134 e-Letters

  • Overuse of diagnostic testing: possible explanations and solutions

    The recent article by Muskens et al "Overuse of diagnostic testing in healthcare: a systematic review" published online on May 10, 2021, admirably describes the prevalence and overuse of low-value diagnostic tests in multiple healthcare settings, but does not offer possible explanations or solutions. Some salient reasons are (1): 1. Physicians do not consider healthcare costs during a diagnostic workup; 2. Malpractice concerns; 3. An excessive fee-for-service mentality--more tests and consultations generate more income; 4. Lack of trust in clinical skills versus high technology testing; 5. Believing that diagnostic workups should eliminate all conceivable etiologies; and 6. Patients may experience greater satisfaction with more testing.

    Underlying these last three possibilities is the failure to appreciate that in science, especially after Darwin, Einstein and Heisenberg, absolute certainty is considered unachievable. Facts and theories, and clinical diagnoses, are now rated on the probability that they are true. A diagnosis is more probable than not, or more probable than another, based on degrees of evidence. Hence recent interest in Bayesianism, which analyses evidence in terms of probability. When determining the efficacy of additional tests, Bayesianism requires a pre-test (a priori) probability estimate of the diagnosis. The more probable a diagnosis is clinically (a priori) and the greater the diagnostician's clinical confidence, the less nec...

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  • Professor Julian Bion

    We thank Professors Marang-van de Mheen and Vincent for their comments [1] on our examination of variations in weekend and weekday admission care quality during the introduction of seven day services in England [2]. Their analysis and logic models demonstrate with admirable simplicity the complexity of these causal pathways.
    One of the pathways which is not highlighted in the literature is how quality of pre-hospital care may impact on the post-admission phase in hospital. Using exploratory data from the 20 hospitals in our data set, we have shown that while in-hospital care quality did not vary between weekend and weekday admissions, and had improved over time, there was a concurrent deterioration in performance indicators related to care in the community preceding hospital admission. Weekend admissions were much less likely to have been referred by family doctors, and more likely to attend hospital by emergency ambulance, to be dependent on others for activities of daily living, and to be candidates for palliative care. These differences became more marked with the passage of time. In a separate single-centre study we have shown that patients admitted at weekends are sicker than those admitted on weekdays [3]. We therefore contend that while there may be opportunities to improve hospital care across all days of the week, the cause for the weekend effect may reside in community healthcare services. As the weekend effect is a global phenomenon [4], policy makers a...

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  • Does CPOE use result in significant decreases to patient harm? A word of caution

    We are writing in response to Abraham et al.’s recent review of systematic reviews (SR) targeting the impact of computerised provider order entry (CPOE) on clinical and safety outcomes [1]. We commend the authors’ inclusion of medication errors and adverse drug events (ADE) among the outcomes assessed. This is particularly timely given the World Health Organisation’s 2017 announcement of the third Global Patient Safety Challenge to motivate actions to reduce medication errors causing actual patient harm by half in five years [2]. Abraham et al. concluded that, based on the evidence reported by three SR of inpatient populations, pooled studies showed significant reduction in ADEs with CPOE use, with considerable variation in the magnitude of relative risk reduction [1]. However, there are significant limitations to the studies on which this conclusion is based, and we believe a more cautious approach should be taken when assessing the current evidence.

    Firstly, as the authors acknowledged, there was variation in the definitions of ADE across the three SR and the 18 studies they included. We agree that these are significant limitations when trying to summarise the impact of CPOE on ADE. To be clear, the included studies assessed preventable ADEs (10 studies) and/or potential ADEs (15 studies), and three studies did not specify the type of ADE. An ADE can be preventable, non-preventable, or potential [3]. A preventable ADE refers to a medication error which reached th...

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  • Adherence Issues in Population with Intellectual Disabilities.

    Adherence Issues in Population with Intellectual Disabilities
    Bernadette Flood PhD MPSI, Pharmacist, Daughters of Charity Disability Support Services

    Link to Original article: Medication non-adherence: an overlooked target for quality improvement interventions

    Commentary on: Medication non-adherence: an overlooked target for quality improvement interventions, Bryony Dean Franklin, Gary Abel, Kaveh G Shojania (2019-12-20). 10.1136/bmjqs-2019-009984

    Non adherence to prescribed medication is a complex problem. The complexity is increased in vulnerable population groups such as the population with intellectual disabilities. A person with an intellectual disability may often be dependent on ‘healthcare by proxy’ where another person makes healthcare decisions on their behalf. People with intellectual disabilities may also be ‘invisible’ to pharmacists dispensing prescribed medicines. Many pharmacists may have little experience of the challenges faced by this high risk group of patients [1] who may be prescribed high risk medications such as diabetic medicines including insulin and anti-epileptic medications. People with intellectual disabilities and their family carers, support workers etc. may be unaware of the consequences of poor adherence to prescribed medicines. The difficulties of involving a parent proxy in a three-way relationship involving an adult at risk of lacking decision-making capacity, their proxy, and a treating clinician have been ra...

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  • Response to Aiken and Sloan

    To the editor,

    In their editorial commenting on our paper “Association of registered nurse and nursing support staffing with inpatient hospital mortality,” [1] Aiken and Sloane misrepresent our study results, conclusions and implications. They characterize our study as examining the impact of substitution of nursing support staff for professional nurses or registered nurses (RNs) (commonly described as skill mix). This is done despite acknowledging that we stated our findings should not be interpreted to mean that nursing aides can safely substitute for RNs. Furthermore, as Aiken and Sloane acknowledge each of us have published multiple studies [2 3] showing efforts to deskill the nursing work force will increase deaths, adverse events and costs. This conclusion was also restated in a recent editorial in this journal by one of us. [4]

    Aiken and Sloane discuss the paper as though it is about skill mix, characterizing our findings as “counter” to our earlier published papers that did analyze skill mix. However, the current paper and the recent Griffith’s paper Aiken and Sloane also reference[5], “examine nursing support staffing not as a substitute for RNs, as studies of skill mix do, but …rather examine the impact of shortfalls in support staffing given established RN- nursing support staffing models.” What our paper and Griffiths paper do is examine shortfalls from established levels of nurse support staffing as a complement of typical RN staffing withi...

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  • NPS MedicineWise evaluation finds changes in general practitioners prescribing of proton pump inhibitors following education programs

    I write in response to the article published in your journal “Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia” (Bruno C et al., BMJ Qual Saf 2019). I am writing as NPS MedicineWise evaluation found a significant impact on general practitioner prescribing of proton pump inhibitors (PPIs) following their educational programs in 2009 and 2015. I acknowledge that the article is well written, the methods are well described, and the approach includes a number of sensitivity analyses. However, I would like to highlight some key points on the analysis methods used that differ from the approach taken by NPS MedicineWise and about which I have some concerns.

    The 2015 NPS MedicineWise educational program on PPIs was part of a larger educational strategy over a decade to support best-practice prescribing of PPIs by general practitioners (GPs) and included Pharmaceutical Benefits Scheme (PBS) feedback to GPs in Australia. This consists of a letter that includes information of the individual GP’s prescribing of PPIs compared to their peers. Programs launched in 2009 and 2018 on PPI prescribing for GPs also included face-to-face educational visits to GP practices. The 2015 campaign, which did not include these face-to-face visits, aimed to reinforce the impact of the earlier 2009 campaign.

    NPS MedicineWise has conducted an evaluation of the 2009 and 2015 education programs on GP prescribing o...

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  • The éléphant in the room

    We thank the French Society of Emergency Medicine for such a large study. However it is difficult to conclude regarding a number of limitations due to the observational cross-sectional study scheme.
    The main critics concern the 3 measurements tools allowing to decide appropriateness of ED visits or not. Appropriate Use Score Method: the authors decide a cut-off based on Italian litterature data which is not French sounded; Possible GP Use Method : it would be more accurate to have an external evaluation instead of a judge and part one ; Resource Utilisation Method : the elephant in the room is the result of consultation and the final diagnostic as well.
    I don’t discuss here the relevance of a number of items as distance between home and ED Departments, medical density and so far.
    Specifically I doubt it is possible to interpret socioeconomic and territorial factors results without diagnostics and diagnostic frequency on June, 11, 2013
    We are looking forward for more studies informing use of ED departments.

  • Specialty differences in patient experience results: The patients or the doctors?

    As a non-physician often working as a researcher with physicians, I didn't know whether to laugh or cry at the explanation in this article as to why certain specialties might get lower patient satisfaction scores than internists. Yes, it may well be that the episodic nature of the encounter with a non-chosen physician leads to lower satisfaction. But given the long history of jokes within medicine based on the personality type differences among specialties, and, one would think, given the authors' personal experiences in say, their last dermatology appointment, might not differences among doctors rather than patient issues be at least be presented as a hypothesis? The briefest of Googling finds a post in the KevinMD blog, directed towards physicians, on "remarkably distinct" cultures. (The blog is here: https://www.kevinmd.com/blog/2018/07/what-personality-type-fits-your-med.... One of the literature links is here: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2923.2011.04099.x)

    I admire the question and rigor the researchers used in answering it. But, in the Discussion, simply assuming "differences in perception must be due to the patient" fails to meet the test of common sense.

  • The problem with non-clinical incident reports

    We can only reiterate the points brought forward by Carl Macrae in “The problem with incident reporting”. In our own work with incident reporting systems in the UK and Austria we observe that an estimated 50% of incident reports are eliminated without further consideration due to their non-clinical nature, even if they may affect patient safety. The remaining clinical reports are then pigeonholed to fit existing medical categories of expertise for further investigation. Hence, current incident reporting practices do not truly reflect the systemic complexities of medical errors, which are composed of both clinical and non-clinical elements. Incident reporting systems in healthcare need to either use more stringent reporting criteria to exclude non-clinical incidents upfront (even if they affect patient safety), but this would mean cutting themselves short of opportunities for whole system improvement. Alternatively, non-clinical reports should be further investigated to determine their potential contribution to (un)safe practice. This is likely to require the inclusion of non-clinical, organisational experts in the analysis of incident reports.

  • Authors response to comment by Maureen E. Burger

    We appreciate the concerns raised and agree that accurately presenting the findings of our study regarding patient-reported possible PICC-related complications is important. We took several steps to ensure transparency in how we presented our data. First, we were vigilant about consistently defining our outcomes as “possible complications” in all key areas of the paper including the main outcomes and conclusions section of the abstract, study measures section in the methods, main findings in the results section and in the discussion. The fact that the term “possible” or “potential” was not always used or some terms appeared to be used interchangeably was to improve readability of the article. In general, however, we were conscientious about clearly noting that we asked patients about signs or symptoms of a potential complication or adverse effect. Second, we purposefully chose to not present the data as complication rates (implying that these were actual events), but as the percentage of patients reporting a given event – thus we faithfully represented what we were told by patients during follow-up assessments. Third, we took these approaches because our primary objective was to accurately present the data collected from our patients; if something mattered enough to a patient to tell us about it, then it should matter to us as healthcare professionals regardless of internal standards that we may use to define serious medical complications. While that’s not to say that f...

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