Using the Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) quality indicators (QIs), we conducted a comprehensive evaluation of the quality of care provided in our institution to patients diagnosed with advanced cancer in 2006.Patients diagnosed with a Stage IV solid tumor were identified from the hospital's cancer registry. Using data abstracted from medical records, care was assessed using 41 explicit QIs. Mean percent adherence to QIs was calculated overall, as well as across five clinical domains: (1) Pain, (2) Depression and Psychosocial Distress, (3) Dyspnea, (4) Treatment Toxicity, (5) Other Symptoms, and (6) Information and Care Planning.The study cohort (n = 118) was almost all male (2% female) and mean age was 65.9 years (standard deviation [SD] 9.9 years). The most common cancers were lung and head and neck cancer (23% each); 17% had prostate cancer; 13% had colorectal cancer; and the rest (24%) had breast, esophageal, stomach, genitourinary, liver/biliary, or pancreas cancer. Patients received 51% (95% confidence interval [CI] 48%-54%) of recommended care. Adherence to recommended care within domains ranged from 38% (95% CI 35%-42%) for Other Symptoms to 79% (95% CI 73%-86%) for Information and Care Planning.This study suggests that the quality of supportive care for patients with advanced cancer can be greatly improved. Future efforts should use the ASSIST indicators to evaluate the quality of supportive care in larger and more diverse cohorts of advanced cancer patients.
A fibrilação atrial (FA) é uma arritmia cardíaca comum que afeta milhões de pessoas globalmente, aumentando o risco de morte e outras complicações graves, como acidente vascular cerebral (AVC) e demência. Apesar dos avanços científicos, o manejo da FA ainda enfrenta desafios. A condição muitas vezes é assintomática, mas pode causar sintomas como palpitações, dispneia e fadiga. O diagnóstico é confirmado pelo eletrocardiograma (ECG), que mostra ritmo cardíaco irregular e ausência de onda P. Estratégias de tratamento visam melhorar os sintomas, reduzir o risco de AVC e controlar fatores de risco como obesidade e hipertensão. A prevalência da FA está em ascensão, especialmente devido ao envelhecimento da população e fatores de risco como obesidade e hipertensão. O diagnóstico pode ser desafiador devido à natureza assintomática em alguns pacientes, mas avanços em dispositivos vestíveis têm facilitado a detecção precoce. O tratamento inclui anticoagulação para prevenir AVC, controle da frequência cardíaca e do ritmo, e possivelmente ablação por cateter para controlar o ritmo em pacientes sintomáticos. A abordagem terapêutica é individualizada, considerando o risco de sangramento e as comorbidades do paciente. Anticoagulantes orais diretos (DOACs) são preferidos devido ao seu perfil de risco de sangramento e facilidade de uso. O controle do ritmo pode ser alcançado com medicamentos como flecainida e amiodarona, ou através de ablação por cateter em casos refratários. Em resumo, a FA é uma condição cardíaca comum e séria que requer uma abordagem multidisciplinar para melhorar a qualidade de vida dos pacientes e reduzir complicações graves como AVC. O diagnóstico precoce, o manejo dos fatores de risco e opções terapêuticas eficazes são cruciais para lidar com essa condição complexa.
6011 Background: A prior study using administrative data from 2001-2004 suggested VHA patients were less likely to receive cancer-directed therapy for NSCLC. We conducted chart reviews to assess VHA quality of NSCLC care and how often recommended therapy was foregone due to personal preference or clinical judgment. Methods: NSCLC cases diagnosed in 2007 were identified by VHA Central Cancer Registry. Exclusion criteria included death or hospice ≤30 days of diagnosis or clinical trial enrollment. Data were abstracted from medical records to calculate percent of eligible patients fulfilling quality indicator (QI) specifications: (1) resection for Stage I/II, (2) adjuvant chemotherapy for Stage II/IIIA, (3) chemoradiation for unresected Stage III, (4) platinum-based chemotherapy for Stage IV. Criteria for meeting QIs were receipt of recommended treatment, patient refusal, or contraindication – i.e., documented reason why specified care was inappropriate, including poor performance status (PPS). Results: Among 3414 eligible patients nationwide, QI performance was: Stage I/II resection 98%; Stage II/IIIA chemotherapy 80%; Stage III chemoradiation 88%; Stage IV chemotherapy 96%. Of Stage I/II patients, 7% refused surgery and 35% had a contraindication. Of resected Stage II/IIIA patients, 12% refused chemotherapy while 15% of unresected Stage III patients refused treatment and 57% had a contraindication to chemotherapy, radiation, or both. Chemotherapy was documented as inappropriate in 9% of advanced NSCLC patients; <1% refused it. Compared to white patients, higher proportions of black patients refused surgery or had PPS documented as a reason to forego it (p<0.01), though refusal and PPS rates did not differ by race for other treatments. Black patients were more likely to have a contraindication to radiation (p<0.01). Conclusions: VHA performance on NSCLC treatment QIs is higher than previously shown, though a substantial number of patients do not receive therapy due to refusal or reasons why specified care is inappropriate. Racial disparities may be explained, in part, by personal preference and contraindications.
213 Background: Quality measures based on chart abstraction are the “gold-standard,” but the costs of measurement limit widespread adoption. Electronically specified measures (e-measures) promise to change this; however, the fidelity of electronic abstraction compared to chart abstraction is unknown. We sought to validate e-measure versions of VHA-developed prostate cancer quality of care measures. Methods: Quality measures were chart abstracted on 11,263 men in the VHA with incident prostate cancer in 2008. We identified and linked VHA cancer registry and administrative data for the same cohort. E-measures were specified iteratively and validated by comparing the sensitivity and specificity of measure denominators and numerators, and the overall pass rates to chart abstracted results. Results: 3 of 6 quality measures and 7 of 10 descriptive measures were successfully validated (see Table). Conclusions: The VHA’s electronic medical record environment and information technology infrastructure are sufficiently advanced to support valid e-measurement that is equivalent to that performed by chart abstraction. [Table: see text]
Since September 2017, standing electric scooters have proliferated rapidly as an inexpensive, easy mode of transportation. Although there are regulations for safe riding established by both electric scooter companies and local governments, public common use practices and the incidence and types of injuries associated with these standing electric scooters are unknown.
Objective
To characterize injuries associated with standing electric scooter use, the clinical outcomes of injured patients, and common use practices in the first US metropolitan area to experience adoption of this technology.
Design, Setting, and Participants
This study of a case series used retrospective cohort medical record review of all patients presenting with injuries associated with standing electric scooter use between September 1, 2017, and August 31, 2018, at 2 urban emergency departments associated with an academic medical center in Southern California. All electric scooter riders at selected public intersections in the community surrounding the 2 hospitals were also observed during a 7-hour observation period in September 2018.
Main Outcomes and Measures
Incidence and characteristics of injuries and observation of riders' common use practices.
Results
Two hundred forty-nine patients (145 [58.2%] male; mean [SD] age, 33.7 [15.3] years) presented to the emergency department with injuries associated with standing electric scooter use during the study period. Two hundred twenty-eight (91.6%) were injured as riders and 21 (8.4%) as nonriders. Twenty-seven patients were younger than 18 years (10.8%). Ten riders (4.4%) were documented as having worn a helmet, and 12 patients (4.8%) had either a blood alcohol level greater than 0.05% or were perceived to be intoxicated by a physician. Frequent injuries included fractures (79 [31.7%]), head injury (100 [40.2%]), and contusions, sprains, and lacerations without fracture or head injury (69 [27.7%]). The majority of patients (234 [94.0%]) were discharged home from the emergency department; of the 15 admitted patients, 2 had severe injuries and were admitted to the intensive care unit. Among 193 observed electric scooter riders in the local community in September 2018, 182 (94.3%) were not wearing a helmet.
Conclusions and Relevance
Injuries associated with standing electric scooter use are a new phenomenon and vary in severity. In this study, helmet use was low and a significant subset of injuries occurred in patients younger than 18 years, the minimum age permitted by private scooter company regulations. These findings may inform public policy regarding standing electric scooter use.
Abstract Objective: To analyze the first referral service for rare diseases accredited by the Brazilian Ministry of Health, focusing on referral from the primary healthcare network through to diagnosis. Methods: This is a descriptive study with patients treated between 2016 and 2021 at a referral hospital service located in Curitiba, Paraná, Brazil. Clinical and epidemiological data were obtained from medical records, as were the results of genetic tests at the hospital’s clinical analysis laboratory. Qualitative data were expressed as absolute and relative frequencies, while quantitative data were expressed as medians and interquartile ranges and compared using the Kruskal-Wallis test. Results: The study included 1,751 cases, 34.1% were diagnosed with rare diseases, with average time until diagnosis being 3.0 years, whereby mucopolysaccharidosis type II (4.0%) and tuberous sclerosis (3.9%) were the most common. Greater length of time for obtaining diagnosis (p-value 0.004) and receiving specialized care (p-value<0.001) was found in patients from the interior region of Paraná state, compared to those residing in Curitiba city and its metropolitan region. Conclusion: Diagnosis of rare diseases occurred in approximately one third of cases. The average time until diagnosis suggests a possible positive impact of implementing the referral service. The longer time until diagnosis and specialized care found among patients from the interior region of Paraná represent challenges regarding adequate referral to specialized services.
In discrete choice experiments, patients are presented with sets of health states described by various attributes and asked to make choices from among them. Discrete choice experiments allow health care researchers to study the preferences of individual patients by eliciting trade-offs between different aspects of health-related quality of life. However, many discrete choice experiments yield data with incomplete ranking information and sparsity due to the limited number of choice sets presented to each patient, making it challenging to estimate patient preferences. Moreover, methods to identify outliers in discrete choice data are lacking. We develop a Bayesian hierarchical random effects rank-ordered multinomial logit model for discrete choice data. Missing ranks are accounted for by marginalizing over all possible permutations of unranked alternatives to estimate individual patient preferences, which are modeled as a function of patient covariates. We provide a Bayesian version of relative attribute importance, and adapt the use of the conditional predictive ordinate to identify outlying choice sets and outlying individuals with unusual preferences compared to the population. The model is applied to data from a study using a discrete choice experiment to estimate individual patient preferences for health states related to prostate cancer treatment.
Background: Intravenous recombinant tissue plasminogen activator (IV rt-PA) is the only FDA approved thrombolytic treatment for acute ischemic stroke offering at least a 30% chance of improvement over placebo. Purpose: The purpose of the study was to examine the effect of hypertension (HTN) and other various covariates of patients receiving IV rt-PA thrombolysis treatment for ischemic stroke on clinical outcome scores over time: mRS (modified Ranking Scale) & NIHSS (National Institute of Health Stroke Scale). Methods: A retrospective analysis utilized repeated measures design (SAS Windows version 9.3) on patients receiving IV rt-PA thrombolysis treatment for ischemic stroke from Jan 1, 2012 to Dec 31, 2012. The total cohort used for analysis, N=60. Two cases were not included due to death. Baseline measures were taken at admission and one follow-up time point at discharge. All covariates were included first in univariate models. Those which were found to be significant were then included in multivariate analysis. All statistical significance tests were 2-sided, α=.05 was considered statistically significant. Results: In univariate analyses, there is a significant time effect (p=0.0001), evidenced by the decrease in NIHSS over time and a significant difference in average NIHSS scores between those with and without HTN (p=0.0016). A test of interaction of HTN status by time was not significant ( p >0.05). NIHSS scores appear to decrease faster for those without HTN, however, this difference in rate is not significant. Not having HTN was associated with a decrease in mean NIHSS score over time, while having a hemorrhagic transformation (HT) is associated with an increase in mean NIHSS score. Age, gender, ethnicity, and IV rt-PA door to needle time were not found to be significant predictors of mean NIHSS scores over time. Conclusions: Patients with hemorrhagic transformation were associated with poorer clinical outcomes, as expected. These patients receiving IV rt-PA for acute ischemic stroke generally improved, as expected. It was interesting to note that individuals with HTN appear to be admitted and discharged with higher NIHSS scores versus those without HTN, despite HTN being promptly treated when present. This demonstrates the importance of HTN prevention and blood pressure control treatment.
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