A patient who changed my practice: The case for patient-based evidence versus trial-based evidence

A patient who has an unequivocal psychotic illness within the schizoaffective spectrum is described. Over the course of the past 10 years she has convinced me that her way of looking at her own illness, particularly her refusal to take medication, has merits that cannot be dismissed as the overwrought workings of a disturbed mind. Her experience has helped me to understand that it is still possible to be an advocate of evidence-based medicine and yet accommodate the wishes of patients in a way that sometimes elevates personal patient-based evidence above that of external criteria. ( Int J Psych Clin Pract 2000; 4: 253 - 255)     

With how many users should you test a medical infusion pump? Sampling strategies for usability tests on high-risk systems

Usability testing is recognized as an effective means to improve the usability of medical devices and prevent harm for patients and users. Effectiveness of problem discovery in usability testing strongly depends on size and representativeness of the sample. We introduce the late control strategy, which is to continuously monitor effectiveness of a study towards a preset target.A statistical model, the LNB_zt model, is presented, supporting the late control strategy. We report on a case study, where a prototype medical infusion pump underwent a usability test with 34 users. On the data obtained in this study, the LNB_zt model is evaluated and compared against earlier prediction models.The LNB_zt model fits the data much better than previously suggested approaches and improves prediction. We measure the effectiveness of problem identification, and observe that it is lower than is suggested by much of the literature. Larger sample sizes seem to be in order. In addition, the testing process showed high levels of uncertainty and volatility at small to moderate sample sizes, partly due to users’ individual differences. In reaction, we propose the idiosyncrasy score as a means to obtain representative samples. Statistical programs are provided to assist practitioners and researchers in applying the late control strategy.     

Pilot of the Patient Concerns Inventory – Ward Discharge in Patients following major reconstructive surgery for head and neck cancer

Planning discharge from hospital following microvascular free-tissue surgery can be complex and challenging. Planning involves the patient, carers, and multiple health professionals. Poor communication and expectations can delay discharge or give a suboptimal discharge process. It was hypothesised that prompt-list modelled along the principals of the Patient Concerns Inventory (PCI) could be help in discharge planning. The aim of this study was to define the items and format of a PCI-Ward Discharge (PCI-WD) and undertake a small pilot. Items appropriate for the PCI-WD were formulated through discussion with patients, carers, ward staff, Head and Neck Clinical Nurse Specialists, and clinicians. The pilot took place over three months from December 2019 through to February 2020. Audit approval was given by the hospital Audit Department. The PCI-WD comprises 43 items. Items from existing PCIs for use at diagnosis and follow-up consultations were reduced in number and 38 new or modified items added; six treatment related, five social care and social well-being, four psychological, emotional, and spiritual well-being, seven physical and functional well-being, and 16 discharge related. The pilot involved 14 free-tissue transfer patients, seven male, seven female, with an age range of 57 to 87 and a mean age of 72. Eight PCI-WD were returned. PCI-WD items identified most frequently were ‘surgery site other than head/neck’, ‘when do I come back to hospital’, ‘dental check-up/oral health care’ and ‘diet/eating’. Early findings suggest that PCI-WD could be a useful tool in aiding the discharge process. Further evaluation is required.     

Evaluación de la efectividad de la versión en español de un curso de comunicación de malas noticias

IntroductionGood communication by health professionals is associated with better patient outcomes. The Program to Enhance Relational and Communication Skills (PERCS) has been adapted to other cultures. The objective of this study is to describe the effectiveness of the Spanish version of the PERCS program, from the perspective of the participants, at the end of the course and 6 months after the course.MethodsA process of cultural and epidemiological adaptation of the PERCS program to the reality of Peru was carried out. A qualitative and quantitative approach was used to evaluate the educational impact of the program.ResultsThirty-nine professionals participated voluntarily. Participants found it more difficult to communicate ominous diagnoses (48.15%). Anxiety is the most frequent emotion when faced with difficult communications (77.78%). Almost all (92%) stated that the course improved their preparation, and 88.9% that it reduced their anxiety. At 6 months, participants recognised the importance of honesty and empathy, as well as some steps in conducting the patient-centred interview.DiscussionAn intensive training program in difficult communication can be adapted to Spanish, and positively impact the skills, self-confidence, and self-perception of learning in Peruvian professionals, in relation to promoting communication focused on the needs of the patient and family.     

Timeline for maximal subjective outcome improvement following total ankle arthroplasty

BackgroundMaximal medical improvement (MMI) establishes the timepoint when patients no longer experience clinically significant improvements following surgery. The purpose of this investigation is to establish when patients achieve MMI following total ankle arthroplasty (TAA) through the use of patient reported outcome measures (PROMs).MethodsA systematic review to identify studies on TAA which reported consecutive PROMs for two years postoperatively was performed. Pooled analysis was done at 6 months, 12 months, and 24 months. Clinically significant improvement was defined as improvement between time intervals exceeding the minimal clinically important difference.ResultsTwelve studies and 1514 patients met inclusion criteria. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Score and Visual Analog Scale scoring systems. The Short Musculoskeletal Function Assessment Dysfunction and Bother subsections showed maximal clinically significant improvement by 1 year postoperatively.ConclusionFollowing TAA, MMI is seen by one year postoperatively. Physicians may allocate the majority of resources within the first year when most of the improvement is perceived. This data may help inform preoperative counseling as it establishes a timeline for MMI.Level of evidenceIV.