140 e-Letters

  • 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.

  • 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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  • 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.

  • Optimal threshold of professional nurse staff and complementary staff needed to achieve optimal outcomes

    "What is needed now is an understanding of what is the threshold of professional nurse staff and complementary staff needed to achieve optimal outcomes, and how are these levels influenced by patient nursing acuity and the education, experience, organisation and work environment of the nurse workforce." --- I agree with you. Further, this study may be approached by Park's Optimized Nurse Staffing (Sweet Spot) Estimation Theory (Park, 2017): https://onlinelibrary.wiley.com/doi/full/10.1111/jan.13284. I am doing the research now.

  • 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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  • Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study

    Krein, et al (Patient-Reported Complications Related to Peripherally Inserted Central Catheters: A Multicenter Prospective Cohort Study; Feb 2019) should be commended for sharing the results of this very interesting study. After reading it a few times, I am compelled to share the following concerns with you and the research team. The knowledge regarding PICC-related complications is indeed incomplete, but I am not sure if the main outcome(s) of your study are clearly represented to the reader.

    The word “possible” is critical to correctly interpreting the results of this study. The term “complication” implies a medical diagnosis or medical confirmation – which your study attempted to do by conducting the chart reviews to confirm the presence or absence of a PICC complication, with limited success. Terms such as signs, symptoms, issues, adverse effects, and complications are used interchangeably throughout the paper to describe the patients’ self-reported experience, but without the benefit of operational definitions. These are not synonyms. Definitions help us to have a common understanding of a word or topic; they help us get on the same page when reading about an issue.

    The word “possible” seems appropriate in the main outcome(s) statement, but is curiously missing from the report title. The phrase “medical complications” is used in the title of Table 2 – which clearly reports predominantly patient self-reported symptoms. The same bias is exhibited...

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  • Beware the pitfalls of nudge theory

    O’Reilly-Shah et al. present a novel approach to quality improvement in anaesthesia by attempting to elicit change in practice using ‘nudge theory’ derived from the field of behavioural economics [1]. Translating new research evidence into common clinical practice is an important quality issue and cheap and effective strategies to achieve this are of interest. O’Reilly-Shah et al. hypothesised that using ‘nudge-type’ interventions, an audit-feedback dashboard as well as changes to mechanical ventilator default settings, might improve anaesthesia provider compliance with this ‘lung protective’ ventilation strategy in the general operating theatre environment.
    I disagree with the conclusion that the authors have drawn, that these interventions might improve clinical and financial outcomes. My disagreement stems from the clinical rationale of the intervention, which overlaps onto the assumptions built into the ‘nudge theory’ of behavioural economics itself.
    Sunstein & Thaler, who have influenced large scale policy making in several countries, describe nudge theory as a form of choice architecture that “alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives” [2, 3]. Their philosophy is described as “libertarian paternalism”, as it influences choices that make people better off as judged by themselves, while preserving their freedom to choose otherwise. This is presumably what the interve...

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  • Health technology: boon or bane?

    I read this paper1 first published on 5 March 2018 in your journal with great interest.

    The great pace of health information technology (health IT) advancement in recent decades held promise in improving patient safety and quality of care, but unfortunately there has since been inadvertent consequences and carry-over effects of technology-related safety concerns in its use and implementation.2 This paper has further fuelled the boon or bane debate of health IT.3

    Ironically, the implementation of a national, multifaceted, quality improvement (QI) programme of ‘de-implementing’ electronic health record (EHR) notifications to primary care physicians (PCPs) has shown some benefit.1 This has, in some way, proven that being too reliant on technology in healthcare may yet rear its ugly head.

    The paper has shown that high volume of EHR notifications can overwhelm PCPs;1 the proposed measure of breaking these down into “low-value” and “high-value”, and enforcing certain mandatory ones, may merely be an intermediate stopgap technique. Determining which is which, by its nature, is difficult to do and standardise.

    Further, implementing a nationwide programme such as this poses certain challenges that the authors have not considered – will there be a difference between urban and rural healthcare facilities in its implementation, given resource limitations?4 Will technology have improved or changed by the time this programme is fully implemented nationwide?...

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