation improves our ability to develop evaluation models that are adaptive and sensitive to the characteristics of wicked problems and provides a strong theoretical basis from which to analyze and interpret findings.     

When requests become orders--a formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service

PURPOSE: The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services. METHODS: An in-depth qualitative study using observation, focus groups and interviews with pathology staff, managers, clinicians and information systems staff during implementation of a CPOE system in 2004 at a major Australian teaching hospital. RESULTS: Pathology laboratories experienced a shift in their work roles resulting in altered work practices, responsibilities and procedures. These changes were marked by terminological and procedural changes in the test order process from when clinicians issued a request for a test, to the new system that established clinical orders at the point of care. This change was accompanied by some organizational dysfunctions including the emergence of a new category of "frustrated" orders without specimens; problems with the procedure of adding tests to previously existing specimens; the appearance of discrepancies in the recorded time of specimen collection. In response to these changes, hospital and pathology staff adopted a variety of means to cope with their changed circumstances. These ranged from efforts to increase clinical awareness to compensatory laboratory workarounds and enforced rule changes. CONCLUSIONS: CPOE systems can have a major impact on the nature of the work of pathology laboratories. Understanding how and why these changes occur can be enhanced through considering the organizational and social contexts involved. The effectiveness of CPOE systems will rely on how administrators and staff approach and deal with these challenges.     

Critical incidents and journey mapping as techniques to evaluate the impact of online evidence retrieval systems on health care delivery and patient outcomes

BACKGROUND: Online evidence retrieval systems are a potential tool in supporting evidence-based practice. Effective and tested techniques for assessing the impact of these systems on care delivery and patient outcomes are limited. PURPOSE AND METHODS: In this study we applied the critical incident (CI) and journey mapping (JM) techniques to assess the integration of an online evidence system into everyday clinical practice and its impact on decision making and patient care. To elicit incidents semi-structured interviews were conducted with 29 clinicians (13 hospital physician specialists, 16 clinical nurse consultants (CNCs)) who were experienced users of the online evidence system. Clinicians were also asked questions about how they had first used the system and how their use and experiences had changed over time. These narrative accounts were then mapped and scored using the journey mapping technique. RESULTS: Clinicians generated 85 critical incidents. Three categories of impact were identified: impact on clinical practice, impact on individual clinicians and impact on colleagues through the dissemination of information gained from the online evidence system. One quarter of these included specific examples of system use leading to improvements in patient care. Clinicians obtained an average journey mapping score of 22 out of a possible score of 36, demonstrating a good level of system integration. Average scores of doctors and CNCs were similar. However individuals with the same scores often had very different journeys in system integration. CONCLUSIONS: The CI technique provided clear examples of the way in which system use had influenced practice and care delivery. The JM technique was found to be a useful method for providing a quantification of the different ways and extent to which, clinicians had integrated system use into practice, and insights into how system use can influence organisational culture. The development of the journey mapping stages provides a structure by which the program logic of a clinical information system and its desired outcomes can be made explicit and be based upon users' experiences in everyday practice. Further work is required using this technique to assess its value as an evaluation method.     

Trust, communication, theory of mind and the social brain hypothesis: deep explanations for what goes wrong in health care

PURPOSE: The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology. DESIGN/METHODOLOGY/APPROACH: This paper explains how this is carried out, and explores some of the adverse consequences for patient care. Evolutionary psychology provides a means of explaining important mental capacities and constructs including theory of mind and the social brain hypothesis. To have a theory of mind is to be able to read others' behaviours, linguistic and non-verbal cues, and analyse their intentions. To have a social (or Machiavellian) brain means being able to assess, compete with and, where necessary, outwit others. In the tough and complex environment of the contemporary health setting, not too different from the Pleistocene, humans display a well-developed theory of mind and social brains and, using mental attributes and behavioural repertoires evolved for the deep past in hunter-gatherer bands, survive and thrive in difficult circumstances. FINDINGS: The paper finds that, while such behaviours cannot be justified, armed with an evolutionary approach one can predict survival mechanisms such as turf protection, competitive strategies, sending transgressors and whistleblowers to Coventry, self-interest, and politics and tribal behaviours. ORIGINALITY/VALUE: The paper shows that few studies examine contemporary health sector behaviours through an evolutionary psychology lens or via such deep accounts of human nature.