139 e-Letters

  • Acute frailty in the community

    I work in a hospital at home (H@H) service and have found the AFN website a very useful learning resource and regularly recommend it to my Clinical practitioners and nurses. Read the paper with interest and tend to agree with the conclusion reached by the authors.
    Given that the flow of patients to hospital are from the community the way we deal with an acute frailty crisis in the community needs to be looked at. The atypical presentation of acute illness in the frail older person coupled with the move to virtual consultations ( due to work pressure on GPs) has led to a delay in the diagnosis and treatment of acute illness in this group of patients. We often come across the scenario of patients being prescribed multiple courses of antibiotics when the underlying diagnosis is not an infection. The consequence is that the patients become deconditioned even before they enter an Acute frailty unit (AFU) making them less responsive to all the interventions prescribed. I am sure a proportion of patients on an AFU do not need to be there if their acute illness was dealt with promptly in the community.
    A H@H service is well placed to deal with acute frailty crisis in the community but needs to be able to respond in a timely way to the high risk frail older population which are care home residents, the housebound older patient and the frail older person on the ambulance stack waiting a paramedic response. If this service is well resourced it will enable an AFU to...

    Show More
  • A Poor Statistical Approach is Better than Not Having an Approach

    Dear BMJ Quality and Safety,

    Having perused the article titled "Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review," I found it captivating and of great significance. The notion behind this study is quite innovative, as it tackles the concerns of policymakers who worry about the potential to erroneously misdiagnose emergency patients, who indeed are in the most need of care. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.

    Given my keen interest in this study, and to enhance its quality and the reliability of the final findings, I would like to offer a few suggestions.

    I find that the authors have stated that they dropped the chance for a quantitative meta-analysis as they found substantial heterogeneity. I agree with them on decreased reliability of a pooled estimate with high heterogeneity. However, I believe that a quantitative estimate, even accompanied by considerable heterogeneity, is still much more convenient for readers to infer and relate. In fact, having a high heterogeneity is a good chance for authors to investigate the factors and covariates, providing a more precise insight into the complex relationships, and substantially improving the quality of the study. Therefore, I suggest an appendix that provides such data. Providing the limitation...

    Show More
  • Prescribing medications with indications: the script has been flipped

    In the editorial authored by G.D. Schiff, B. L. Lambert, and A. Wright, the concept of "indication-based prescribing" is explored. This involves clearly documenting the reason, or indication, for prescribing a medication and linking it to the prescription itself. Despite recommendations and evidence supporting its potential to enhance medication safety and patient comprehension, this essential piece of information is frequently absent from current practices.

    The authors advocate for a drastic reimagining of the prescription process. Rather than treating the indication as a supplementary detail, it should serve as the inception point. Under this proposed model, the prescriber would initially enter the medical condition to be addressed. The electronic prescribing system would then recommend the most appropriate and evidence-based medication for the patient. This suggestion, although raising issues about autonomy and trust, is posited to elevate prescription safety, patient education, medication reconciliation, deprescribing, and efficiency in prior authorization processes.

    A further innovative proposal places the prescriber in full control. We have developed clinical decision support software enabling the prescriber to begin with either a) an indication, b) a medication, or c) the administration route. The software then filters the remaining pertinent options. As the combination of these three elements, along with the patient's specific context,...

    Show More
  • 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 the...

    Show More
  • Better consistency and quality with the use of CDSS (Clinical Decision Support Systems)

    The authors of this paper describe GP decision-making as ‘good but not good enough’. Their paper also highlights considerable variation among clinicians with the highest referrers being more than two times more likely to refer patients with red flag symptoms for cancer investigation than the lowest referrers. When we consider this wide disparity among individual doctors, we must look at how we can objectively and consistently reduce this. How can we make the diagnostic process in primary care ‘reliable, not heroic’ [1]?

    Previous papers have considered interventions that can reduce the global burden of diagnostic errors in primary care [2], including the use of information technology tools. Perhaps we can consider that better use of technology such as Clinical Decision Support Systems (CDSS) could improve clinical diagnostics especially in those areas with clear guideline-based practice such as in the decision to refer urgently for suspected cancer [3]. These tools can be used to provide appropriate suggestions for differentials at any point in the clinical consultation or offer ‘alerts’ at the end of the consultation if there are important diagnoses that haven’t been considered [4].

    Uptake of CDSS has been poor [5] and clinician response to these tools when they have been implemented are mixed [6] despite them showing that they increase physician’s diagnostic accuracy [7, 8]. At present, clinical work mostly only uses inconsistently implemented ‘alerts’. Some...

    Show More
  • Inadequate limitations

    We feel that this article and accompanying press release have failed to fully acknowledge some significant limitations of the study. We feel these limitations are important when making the conclusion that following guidelines by earlier referral would be associated with earlier cancer diagnosis.
    1. There is no recognition that the cancer diagnosed in the year following index consultation may not have any association with the index consultation. For example a non-urgent referral for breast lump who developed bladder carcinoma in the following year would be included as someone who could have benefitted from earlier referral.
    2. There is no attempt to acknowledge screening cancer diagnoses. Again these would be included despite them being unrelated to any previous “red flag” symptoms.
    3. Most significantly, there is no acknowledgement that not “following guidelines” is often an important part of shared decision-making that prevents morbidity related to diagnostic processes and treatment. Although the article explains that co-morbidities and age greater than 85 are associated with lower referral rates; it fails to recognise that any delay in cancer diagnosis in this group would often not be considered a “missed opportunity”,. There is sometimes no clinical benefit to the patient of earlier diagnosis. In relation to this It also fails to recognise that many local 2ww guidelines include severe frailty as an exclusion criteria for an urgent or 2w...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More