BMJ Quality & Safety最新文献

{"title":"Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study.","authors":"Caitríona Cox, Thea Hatfield, Zoë Fritz","doi":"10.1136/bmjqs-2023-017037","DOIUrl":"10.1136/bmjqs-2023-017037","url":null,"abstract":"<p><strong>Background: </strong>Safety-netting is intended to protect against harm from uncertainty in diagnosis/disease trajectory. Despite recommendations to communicate diagnostic uncertainty when safety-netting, this is not always done.</p><p><strong>Aims: </strong>To explore how and why doctors safety-netted in response to several clinical scenarios, within the broader context of exploring how doctors communicate diagnostic uncertainty.</p><p><strong>Methods: </strong>Doctors working in internal medical specialties (n=36) from five hospitals were given vignettes in a randomised order (all depicting different clinical scenarios involving diagnostic uncertainty). After reading each, they told an interviewer what they would tell a 'typical patient' in this situation. A follow-up semistructured interview explored reasons for their communication. Interviews were recorded, transcribed and coded. We examined <i>how</i> participants safety-netted using a content analysis approach, and <i>why</i> they safety-netting with thematic analysis of the semistructured follow-up interviews using thematic analysis.</p><p><strong>Results: </strong>We observed n=78 instances of safety-netting (across 108 vignette encounters). We found significant variation in how participants safety-netted. Safety-netting was common (although not universal), but clinicians differed in the detail provided about symptoms to be alert for, and the action advised. Although many viewed safety-netting as an important tool for managing diagnostic uncertainty, diagnostic uncertainty was infrequently explicitly discussed; most advised patients to return if symptoms worsened or new 'red flag' symptoms developed, but they rarely linked this directly to the possibility of diagnostic error. Some participants expressed concerns that communicating diagnostic uncertainty when safety-netting may cause anxiety for patients or could drive inappropriate reattendance/over-investigation.</p><p><strong>Conclusions: </strong>Participants safety-netted variously, even when presented with identical clinical information. Although safety-netting was seen as important in avoiding diagnostic error, concerns about worrying patients may have limited discussion about diagnostic uncertainty. Research is needed to determine whether communicating diagnostic uncertainty makes safety-netting more effective at preventing harm associated with diagnostic error, and whether it causes significant patient anxiety.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"769-779"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142139172","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond polypharmacy to the brave new world of minimum datasets and artificial intelligence: thumbing a nose to Henry.","authors":"Adam Todd, Barbara Hanratty","doi":"10.1136/bmjqs-2024-017577","DOIUrl":"10.1136/bmjqs-2024-017577","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"762-764"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494910","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety netting: time to stop relying on verbal interventions to manage diagnostic uncertainty?","authors":"Georgia B Black","doi":"10.1136/bmjqs-2024-017344","DOIUrl":"10.1136/bmjqs-2024-017344","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"759-761"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494912","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"'We listened and supported and depended on each other': a qualitative study of how leadership influences implementation of QI interventions.","authors":"Liane Ginsburg, Adam Easterbrook, Ariane Geerts, Whitney Berta, Lynda van Dreumel, Carole A Estabrooks, Peter G Norton, Adrian Wagg","doi":"10.1136/bmjqs-2024-017795","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017795","url":null,"abstract":"<p><strong>Background: </strong>There is growing recognition in the literature of the 'Herculean' efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation of quality improvement (QI) and other complex team-level interventions; however, the processes by which leaders facilitate change are not well understood. The aim of this study is to examine 'how' leadership influences implementation of QI interventions.</p><p><strong>Methods: </strong>We drew on the leadership literature and used secondary data collected as part of a process evaluation of the Safer Care for Older Persons in residential Environments (SCOPE) QI intervention to gain insights regarding the processes by which leadership influences QI implementation. Specifically, using detailed process evaluation data from 31 unit-based nursing home teams we conducted a thematic analysis with a codebook developed a priori based on the existing literature to identify leadership processes.</p><p><strong>Results: </strong>Effective leaders (ie, those who care teams felt supported by and who facilitated SCOPE implementation) successfully developed and reaffirmed teams' commitment to the SCOPE QI intervention (theme 1), facilitated learning capacity by fostering follower participation in SCOPE and empowering care aides to step into team leadership roles (theme 2) and actively supported team-oriented processes where they developed and nurtured relationships with their followers and supported them as they navigated relationships with other staff (theme 3). Together, these were the mechanisms by which care aides were brought on board with the intervention, stayed on board and, ultimately, transplanted the intervention into the facility. Building learning capacity and creating a culture of improvement are thought to be the overarching processes by which leadership facilitates implementation of complex interventions like SCOPE.</p><p><strong>Conclusions: </strong>Results highlight important, often overlooked, relational and sociocultural aspects of successful QI leadership in nursing homes that can guide the design, implementation and scaling of complex interventions and can guide future research.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142614528","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Global perspectives on opioid use: shifting the conversation from deprescribing to quality use of medicines.","authors":"Aili Veronica Langford, Chung-Wei Christine Lin, Suzanne Nielsen","doi":"10.1136/bmjqs-2024-017657","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017657","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142614512","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From insight to action: tackling underperformance in health professionals.","authors":"William Martinez","doi":"10.1136/bmjqs-2024-017682","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017682","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142581277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature.","authors":"Elena Faugno, Alison A Galbraith, Kathleen Walsh, Paul J Maglione, Jocelyn R Farmer, Mei-Sing Ong","doi":"10.1136/bmjqs-2024-017506","DOIUrl":"10.1136/bmjqs-2024-017506","url":null,"abstract":"<p><strong>Objective: </strong>Diagnostic delay is a pervasive patient safety problem that disproportionately affects historically underserved populations. We aim to systematically examine and synthesise published qualitative studies on patient experiences with diagnostic delay among historically underserved racial and ethnic populations.</p><p><strong>Data sources: </strong>PubMed.</p><p><strong>Eligibility criteria: </strong>Primary qualitative studies detailing patient or caregiver-reported accounts of delay in the diagnosis of a disease among underserved racial and ethnic populations; conducted in the USA; published in English in a peer-reviewed journal (years 2012-2022); study cohort composed of >50% non-white racial and ethnic populations.</p><p><strong>Data analysis: </strong>Primary outcomes were barriers to timely diagnosis of a disease. Screening and thematic abstraction were performed independently by two investigators, and data were synthesised using the 'Model of Pathways to Treatment' conceptual framework.</p><p><strong>Results: </strong>Sixteen studies from multiple clinical domains were included. Barriers to timely diagnosis emerged at the socioeconomic and sociocultural level (low health literacy, distrust in healthcare systems, healthcare avoidance, cultural and linguistic barriers), provider level (cognitive biases, breakdown in patient-provider communication, lack of disease knowledge) and health systems level (inequity in organisational health literacy, administrative barriers, fragmented care environment and a lack of organisational cultural competence). None of the existing studies explored diagnostic disparities among Asian Americans/Pacific Islanders, and few examined chronic conditions known to disproportionately affect historically underserved populations.</p><p><strong>Discussion: </strong>Historically underserved racial and ethnic patients encountered many challenges throughout their diagnostic journey. Systemic strategies are needed to address and prevent diagnostic disparities.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"County-level racial bias is associated with worse care for white and especially black older US adults: a cross-sectional observational study.","authors":"Matthew L Mizel, Ann Haas, John L Adams, Steven C Martino, Amelia M Haviland, Bonnie Ghosh-Dastidar, Jacob W Dembosky, Malcolm Williams, Gary Abel, Jessica Maksut, Jennifer Gildner, Marc N Elliott","doi":"10.1136/bmjqs-2024-017430","DOIUrl":"10.1136/bmjqs-2024-017430","url":null,"abstract":"<p><strong>Objective: </strong>To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).</p><p><strong>Design: </strong>Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.</p><p><strong>Participants: </strong>We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003-2018, patient experience and influenza immunisation data from respondents to the 2009-2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009-2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8-2.9 million per measure).</p><p><strong>Main outcome measures: </strong>Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.</p><p><strong>Results: </strong>In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2-0.3 or less).</p><p><strong>Conclusions: </strong>To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142387871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Large language models in healthcare information research: making progress in an emerging field.","authors":"Harish Tayyar Madabushi, Matthew D Jones","doi":"10.1136/bmjqs-2024-017896","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017896","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-10-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Variation in the use of primary care-led investigations prior to a cancer diagnosis: analysis of the National Cancer Diagnosis Audit.","authors":"Nurunnahar Akter, Georgios Lyratzopoulos, Ruth Swann, Greg Rubin, Sean McPhail, Meena Rafiq, Abodunrin Aminu, Nadine Zakkak, Gary Abel","doi":"10.1136/bmjqs-2024-017264","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017264","url":null,"abstract":"<p><strong>Introduction: </strong>Use of investigations can help support the diagnostic process of patients with cancer in primary care, but the size of variation between patient group and between practices is unclear.</p><p><strong>Methods: </strong>We analysed data on 53 252 patients from 1868 general practices included in the National Cancer Diagnosis Audit 2018 using a sequence of logistic regression models to quantify and explain practice-level variation in investigation use, accounting for patient-level case-mix and practice characteristics. Four types of investigations were considered: any investigation, blood tests, imaging and endoscopy.</p><p><strong>Results: </strong>Large variation in practice use was observed (OR for 97.5th to 2.5th centile being 4.02, 4.33 and 3.12, respectively for any investigation, blood test and imaging). After accounting for patient case-mix, the spread of practice variation increased further to 5.61, 6.30 and 3.60 denoting that patients with characteristics associated with higher use (ie, certain cancer sites) are over-represented among practices with lower than the national average use of such investigation. Practice characteristics explained very little of observed variation, except for rurality (rural practices having lower use of any investigation) and concentration of older age patients (practices with older patients being more likely to use all types of investigations).</p><p><strong>Conclusion: </strong>There is very large variation between practices in use of investigation in patients with cancer as part of the diagnostic process. It is conceivable that the diagnostic process can be improved if investigation use was to be increased in lower use practices, although it is also possible that there is overtesting in practices with very high use of investigations, and in fact both undertesting and overtesting may co-exist.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-10-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494913","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}