1,722,272 research outputs found
Patient safety and healthcare improvement at a glance
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Usage of allergy codes in primary care electronic health records: a national evaluation in Scotland
Full text linkBackground: The UK's NHS intends to move from the current Read code system to the international, detailed Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) to facilitate more clinically appropriate coding of conditions and associated risk factors and outcomes. Given concerns about coding behaviour of general practitioners, we sought to study the current coding patterns in allergies and identify lessons for the future migration to SNOMED-CT.Methods: Data from 2 014 551 primary care consultations in over 100 000 patients with one or more of 11 potentially allergic diseases (anaphylaxis, angioedema, asthma, conjunctivitis, drug allergies, eczema, food allergy, rhinitis, urticaria, venom allergy and other probable allergic disorders) from the Scottish Primary Care Clinical Informatics Unit Research (PCCIU-R) database were descriptively analysed and visualized to understand Read code usage patterns.Results: We identified 352 Read codes for these allergic diseases, but only 36 codes (10%) were used in 95% of consultations; 73 codes (21%) were never used. Half of all usage was for Quality and Outcomes Framework codes for asthma. Despite 149 detailed codes (42%) being available for allergic triggers, these were infrequently used.Conclusions: This analysis of Read codes use suggests that introduction of the more detailed SNOMED-CT, in isolation, will not improve the quality of allergy coding in Scottish primary care. The introduction of SNOMED-CT should be accompanied by initiatives aimed at improving coding quality, such as the definition of terms/codes, the availability of terminology browsers, a recommended list of codes and mechanisms to incentivize detailed coding of the condition and the underlying allergic trigger
Facilitating health information exchange in low- and middle-income countries: conceptual considerations, stakeholders perspectives and deployment strategies illustrated through an in-depth case study of Pakistan
Full text linkBackground
Health information exchange (HIE) may help healthcare professionals and policymakers
make informed decisions to improve patient and population health outcomes. There is,
however, limited uptake of HIE in many low- and middle-income countries (LMICs). While
resource constraints are an obvious barrier to implementation of HIE, it is important to
explore what other political, structural, technical, environmental, legal and cultural factors
may be involved. In particular, it is necessary to understand associated barriers in relation to
context-specific HIE processes and deployment strategies in LMICs with a view to
discovering how these can be overcome. My home country Pakistan is currently struggling
to implement HIE at scale and so I undertook a detailed investigation of these issues in the
context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan
and in LMICs more generally.
Aims
The concept of HIE is evolving both over time and by context. To gain a clearer
understanding of this terrain, I began by identifying different definitions of HIE in the
literature to understand how these had evolved and the underlying conceptual basis for these
changes. Second, I sought to understand the barriers and facilitators to the implementation
and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore
and understand in-depth stakeholders perspectives on the context of and deployment
strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons
for LMICs.
Methods
I undertook a phased programme of work. Phase 1 was a scoping review of definitions,
which involved systematically searching the published literature in five academic databases
and grey literature using Google to identify published definitions of HIE and related terms.
The searches covered the period from January 1900 to February 2014. The included
definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE
in LMICs, I conducted a systematic review and searched for published and on-going
(conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11
academic databases and looked for unpublished work through Google interface from January
1990 to July 2014. Eligible studies were critically appraised and then thematically analysed.
Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of
interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE,
and barriers and facilitators to its deployment. I also collected evidence through
observational field notes and by analysing key international, national and regional policy
documents. I used a combination of deductive thematic analysis informed by the theory of
Diffusion of Innovations in Health Service Organisations that highlighted attributes of the
innovation, the behaviour of adopters, and the organisational and environmental influences
necessary for the success of implementation; and a more inductive iterative thematic analysis
approach that allowed new themes to evolve from the data. The findings from these three
phases of work were then integrated to identify potentially transferable lessons for Pakistan
and other LMICs.
Results
In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from
scientific databases and 165 from Google. Eleven attributes emerged from the analysis that
characterised HIE into two over-riding concepts. One was the ‘process’ of electronic
information transfer among various healthcare stakeholders and the other was the HIE
‘organisation’ responsible to oversee the legal and business issues of information transfer.
The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of
63 studies met the inclusion criteria. Low importance given to data informed decision
making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack
of feedback were considered to be major challenges to implementing HIE in LMICs, but
strong leadership and clear policy direction coupled with the financial support to acquire
essential technology, provide training for staff, assessing the needs of individuals and data
standardisation all promoted implementation.
The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case
study. The complete dataset comprised of 39 interviews from 43 participants (including two
group interviews), field observations, and a range of local and national documents. Findings
showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and
fragmented form. The district health information system was responsible for electronically
transferring statistical data of public health facilities from districts to national offices via
provincial intermediaries. Many issues were attributed to the absence of effective HIE, from
‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and
facilitators to HIE were similar to the findings in Phase 2, but new findings included
problems perceived to be the result of devolution of health matters from the federal to
provincial governments, the politicised behaviour of international organisations, healthcare
providers’ resistance to recording consultations to avoid liability and poor documentation
skills. Public pressure to adopt mobile technology frameworks was found to be a novel
facilitator whereas sharing regional health information with international organisations was
perceived by some participants as disadvantageous as there were concerns that it may have
enhanced espionage activities in the region.
Conclusions
HIE needs to be considered in both organisational and process terms. Effective HIE is
essential to the provision of high quality care and the efficient running of health systems.
Structural, political and financial considerations are important barriers to promoting HIE in
LMICs, however, strong leadership, vision and policy direction along with financial support
can help to promote the implementation of HIE in LMICs. Similarly, the federal and
provincial governments could play an important role in implementing HIE in Pakistan along
with the support of international organisations by facilitating HIE processes at federal and
provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At
a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using
leapfrog mobile technologies to facilitate care processes for local organisations and patients.
Specifically, the study on Pakistan has highlighted that LMICs may achieve modest
successes in HIE through use of patient held records and use of now ubiquitous mobile
phone technology with some patient and organisational benefits, but scaling these benefits is
dependent on the creation of national structures and strategies which are more difficult to
achieve in the low advanced informatics skill and resource settings that characterise many
LMICs
Upskilling healthcare professionals to manage clinical allergy
No full textIt has long been recognised that given the high prevalence and considerable impact of allergic disease globally, there needs to be a focus on appropriate training for clinical professionals. The health-economic consequences of allergic disease are significant, with both direct healthcare costs (doctor, nurse and dietitian consultations, hospital admissions and prescribed medications) and indirect costs (lost school and work time, reduced productivity and over-the-counter medications). There is also a well recognised impairment of quality of life, with less tangible costs including anxiety, distress, discomfort, disability and, occasionally, death. To help to mitigate these effects, there is a need to upskill the professional workforce at all levels, and also to equip those trained with the skills to become future healthare professional trainers. Upskilling the workforce from the grass-roots of undergraduate study in Medical, Nursing and Allied Health Professionals (AHP) through the entirety of training to senior consultant levels could have a major beneficial impact on the patient and their families, lead to a reduction in emergency use of clinical service, and help increase economic productivity.</p
Computer decision support systems for asthma:a systematic review
Full text linkBACKGROUND: Increasing use of electronic health records offers the potential to incorporate computer decision support systems (CDSSs) to prompt evidence-based actions within routine consultations.AIM: To synthesise the evidence for the use of CDSSs by professionals managing people with asthma.MATERIALS AND METHODS: We systematically searched Medline, Embase, Health Technology Assessment, Cochrane and Inspec databases (1990 to April 2012, no language restrictions) for trials, and four online repositories for unpublished studies. We also wrote to authors. Eligible studies were randomised controlled trials of CDSSs supporting professional management of asthma. Studies were appraised (Cochrane Risk of Bias Tool) and findings synthesised narratively.RESULTS: A total of 5787 articles were screened, and eight trials were found eligible, with six at high risk of bias. Overall, CDSSs for professionals were ineffective. Usage of the systems was generally low: in the only trial at low risk of bias the CDSS was not used at all. When a CDSS was used, compliance with the advice offered was also low. However, if actually used, CDSSs could result in closer guideline adherence (improve investigating, prescribing and issuing of action plans) and could improve some clinical outcomes. The study at moderate risk of bias showed increased prescribing of inhaled steroids.CONCLUSIONS: The current generation of CDSSs is unlikely to result in improvements in outcomes for patients with asthma because they are rarely used and the advice is not followed. Future decision support systems need to align better with professional workflows so that pertinent and timely advice is easily accessible within the consultation.</p
National clinical practice guidelines for food allergy and anaphylaxis: an international assessment
Full text linkBackground: clinical practice guidelines are important tools to promote evidence-based clinical care, but not all countries have the capacity or infrastructure to develop these in-house. The European Academy of Allergy and Clinical Immunology has recently developed guidelines for the prevention, diagnosis and management of food allergy and the management of anaphylaxis. In order to inform dissemination, adaptation and implementation plans, we sought to identify countries that have/do not have national guidelines for food allergy and anaphylaxis.Methods: two reviewers independently searched PubMed to identify countries with guidelines for food allergy and/or anaphylaxis from the inception of this database to December 2016. This was supplemented with a search of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse in order to identify any additional guidelines that may not have been reported in the peer-reviewed literature. Data were descriptively and narratively synthesized.Results: overall, 5/193 (3%) of countries had at least one guideline for food allergy or anaphylaxis. We found that one (1%) country had a national guideline for the prevention of food allergy, three (2%) countries had a guideline for the diagnosis of food allergy and three (2%) countries had a guideline for the management of food allergy. Three (2%) countries had an anaphylaxis guideline.Conclusions: this study concludes that the overwhelming majority of countries do not have any national clinical practice guidelines for food allergy or anaphylaxis
Elevated blood pressure and risk of mitral regurgitation: A longitudinal cohort study of 5.5 million United Kingdom adults
Full text linkBackgroundMitral regurgitation in people without prior cardiac disease is considered a degenerative disease with no established risk factors for its prevention. We aimed to test the hypothesis that elevated systolic blood pressure (SBP) across its usual spectrum is associated with higher risk of mitral regurgitation.Methods and findingsWe used linked electronic health records from the United Kingdom Clinical Practice Research Datalink (CPRD) from 1 January 1990 to 31 December 2015. CPRD covers approximately 7% of the current UK population and is broadly representative of the population by age, sex, and ethnicity. About 5.5 million UK patients with no known cardiovascular or valve disease at baseline were included in this cohort study. We investigated the relationship between blood pressure (BP) and risk of mitral regurgitation using Cox regression models. Our primary exposure variable was SBP and our primary outcome was incident reports of mitral regurgitation, which were identified from hospital discharge reports or primary care records. Of the 5,553,984 patients in the CPRD that met our inclusion criteria, during the 10-year follow-up period, 28,655 (0.52%) were diagnosed with mitral regurgitation and a further 1,262 (0.02%) were diagnosed with mitral stenosis. SBP was continuously related to the risk of mitral regurgitation with no evidence of a nadir down to 115 mmHg (p ConclusionsLong-term exposure to elevated BP across its whole spectrum is associated with an increased risk of primary and secondary mitral regurgitation. These findings suggest that BP control may be of importance in the prevention of mitral regurgitation
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