We were interested to read the recent article on patient safety in remote primary care encounters by Payne et al. We have been reviewing the use of remote consultations specifically for paediatric asthma patients and would like to thank the authors for their work.
Firstly, we agree with the authors’ findings that a remote environment may exacerbate existing inequalities such as economic and language barriers. We would add that an additional factor that must be assessed is a patient’s ability to use technology. Pinnock et al. highlight the risk of virtual consultations to those who lack “e-literacy (or digital healthcare literacy)” (2). These patients must be identified and offered additional support or alternative methods of consultation to maintain the utmost level of care.
Payne et al. highlight the need for a more definitive approach to escalating care rather than a “rule of thumb” or “if in doubt, put it down as urgent” approach (1). We would echo that there need to be clear guidelines and more specific thresholds for escalating care from remote to in-person visits. One suggestion by Galway et al. is having a lower threshold for seeing younger children face to face (3). Galway et al. also suggest having alternative “red-flag” signs that are unique to the remote setting. For example, multiple calls from a patient may indicate the need to escalate their care to face-to-face. More of these red-flag signs unique to this setting need to be...
We were interested to read the recent article on patient safety in remote primary care encounters by Payne et al. We have been reviewing the use of remote consultations specifically for paediatric asthma patients and would like to thank the authors for their work.
Firstly, we agree with the authors’ findings that a remote environment may exacerbate existing inequalities such as economic and language barriers. We would add that an additional factor that must be assessed is a patient’s ability to use technology. Pinnock et al. highlight the risk of virtual consultations to those who lack “e-literacy (or digital healthcare literacy)” (2). These patients must be identified and offered additional support or alternative methods of consultation to maintain the utmost level of care.
Payne et al. highlight the need for a more definitive approach to escalating care rather than a “rule of thumb” or “if in doubt, put it down as urgent” approach (1). We would echo that there need to be clear guidelines and more specific thresholds for escalating care from remote to in-person visits. One suggestion by Galway et al. is having a lower threshold for seeing younger children face to face (3). Galway et al. also suggest having alternative “red-flag” signs that are unique to the remote setting. For example, multiple calls from a patient may indicate the need to escalate their care to face-to-face. More of these red-flag signs unique to this setting need to be identified and then relayed to professionals during specific training on consulting remotely.
Payne et al. highlight that one major challenge to remote consults is the inability to perform physical examination of patients. We agree that the inability to examine a patient means that remote consults are not always appropriate. With particular regards to asthma patients, Eguiluz-Gracia et al. suggested that this limited or inaccurate clinical information can lead to an increased risk of corticosteroid over-prescription (5). As Payne et al. rightly point out, a preliminary rather than definitive diagnosis is perhaps the way forward. Payne et al. also described the limited opportunities for demonstrating or checking patients’ technique, however Agerskov et al. concluded that spirometry can still be effectively carried out remotely (4). Our own recommendation and clinician practice is not to use remote consultations for first diagnostic consultation but rather in a follow-up setting, and instead arrange in-person consultations for an initial diagnosis.
Lastly, we would like to highlight some risks. Payne et al. identify the dangers of relying on information from a third party due to it potentially being inaccurate. In addition to this, another potential danger that requires research is whether remote consultations still enable doctors to safeguard effectively. Southgate et al. also highlight that there is a lack of literature on safeguarding in remote consults (6). We feel that resolving this is paramount to the future of remote consultations and maintaining patient safety.
References:
1. Payne R, Clarke A, Swann N, et al Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis BMJ Quality & Safety Published Online First: 28 November 2023. doi: 10.1136/bmjqs-2023-016674
2. Pinnock H, Noble M, Lo D, et al. Personalised management and supporting individuals to live with their asthma in a primary care setting. Expert Rev Respir Med. 2023;17(7):577-596. doi:10.1080/17476348.2023.2241357
3. Galway N, Stewart G, Maskery J, et al. Fifteen-minute consultation: A practical approach to remote consultations for paediatric patients during the COVID-19 pandemic. Arch Dis Child Educ Pract Ed. 2021;106(4):206-209. doi:10.1136/archdischild-2020-320000
4. Agerskov N, Coughlin S, Parrott H, et al. Quality of Unsupervised Home Spirometry in Children with Asthma. B9. B009 PATIENT, FAMILY, AND PROVIDER EXPERIENCES IN CRITICAL CARE AND CHRONIC PATIENT MANAGEMENT. May 1, 2021, A1088-A1088
5. Eguiluz-Gracia I, van den Berge M, Boccabella C, et al. Real-life impact of COVID-19 pandemic lockdown on the management of pediatric and adult asthma: A survey by the EAACI Asthma Section. Allergy. 2021;76(9):2776-2784. doi:10.1111/all.14831
6. Southgate G, Yassaee AA, Harmer MJ, et al. Use of Telemedicine in Pediatric Services for 4 Representative Clinical Conditions: Scoping Review. J Med Internet Res. 2022;24(10):e38267. Published 2022 Oct 26. doi:10.2196/38267
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...
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 see the right patients at the right time. Both these services cannot work in isolation of each other.
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...
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 limitations and defects in the quantitative synthesis of the evidence, together with a narrative review of the findings, will let readers draw conclusions at their discretion.
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,...
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, can precisely shape the resultant medication order, this system ensures a safe and efficient computerized order entry.
Furthermore, through an innovative computational approach, the order goes beyond simply determining the prescription; it also calculates the preparation and administration of the medication. This allows the same order to be viewed from the perspectives of various stakeholders: the prescriber, pharmacist, nursing staff, and the patient.
The true test of the system lies in its practical application. We've made this system available online for trials. Currently, it incorporates a Dutch dataset of products, dosing rules, and solution rules. However, its principles are universally applicable.
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...
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 patient and resulted in actual patient harm. A non-preventable ADE, or adverse drug reaction, is defined as harm resulting from an unexpected reaction to a drug where there was no medication error. A potential ADE, or near-miss, is typically defined as a medication error with the potential for harm but in which no harm occurred due to patient circumstance or an intervention [3]. In the wider medication safety literature, many studies which assess ADEs do not delineate whether this harm was, the much more frequently occurring, potential harm or the relatively rare actual harm [4].
Further limitations of the studies of ADEs and CPOEs not discussed were the data collection methods. There is significant variation in the methods undertaken by the included studies to identify ADEs. Firstly, there were eight studies using voluntary incident reports as the only source for identifying ADEs. Incident reports are known to result in significant under-estimation of errors and ADEs [5]. Eight studies used the more rigorous chart and record review. Finally, the study designs do not allow for drawing causal conclusions. That is, there were no randomised controlled trials. Except for one cohort study, all the studies used before-after designs, only one of which included a control.
In conclusion, only half the studies (n=10) included assessed the impact of CPOE on actual patient harm resulting from a medication error. Of these studies, only three reported a significant reduction in patient harm, with the most recent data collection completed in 2010. Five studies reported no significant effect and two studies reported an increase. Of the six studies identifying preventable ADE by chart review, three studies reported a significant reduction (a pooled total of 157 events compared to 139 events) and three studies reported no significant effect.
Considering the very significant limitations across studies, we believe there is not yet convincing evidence of the direct impact of CPOE on actual patient harm. This conclusion remains consistent with two earlier umbrella reviews [6, 7].
References:
1. Abraham, J., et al., Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews. BMJ Quality & Safety, 2020: p. bmjqs-2019-010436.
2. Donaldson, L.J., et al., Medication without harm: WHO's Third Global Patient Safety Challenge. The Lancet, 2017. 389(10080): p. 1680-1681.
3. Bates, D.W., et al., Relationship between medication errors and adverse drug events. J Gen Intern Med, 1995. 10(4): p. 199-205.
4. Gates, P.J., et al., Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 2019. 42(8): p. 931-939.
5. Westbrook, J.I., et al., What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care, 2015. 27(1): p. 1-9.
6. Ranji, S.R., S. Rennke, and R.M. Wachter, Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review. BMJ Qual Saf, 2014. 23(9): p. 773-80.
7. Weir, C.R., N. Staggers, and T. Laukert, Reviewing the impact of computerized provider order entry on clinical outcomes: The quality of systematic reviews. International Journal of Medical Informatics, 2012. 81(4): p. 219-231.
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...
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 2ww referral.
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...
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’. Sometimes, these alerts can reduce inappropriate prescribing and improve patient health [9] although poorly implemented alerts can add to the doctor’s burden [10]. Only small studies have previously looked at the acceptability of these alerts [11] which highlights an area rich for further action and research to improve patient outcomes.
Investment in better and more effective technologies in the primary care consulting room has the potential to reduce the disparity between different doctors’ referral rates and provide a more consistent adherence to the cancer referral guidelines potentially increasing our detection rate.
References
1 Schiff GD, Bates DW. Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? New England Journal of Medicine 2010;362:1066–9. doi:10.1056/NEJMp0911734
2 Singh H, Schiff GD, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Quality & Safety 2017;26:484–94. doi:10.1136/bmjqs-2016-005401
3 Graber ML. Reaching 95%: Decision support tools are the surest way to improve diagnosis now. BMJ Quality & Safety Published Online First: October 2021. doi:10.1136/bmjqs-2021-014033
4 Nurek M, Kostopoulou O, Delaney BC, et al. Reducing diagnostic errors in primary care. A systematic meta-review of computerized diagnostic decision support systems by the LINNEAUS collaboration on patient safety in primary care. European Journal of General Practice 2015;21:8–13. doi:10.3109/13814788.2015.1043123
5 Cheraghi-Sohi S, Alam R, Hann M, et al. Assessing the utility of a differential diagnostic generator in UK general practice: A feasibility study. Diagnosis 2021;8:91–9. doi:10.1515/dx-2019-0033
6 Ford E, Edelman N, Somers L, et al. Barriers and facilitators to the adoption of electronic clinical decision support systems: A qualitative interview study with UK general practitioners. BMC Medical Informatics and Decision Making 2021;21. doi:10.1186/s12911-021-01557-z
7 Kostopoulou O, Rosen A, Round T, et al. Early diagnostic suggestions improve accuracy of GPs: A randomised controlled trial using computer-simulated patients. British Journal of General Practice 2015;65:e49–54. doi:10.3399/bjgp15X683161
8 Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX) Generators: A Systematic Review and Meta-Analysis. PLOS ONE 2016;11:e0148991. doi:10.1371/journal.pone.0148991
9 McKibben S, Bush A, Thomas M, et al. An electronic alert to reduce excessive prescribing of short-acting Beta2-agonists for people with asthma in East London: A retrospective case-control study using routine primary care data. In: M-Health/e-health. European Respiratory Society 2020. 1364. doi:10.1183/13993003.congress-2020.1364
10 Cecil E, Dewa LH, Ma R, et al. General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: A qualitative analysis. BMJ Open 2021;11:e045050. doi:10.1136/bmjopen-2020-045050
11 Kelsey EA, Njeru JW, Chaudhry R, et al. Understanding User Acceptance of Clinical Decision Support Systems to Promote Increased Cancer Screening Rates in a Primary Care Practice. Journal of Primary Care & Community Health 2020;11:215013272095883. doi:10.1177/2150132720958832
Conflict of Interest
None declared
2.
Title: “Inadequate limitations”
Author: William P, Hart, Katarzyna, Grellier
In response to the published article Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records"
Rapid response:
Other Contributors:
October 13, 2021
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 by following guidelines, 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 two-week wait guidelines include severe frailty as an exclusion criteria for an urgent or two-week wait referral.
Conflict of Interest
None declared
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...
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 necessary is additional testing. Since it is impossible to prove absence of disease, testing can only support or not support a specific clinical diagnosis.
But there is a quid pro quo: Tests can be harmful and costs uncontrolled. Given the subjective nature of characterizing truth and justifying beliefs, the medical profession might consider differentiating levels of evidence or burdens of proof regarding diagnostic accuracy much as the legal profession does: in less stringent civil cases the burden of proof is preponderant, more likely than not, >50%. In more severe criminal cases the burden of proof is beyond reasonable doubt, indubitable. While this legal dichotomization is probably too simplistic for all clinical issues, it can serve as a guide. Graded burdens of proof for differing clinical presentations could alter physician behavior, enhance patient satisfaction, reduce malpractice concerns, and contribute to lower health care costs without compromising individual patient care.
Parenthetically, after decades of teaching medical students and house staff officers of the importance of clinical skills to minimize excessive testing, I joined a multispecialty healthcare group from which I was eventually dismissed for not ordering enough tests and generating sufficient testing income. My philosophy, which I strongly believe in, came back to bite me.
1. Horowitz SH. Diagnostic decision-making, burdens of proof, and a $6000 per hour memory lapse. JAMA Int Med; 2013;176:1493-1494.
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...
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 and researchers should turn their attention to examining the quality of pre-hospital care at weekends.
1. Marang-van de Mheen PJ, Vincent C. Moving beyond the weekend effect: how can we best target interventions to improve patient care? BMJ Quality & Safety Published Online First: 11 February 2021. doi: 10.1136/bmjqs-2020-012620
2. Bion J, Aldridge C, Girling AJ, et al. Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services National health policy. BMJ Qual Saf 2020. doi:doi:10.1136/bmjqs-2020-011165.
3. Sun J, Girling AJ, Aldridge C, Evison F, Beet C, Boyal A, Rudge G, Lilford RJ, Bion J. Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust. BMJ Qual Saf. 2019 Mar;28(3):223-230. doi: 10.1136/bmjqs-2018-008219.
4. Chen Y-F, Armoiry X, Higenbottam C, et al. Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis. BMJ Open 2019;9:e025764. doi:10.1136/bmjopen-2018-025764
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...
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 rarely considered[2] .
The international trend to deinstitutionalise the care of people with intellectual disabilities will require that this complex group of patients receive support from care givers and health and social care professionals in the community setting to ensure quality medication use. Pharmacists have a role to play.
Pharmacists and Adherence in Population with Intellectual Disabilities
It is thought that only around half of medicines for long-term conditions are taken as prescribed in developed countries, and there is little evidence of any improvement in adherence rates over the past 50 years[4] . Some factors that can impact adherence in the population with intellectual disabilities have been identified in USA [5] :
1. Patients with intellectual disabilities may not have the ability to fully understand the importance or impact of the medications they’re given. This altered perception or ability may have profound effects on treatment, particularly for chronic conditions.
2. Patients with intellectual disabilities can also have various living situations, which can impart more challenges to medication therapy and adherence. These living arrangements can range from total independence to residing in group homes. It was found that patients with intellectual disabilities living in group homes had higher adherence rates compared with those who lived independently or in a family home.
3. Socioeconomic factors may impact these individuals’ ability to adhere to a medication regimen. Medicaid enrolment and minority race/ethnicity have been associated with reduced medication adherence in individuals with intellectual disabilities.
Almost all of the interventions found to be effective for long-term care are complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions have not led to large improvements in adherence and treatment outcomes [6]. More frequent interaction with patients with attention to adherence in every healthcare encounter appears to be a common thread in all interventions.
Pharmacists and others involved must work out how to match patients to the interventions already available. Individual interventions may only be effective when directed at the subset of the population whose reason for non-adherence is targeted by the particular intervention. This is an area in which pharmacists with specialist knowledge of adherence and other medicine related issues in the population with intellectual disabilities can play a role.
References:
[1].Flood, B. and Henman, M.C. (2015), Case study: hidden complexity of medicines use: information provided by a person with intellectual disability and diabetes to a pharmacist. Br J Learn Disabil, 43: 234-242. doi:10.1111/bld.12121 https://onlinelibrary.wiley.com/action/showCitFormats?doi=10.1111%2Fbld....
[2].Redley, M., Prince, E., Bateman, N., et al. (2013), The involvement of parents in healthcare decisions where adult children are at risk of lacking decision‐making capacity: a qualitative study of treatment decisions in epilepsy. Journal of Intellectual Disability Research, 57: 531-538. doi:10.1111/j.1365-2788.2012.01556.x
[3].Hom, C.L., Touchette, P., Nguyen, V., et al. (2015), Living arrangement and medication non‐adherence. J Intellect Disabil Res, 59: 48-54. doi:10.1111/jir.12123
[4].Nieuwlaat R, Wilczynski N, Navarro T et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014; issue 11. Art. No: CD000011.doi:10.1002/14651858.CD000011.pub4
[5].Factors Affecting Adherence in Patients with Intellectual Disabilities. 2016-11-07 09:54:07 Erik Hefti, Pharm D, MS https://www.pharmacytimes.com/contributor/erik-hefti-pharmd-ms/2016/11/f...
[6]. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub3
Conflict of Interest
None declared
Dear Editor,
We were interested to read the recent article on patient safety in remote primary care encounters by Payne et al. We have been reviewing the use of remote consultations specifically for paediatric asthma patients and would like to thank the authors for their work.
Firstly, we agree with the authors’ findings that a remote environment may exacerbate existing inequalities such as economic and language barriers. We would add that an additional factor that must be assessed is a patient’s ability to use technology. Pinnock et al. highlight the risk of virtual consultations to those who lack “e-literacy (or digital healthcare literacy)” (2). These patients must be identified and offered additional support or alternative methods of consultation to maintain the utmost level of care.
Payne et al. highlight the need for a more definitive approach to escalating care rather than a “rule of thumb” or “if in doubt, put it down as urgent” approach (1). We would echo that there need to be clear guidelines and more specific thresholds for escalating care from remote to in-person visits. One suggestion by Galway et al. is having a lower threshold for seeing younger children face to face (3). Galway et al. also suggest having alternative “red-flag” signs that are unique to the remote setting. For example, multiple calls from a patient may indicate the need to escalate their care to face-to-face. More of these red-flag signs unique to this setting need to be...
Show MoreI 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.
Show MoreGiven 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...
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 MoreIn 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 MoreWe 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 MoreWe 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.
Show More1. 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...
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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].
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Show MoreThe 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 MoreWe 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.
Show MoreOne 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...
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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