bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patients who discontinued statin treatment: a protocol for cohort study using primary care data
Authors: Vinogradova Yana , Coupland Carol , Brindle Peter , Hippisley-Cox Julia 
Published: October 2015

IntroductionRisk thresholds for using statins to prevent cardiovascular disease (CVD) have recently been lowered, so an increasing number of patients are now prescribed these drugs. Although the safety of long-term statin use has been generally established, concerns about the balance of risks and benefits of statins still exist for some medical professionals and patients, and issues concerning their side effects are occasionally widely publicised. This study will report the rates of stopping for statins and also identify any patient groups more likely to stop using statins, so possibly increasing their risk of cardiovascular events.Methods and analysisA prospective open cohort study between 1 January 2002 and 30 September 2014 will be based on the general population of people prescribed statins, using records from UK general practices contributing to the Clinical Practice Research Database (CPRD). Participants aged 25–84 years will enter the cohort on the date of their first prescription for a statin and leave on the earliest date of: a cardiovascular event; death; leaving the practice; the last practice upload date or the study end date. If there are no prescriptions within 90 days after the expected finishing date of a prescription, a patient will be defined as a stopper with the discontinuation outcome date as the expected finishing date. Rates of statin discontinuation will be calculated by calendar year, type and dose of statin, age, and morbidities. Cox proportional regression analyses will be run to identify the most important factors associated with discontinuation. Analyses will be run separately for patients without CVD (primary prevention) and with diagnosed CVD (secondary prevention).Ethics and disseminationThe protocol has been reviewed and approved by Independent Scientific Advisory Committee for MHRA Database Research. The results will be published in a peer-reviewed journal.
STANDARDIZATION AND IMPROVEMENT IN PEDIATRIC CELIAC CARE
Authors: Boyle Brendan , Ediger Tracy , Trout Anne , Wegener Neal , Ramachandran Sandhya , Cummings Mike , Reber Stephanie , Hill Ivor 
Published: October 2015

BackgroundLiterature describing practitioner adherence with guidelines for follow up care in patients diagnosed with celiac disease (CD) is limited. NASPGHAN CD guidelines recommend all newly diagnosed patients have repeat serology testing 6 months after diagnosis. Adherence with these recommendations has not been previously described.ObjectivesTo review institutional adherence with national guidelines for patients newly diagnosed with celiac disease. We aimed to increase the percentage of patients having repeat serology testing within 9 months of diagnosis from a baseline of 54% to 90% by December 2015.MethodsKey drivers to improvement included the creation of a reliable, tracking registry and the implementation of a local standard of care. The celiac QI team outlined these divisional expectations through practitioner educational sessions and reporting of practitioner adherence with national guidelines. Improved utilization of administrative staff systematically identified cohorts of patients in need of follow up visits and testing.ResultsBaseline data showed the percentage with repeat testing within 9 months of diagnosis was 54.8% (Q4 2009–Q4 2012). Standardizing care and tracking outcomes increased this percentage to 72.8% (Q1 2013–Q2 2015)-p=0.000. The percentage of patients with a follow up clinic visit within 9 months of diagnosis has increased from a baseline percentage of 82.2% (Q4 2012–Q4 2013) to our current percentage of 96.6% (Q1 2014–Q2 2015)-p=0.000.ConclusionsTargeted communication with practitioners and families after development of a CD patient registry at our institution allowed structured data capture and significantly improved institutional adherence with national guidelines.Figure 1Percentage of patients with serology testing within 9 months of diagnosis.Figure 2Percentage of patients with a follow-up GI visit within 9 months of diagnosis.
REDUCING THE INCIDENCE OF CLABSI IN LATIN AMERICAN ICUS: A MULTI-COUNTRY QUALITY IMPROVEMENT COLLABORATIVE. PRELIMINARY RESULTS FROM THE SECOND PHASE
Authors: Arrieta Jafet , Delgado Pedro , Orrego Carola , Giuffre Carolina , Rodríguez Viviana , Elorrio Ezequiel García 
Published: October 2015

BackgroundCentral line-associated bloodstream infections (CLABSI) are the leading cause of healthcare-associated bloodstream infections, prolonging hospitalizations, and increasing morbidity, healthcare costs and mortality. The CLABSI rate has been estimated at 7.6 episodes per 1,000 central line days in Latin America. In developing countries, CLABSI are usually the result of a failure to follow evidence-based, standardized health practices.ObjectivesThe second phase of the ‘Goodbye Bacteremia' campaign aimed at reducing the CLABSI rate in Latin American Intensive Care Units (ICUs) by 50% or to less than 2 episodes per 1,000 central line days from self-reported baseline within 12 months of the implementation of the campaign.MethodsDesign: Uncontrolled before-and-after CLABSI rates comparison.Setting: 100 ICUs from six Latin American countries.Intervention: We used a quality-improvement collaborative to promote the adoption of bundles of care for the insertion and maintenance of central lines, coupled with education through virtual bi-weekly learning sessions, and continuous feedback, from June 2014 to June 2015.Main outcome measure: CLABSI rate.ResultsThe preliminary reduction on the CLABSI rate was 24.34% from a baseline mean of 2.67 to 2.02 at the end of the campaign. The median CLABSI rate was zero throughout the campaign. The mean percentage compliance increased by 49.49% from a baseline of 65.55% to 97.99% at the end of the campaign for the insertion bundle, and by 14.86% from 82.56% to 94.83% for the maintenance bundle.ConclusionsEvidence-based interventions and multi-country collaborative work contributed to a significant reduction in the incidence of CLABSI in Latin American ICUs.
VULNERABLE CHILDREN AND THEIR CARE QUALITY ISSUES: A DESCRIPTIVE ANALYSIS OF A NATIONAL DATABASE
Authors: Omar Adhnan , Rees Philippa , Evans Huw Prosser , Williams Huw , Cooper Alison , Banerjee Sophie , Hibbert Peter , Makeham Meredith , Parry Gareth , Donaldson Liam , Edwards Adrian , Carson-Stevens Andrew 
Published: October 2015

BackgroundGlobally, two in five children are deemed vulnerable by virtue of their physical, psychological and social characteristics. These children are at increased risk of sub-optimal care and disproportionate levels of iatrogenic harm. There remains a paucity of literature describing initiatives for practice improvement for these children.ObjectivesIdentify safety reports describing vulnerable children in the England and Wales National Reporting and Learning System (NRLS). Characterise reports in terms of what happened and reported causative issues, in order to identify key change concepts (drivers) and related interventions (change ideas) for improvement.MethodsAn operational definition of ‘vulnerability in children’, including key domains and related keywords (Appendix 1, 2), was empirically informed by a scoping review of the published and grey literature. Relevant reports were descriptively analysed. The free text of the four most frequent incident types (Pareto principle) was discussed by a multi-disciplinary team to identify key concepts for improvement.Results2,015 reports were identified involving vulnerable children. The problem areas identified primarily resulted from a fragmentation of care services. This included inefficient transfer of information between primary care services; failure to operationalise care plans in practice; and inconsistent access to healthcare services. Reported causes are outlined in an Ishikawa diagram (figure 1) and summarized in the related driver diagram (figure 2) to mitigate problem areas.ConclusionsAnalysis of patient safety incident reports assisted in the pragmatic identification of key concepts for healthcare professionals to begin more informed discussions about improving the care delivered to vulnerable children.Figure 1Ishikawa diagram illustrating causative factors contributing to patient safety incidents.Figure 2Driver diagram for improved safety and quality of healthcare of vulnerable children in primary care.Appendix 1Process of generating key terms.Appendix 2Process of generating key terms (continued).
PREDICTING OUTCOME MEASURE PERFORMANCE THROUGH MONTE CARLO SIMULATION
Authors: Scoville Richard , Ng Manwai , Parry Gareth , Faniyan Abiola , Richman Adam , Evans Arthur 
Published: October 2015

BackgroundImprovement initiatives rely on measures to assess their impact. When outcomes are expressed as percentages, unanticipated changes to the denominator due to complexities and interactions among processes, population and contextual factors can result in measures that fail to register real improvements. For example a pediatric oral health collaborative focused on the incidence of new dental caries as a key measure. Despite uptake of process changes, a prevalence measure failed to register associated improvement in appointment rates (fig 1). Data exploration suggested the measure was confounded with exposure to process changes and recruitment of new patients.ObjectivesTo assess whether applying Monte-Carlo simulation can help project designers test the performance of outcome measures under an array of anticipated conditions.MethodsData were obtained via a database application installed at each practice which calculated monthly collaborative measures using standard definitions, and produced a file that was uploaded to the collaborative team.A template with a Monte-Carlo simulation platform was constructed to model a typical practice panel. Random variables modeled patient appointment intervals based on hypothetical subpopulations with varying appointment compliance.ResultsThe model tested two alternative definitions of caries incidence, and suggested that a modified definition would more accurately reflect improvements in caries incidence (fig 2).Based on predictions, the application was modified to incorporate two alternative operational definitions, which were then applied retrospectively by selected practices.Data using the revised definitions more closely conformed to simulated predictions (fig 3).ConclusionsMonte Carlo simulation enables advance testing of alternative operational definitions to optimize measure performance.Figure 1Original measure.Figure 2Simulation results: alternative definitions.Figure 3Results: individual team data.
PEDIATRIC CATHETER ASSOCIATED URINARY TRACT INFECTION REDUCTION – AN ACHIEVABLE GOAL
Authors: Fetzer Mike , Humphrey Rhonda , Stack-Simone Stephanie , Stoverock Linda , Groner Jonathan 
Published: October 2015

BackgroundAccording to the Association for Professionals in Infection Control, urinary tract infections are among the most common of healthcare-associated infections (HAIs), accounting for 25.6 percent of all hospital HAIs. 70%–80% of healthcare-associated UTIs are caused by indwelling urethral catheters. Catheter-associated urinary tract infections (CAUTIs) are associated with increased morbidity, mortality, hospital cost, length of stay, and antimicrobial use.ObjectivesThe aim of this project was to decrease our hospital-wide CAUTI rate from 1.3 to <= 0.7 infections per 1000 catheter days.MethodsA multidisciplinary team implemented a comprehensive strategy to decrease CAUTIs and increase patient safety. Evidence based initiatives focused on catheter insertion, utilization, maintenance, and staff/family education. Staff RNs completed simulated insertion training with return demonstration of competency. Daily Goals were completed to reduce unnecessary catheter use. A maintenance bundle was implemented to ensure standardized practice which focuses on the reduction of perineal bio-burden. Staff huddles were required after each CAUTI to determine root causes.ResultsIn 2013–2014, the CAUTI annual rate was 1.3 infections per 1000 catheter days. To date in 2015, the rate is 0.6 infections per 1000 catheter days. The Pediatric Intensive Care Unit has decreased its rate from 2.9 in 2014 to zero in 2015. In addition to reduction in our CAUTI rate, we achieved 193 days between infections.ConclusionsPublished guidelines suggest that implementing evidence based practices can reduce CAUTIs. Our approach resulted in patient care standardization and reduction in patient harm. The reduction strategies used may help positively impact care in other hospitals.Figure 1Figure 2
REDUCING SERIOUS HARM FOR PEDIATRIC CARDIAC INPATIENTS AT A LARGE CHILDREN'S HOSPITAL
Authors: Cooper David , Storey Jean , Mustin Laurie , Anderson Jeffrey , Hanke Sam , Clarke-Meyers Katie , Brown James , Simon Katie , Kimball Thomas 
Published: October 2015

BackgroundSerious harm is a composite outcome that includes the following 10 preventable patient morbidities: Catheter-Associated Blood Stream Infection (CA-BSI), Catheter-Associated Urinary Tract Infection (CA-UTI), Ventilator Associated Pneumonia (VAP), Pressure Ulcer, Serious PIV extravasation, Level 6–9 Adverse Drug Events, Surgical Site Infection (SSI), Serious Falls, Preventable Codes Outside ICU, and Surgical Sentinel Events. Failure to prevent harm results in increased length of stay, cost and mortality.ObjectivesIn efforts to improve system level safety outcomes for cardiac patients, the Heart Institute Safety, Quality and Value leadership aligned strategic priorities and projects across our microsystems to reduce serious harm.MethodsPareto charts identified the largest contributors to serious harm in the Heart Institute. Active QI work was then prioritized to these areas with focused QI consultant and data support. PDSA cycles were then used to test and implement change. Process control charts were used to evaluate change in the Serious Harm rate.ResultsThe largest contributors to harm were identified as CA-BSI, SSI and VAP. For FY15, we were able to reduce Serious Harm from 22.8 to 20.5 per 10,000 patient days and the Centerline was shifted from 30.0 to 18.1 per 10,000 patient days.ConclusionsHaving leadership take a system level approach to drive and support alignment of QI projects resulted in reduction of Serious Harm to cardiac patients. This can be spread to other HI programs to achieve similar results.Figure 1Figure 2
CREATING CULTURES OF SAFETY: PARADOXICAL EFFECTS OF IDENTICAL SAFETY CULTURE INTERVENTIONS ON INPATIENT HOSPITAL UNITS
Authors: Chiou Howard 
Published: October 2015

BackgroundOur knowledge of how to create safety cultures is extremely limited. This research utilized an unusual opportunity to longitudinally study how the same intervention—an evidence-based bundle, including bedside multidisciplinary rounds and a quality-safety checklist—altered culture differently on three inpatient hospital units.ObjectivesUsing methods from both anthropology and quality improvement, this research evaluates the dynamic process of implementing a highly complex culture change intervention by: (1) describing the units at baseline, (2) characterizing the transformation of units during implementation, and (3) identifying the activities and contextual factors that accelerated or hindered the implementation process.MethodsThree inpatient internal medicine units in the US and Australia were studied over two years. Data collection included over 420 hours of ethnographic participant observation, 102 semi-structured interviews with hospital staff, and 141 safety culture questionnaires. Qualitative data was coded and analyzed using modified grounded theory, and triangulated against the quantitative using iterative constant comparison and cross-case analysis.ResultsThe intervention successfully disrupted cultural norms on one unit, but unexpectedly failed to do so at another. The implementation was well-resourced and consistent between units. However, the failed unit suffered from an inadvertent reinforcement of hierarchy within rounds, mutations in the meaning of checklists, and interactions with local hierarchies and conceptions of nurse-patient relationships.ConclusionsThis research informs the design of subsequent culture change interventions, as reports of failure to change culture are rare in the literature. This study uniquely expands previous understanding by building a framework based in the social sciences for understanding and changing safety culture.
USE OF QUALITY IMPROVEMENT (QI) METHODOLOGY TO DECREASE LENGTH OF STAY (LOS) FOR NEWBORNS WITH UNCOMPLICATED GASTROSCHISIS
Authors: McClead Rick , Ryshen Gregory , Dail James , Gossard Mary , Dienhart Molly , Aldrink Jennifer 
Published: October 2015

BackgroundGastroschisis (G), an abdominal wall birth defect, can be repaired surgically, but recovery, feeding advancement, and subsequent hospitalization (LOS) can be prolonged.ObjectivesWe aimed to decrease LOS of G patients from a baseline of 41 days (n=26 patients) to 34 days by December 2010 and sustain for 6 months.MethodsIn 2009, a QI team was established to reduce LOS. Subjects were newborns >34 weeks gestation with uncomplicated G. Model for Improvement and SPC methodology were used. Rational subgroup analysis (RSA) was used to assess impact of surgical approach and other factors on LOS. Subgroup medians were compared via ANOVA of log-transformed data.ResultsFrom June 2010 to August 2015, 100 subjects were evaluated. Special cause variation in LOS was not detected until July 2014. A new baseline of 27 days was established figure 1. RSA revealed a longer LOS for patients undergoing a silicon silo procedure in the operating room (OR) for gradual reduction of abdominal contents followed by a later secondary OR abdominal closure (n=27; LOS, 44.5 days; IQR, 33.5 days) compared to patients undergoing either a primary OR closure (n=48; LOS, 29 days; IQR, 14 days) or a bedside silo placed under local anesthesia followed by secondary OR closure (n=25; LOS, 30 days; IQR, 16 days). (p<0.001). (figure 2 and 3)ConclusionsStandardized care and a change in surgical approach decreased LOS 34% in newborns with G. The causal relationship between LOS, multiple anesthesia and/or excessive bowel manipulation remain to be determined.Figure 1Figure 2Figure 3
UNDERSTANDING VARIATION IN SUCCESS IN A QUALITY IMPROVEMENT INITIATIVE IN SASKATCHEWAN, CANADA.
Authors: Groot Gary , McMullen Linda , Hamilton Jessica , Schwartz Laura 
Published: October 2015

BackgroundUnexplained variation in clinical practice can be an indicator of poor quality of care. In Saskatchewan, Canada the Variation and Appropriateness Working Group (VAWG) engaged three clinical working groups (CWG) to consider the causes of variation in surgical practice.ObjectivesUsing the Model for Understanding Success in Quality Improvement (MUSIQ) framework, we conducted a qualitative study aimed at exploring VAWG's successes and barriers.MethodsWe used semi-structured interviews, meetings notes, and VAWG project documents as data for understanding the functioning and context of the CWGs.ResultsOur comparison of the CWGs highlights the similarities and differences between these groups. All groups identified next steps for understanding the root causes of variation; however, even in the CWG that exhibited positive micro contextual attributes and that made the most progress, success was limited due to the external environment common to all three CWGs. The external environment, the Saskatchewan health care system, did not signal that this work was a priority and physicians did not have the structural support needed to fully engage and advance this work.ConclusionsOur research highlights the importance of both micro and macro contextual factors critical to the success of physician-driven quality improvement. The MUSIQ framework identifies features of the Saskatchewan context that can be built upon, and areas were significant work and investment is needed to increase the likelihood of success in future projects. Lessons learned are impacting the implementation of subsequent work; however, there are still critical factors to be addressed in Saskatchewan.
REDUCING LABORATORY TESTING IN A TERTIARY MEDICAL CENTRE: A RESIDENT-LED MULTILEVEL QUALITY INTERVENTION
Authors: Lee Matilda Xw , Choong Clarice , Teo Winnie ZY , Fan Kristie HR , Lim Lye Heng , Ong Lizhen , Saw Sharon , Lim Tow-Keang , Santosa Amelia , Lahiri Manjari 
Published: October 2015

BackgroundHospital in-patient laboratory testing is steadily rising, contributing to increasing healthcare costs, errors, and unnecessary treatments. Strategies to reduce over-utilization of laboratory tests have been tried with mixed results.ObjectivesTo reduce the volume of the most frequently ordered laboratory tests by 10% over 6 months.MethodsThe most commonly ordered tests in medical wards were determined and a survey was conducted among residents and faculty to determine the perceived causes of over-testing. A resident-led multilevel collaborative campaign was launched. This comprised of education sessions (intern and resident teaching), cost awareness information (mini cards, computer screensavers), publicity (reminders to on-call teams), regular audits and feedback. The focus was on changing test ordering behavior and culture. Monthly average test numbers were compared with those in the preceding year.ResultsThe campaign was launched in 8 medical wards from the period of September 2014 to February 2015. The top 6 laboratory tests/panels (full blood count, renal panel, calcium panel, liver panel, C-reactive protein and acute coronary screen) were selected based on order-volume. There was a 9.4% reduction in tests ordered during the study period, resulting in costs savings estimated at $34,235 per month. Results were sustained over the 6-month study period. Reduced testing had no effect on in-hospital mortality (3.17% post-intervention vs. 3.02% pre-intervention, p=0.47).ConclusionsThe development of a multilevel collaborative initiative resulted in reduction in test-ordering and significant and sustained costs savings. Approaches targeting culture change may be a feasible method of maintaining a lean health care system.Figure 1Run chart.Figure 2Overview of tests per patient day.Figure 3Overview of tests per patient.