BMJ Quality & Safety最新文献

{"title":"‘This time is different’: physician knowledge in the age of artificial intelligence","authors":"Gurpreet Dhaliwal","doi":"10.1136/bmjqs-2024-017141","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017141","url":null,"abstract":"Great diagnosticians are often portrayed as recognising rare diseases that evade the efforts of mere mortals. This makes for great TV and local legends, but does not reflect daily practice, where the most common diagnostic challenge is discriminating between common conditions like pneumonia and heart failure or appendicitis and gastroenteritis. Questions about how to train the brain to make those distinctions are central to the efforts of many clinician educators. An unresolved issue is whether the structure of knowledge (about diseases and diagnostic pathways) in the physician’s long-term memory or the clinician’s mode of cognition (intuitive or analytical thinking) is more deterministic of diagnostic success. A study1 in this issue of BMJQS sheds light on this issue, but also invites a broader question: is physician cognition still essential for this task at all? In a two-phase experiment, Mamede et al 1 asked 68 internal medicine residents to recall from memory the key clinical features of six conditions (vitamin B12 deficiency, inflammatory bowel disease, hyperthyroidism, adrenal insufficiency, appendicitis, endocarditis). Physicians were categorised as high knowledge (HK) or low knowledge (LK) based on their recall of discriminating features, which are essential to differentiate one condition from common competing diagnoses. One week later, the residents were given related clinical vignettes and asked to render a diagnosis. Half of the vignettes had a salient distracting feature (SDF), a clinical finding that may prompt the physician to suspect a condition other than the correct diagnosis. For example, a vignette of a confused patient included a family history of dementia, which was irrelevant in the face of strong evidence for vitamin B12 deficiency. The authors used the SDF as a model for activating the anchoring heuristic , which is a tendency to adhere to an early judgement triggered by a data point. Essentially, …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840466","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":"Checking all the boxes: a checklist for when and how to use checklists effectively","authors":"Myrtede Alfred, Laura H Barg-Walkow, Joseph R Keebler, Alex Chaparro","doi":"10.1136/bmjqs-2023-016934","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016934","url":null,"abstract":"Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts’ feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users’ expertise.","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840739","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":"Taking action on inequities: a structural paradigm for quality and safety","authors":"Tara A Burra, Christine Soong, Brian M Wong","doi":"10.1136/bmjqs-2023-017027","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-017027","url":null,"abstract":"As quality improvement and patient safety (QIPS) practitioners, we aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. Should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement? Inattention to the equity domain in improvement efforts ignores systemic biases and can worsen inequities in health outcomes. How to measure inequity, and growing calls to reframe health equity data measurement, presentation and analysis are central to this discourse. In this issue of BMJ Quality and Safety , Arrington and colleagues1 offer strategies to collect, share and interpret quality data using a racial equity lens. The authors first describe the problems with stratifying quality data by race and ethnicity, which can perpetuate the false notion that race or ethnicity is responsible for differences in health outcomes and inhibit teams from identifying embedded structural or systemic root causes of health inequities. They provide concrete examples of reimagining data collection and presentation that are actionable and feasible. These include considering root causes beyond describing differences among racial groups, choosing reference points equitably (eg, avoiding using outcomes of white patients as reference points), presenting the most specific level of aggregation (eg, identifying race as ‘Chinese’ rather than ‘Asian’), collecting data on strengths (eg, describing groups with positive outcomes) rather than deficits, measuring racism instead of race and collaborating with community partners. Using this framework, the narrative shifts away from race and ethnicity to a focus on unjust systems, structures and practices responsible for health inequities. As articulated by Arrington and colleagues,1 adopting a racial equity lens to the interpretation of stratified QIPS data is an essential skill that …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840503","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":"Assessing quality of direct-to-consumer telemedicine in China: a cross-sectional study using unannounced standardised patients","authors":"Zhen Zeng, Dong (Roman) Xu, Yiyuan Cai, Wenjie Gong","doi":"10.1136/bmjqs-2024-017072","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017072","url":null,"abstract":"Direct-to-onsumer telemedicine (DTCT) has become popular as an alternative to traditional care. However, uncertainties about the potential risks associated with the lack of comprehensive quality evaluation could influence its long-term development. This study aimed to assess the quality of care provided by DTCT platforms in China using unannounced standardised patients (USP) between July 2021 and January 2022. The study assessed consultation services on both hospital and enterprise-sponsored platforms using the Institute of Medicine quality framework. It employed 10 USP cases, covering conditions such as diabetes, asthma, common cold, gastritis, angina, low back pain, child diarrhoea, child dermatitis, stress urinary incontinence and postpartum depression. Descriptive and regression analyses were employed to examine platform characteristics and compare quality across platform types. The results showed that of 170 USP visits across 107 different telemedicine platforms, enterprise-sponsored platforms achieved a 100% success in access, while hospital-sponsored platforms had a success rate of only 47.5% (56/118). Analysis highlighted a low overall correct diagnosis rate of 45% and inadequate adherence to clinical guidelines across all platforms. Notably, enterprise-sponsored platforms outperformed in accessibility, response time and case management compared with hospital-sponsored platforms. This study highlights the suboptimal quality of DTCT platforms in China, particularly for hospital-sponsored platforms. To further enhance DTCT services, future studies should compare DTCT and in-person care, aiming to identify gaps and potential risks associated with using DTCT as alternatives or supplements to traditional care. The potential of future development in enhancing DTCT services may involve exploring the integration of hospital resources with the technology and market capabilities of enterprise-sponsored platforms.","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840502","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":"How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study","authors":"Luis Fernando Sousa Filho, Melanie K Farlie, Terry P Haines, Peter Malliaras","doi":"10.1136/bmjqs-2023-016840","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016840","url":null,"abstract":"Background Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction. Methods This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis. Results We identified six themes: (1) ‘Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships’; (2) ‘Simple features and approaches shape the therapeutic relationship’, including small talk, time spent together and social observation; (3) ‘A sense of belonging and support fosters connections’, facilitated by clinicians providing individualised attention within the group; (4) ‘Developing therapeutic relationships can impact the delivery of core intervention components’, reflecting challenges clinicians faced; (5) ‘Therapeutic relationships can facilitate intervention engagement’, through enhanced patient understanding and confidence and (6) ‘Therapeutic relationships can contribute to patient safety and satisfaction’, with patients feeling more comfortable reporting intervention-related issues. Conclusions Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity. Trial registration number ACTRN12621001650886. All data relevant to the study are included in the article or uploaded as supplementary information.","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840464","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":"Correction: It’s time for the field of geriatrics to invest in implementation science","authors":"BMJ Publishing Group Ltd","doi":"10.1136/bmjqs-2023-016263corr1","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016263corr1","url":null,"abstract":"Prusaczyk B, Burke RE. It’s time for the field of geriatrics to invest …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140811748","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":"Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.","authors":"Kenneth A Michelson, Finn L E McGarghan, Emma E Patterson, Margaret E Samuels-Kalow, Mark L Waltzman, Kimberly F Greco","doi":"10.1136/bmjqs-2022-015314","DOIUrl":"10.1136/bmjqs-2022-015314","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.</p><p><strong>Methods: </strong>This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.</p><p><strong>Results: </strong>Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.</p><p><strong>Conclusion: </strong>Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40386518","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":"It is up to healthcare professionals to talk to us in a way that we can understand: informed consent processes in people with an intellectual disability.","authors":"Jonathon Ding, Richard Keagan-Bull, Irene Tuffrey-Wijne","doi":"10.1136/bmjqs-2023-016830","DOIUrl":"10.1136/bmjqs-2023-016830","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139641569","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":"Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial.","authors":"Sarah Skinner, Léa Pascal, Stéphanie Polazzi, François Chollet, Jean-Christophe Lifante, Antoine Duclos","doi":"10.1136/bmjqs-2022-015390","DOIUrl":"10.1136/bmjqs-2022-015390","url":null,"abstract":"<p><strong>Importance: </strong>Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs.</p><p><strong>Objective: </strong>Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.</p><p><strong>Design: </strong>National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach.</p><p><strong>Setting: </strong>40 surgical departments from distinct hospitals across France.</p><p><strong>Participants: </strong>155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses.</p><p><strong>Intervention: </strong>After the baseline assessment period (2014-2015), hospitals were randomly allocated to the intervention or control groups. In 2017-2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans.</p><p><strong>Main outcomes: </strong>Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer.</p><p><strong>Results: </strong>Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and €2 615 524 (95% CI €32 366 to €5 405 528) was avoided in the intervention hospitals postintervention.</p><p><strong>Conclusions: </strong>Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.</p><p><strong>Trial registration number: </strong>NCT02569450.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11041585/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9962617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Interrupting false narratives: applying a racial equity lens to healthcare quality data.","authors":"Lauren Anita Arrington, Briana Kramer, Serena Michelle Ogunwole, Tanay Lynn Harris, Lois Dankwa, SherWanda Knight, Andreea A Creanga, Kelly M Bower","doi":"10.1136/bmjqs-2023-016612","DOIUrl":"10.1136/bmjqs-2023-016612","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139432154","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}