OBJECTIVES: To evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.
METHODS: A pre (2003) and post-intervention (2005-6) retrospective study was undertaken.
INTERVENTION: Cohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.
RESULTS: The number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.
CONCLUSION: Cohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.
METHODS: A Markov model cohort simulation with a 6-month cycle length to predict acute coronary syndrome, stroke, and heart failure throughout lifetime was performed. A cohort of 399 patients was obtained from two prospective, cluster randomized controlled clinical trials implementing physician-pharmacist collaborative interventions in community-based medical offices in the Midwest, USA. Framingham risk equations and other algorithms were used to predict the vascular diseases. SBP reduction due to the interventions deteriorated until 5 years. Direct medical costs using a payer perspective were adjusted to 2015 dollar value, and the main outcome was quality-adjusted life years (QALYs); both were discounted at 3%. The intervention costs were estimated from the trials, whereas the remaining parameters were from published studies. A series of sensitivity analyses including changing patient risks of vascular diseases, probabilistic sensitivity analysis, and a cost-effectiveness acceptability curve were performed.
RESULTS: The lifetime incremental costs were $26 807.83 per QALY (QALYs gained = 0.14). The intervention provided the greatest benefit for the high-risk patients, moderate benefit for the trial patients, and the lowest benefit for the low-risk patients. If a payer is willing to pay $50 000 per QALY gained, in 48.6% of the time the intervention would be cost-effective.
CONCLUSION: Team-based care such as a physician-pharmacist collaboration appears to be a cost-effective strategy for treating hypertension. The intervention is most cost-effective for high-risk patients.
METHODS: An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation.
RECOMMENDATIONS: Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan.
CONCLUSIONS: The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.
DESIGN/METHODOLOGY/APPROACH: All inpatient referrals to the CLiP team were recorded over a three-month period and compared to previous audit data from 2017. Four audit standards were assessed: the reporting of referrals, timeliness of response indication of reason for referral and presence of a management plan.
FINDINGS: The compliance of reporting using the CLiP form was 70.1 per cent compared to 28 per cent in the audit data from 2017 after interventions were conducted. Analysis of the completed CLiP form reveals that 89 per cent of referrals were seen within the same working day. All referrals included the reason for referral. The most common reason for referral was for depressive disorders, but post-assessment, delirium was the most common diagnosis. In total, 87.8 per cent satisfied the audit criteria for a completed written care plan.
ORIGINALITY/VALUE: Specialised CLiP services are relatively new in Malaysia and this is the first paper to examine the quality of such services in the country. Interventions were effective in improving the compliance of reporting using the CLiP database. The findings suggest that the CLiP services are on par with international audit standards. Furthermore, data from this clinical audit can serve as a benchmark for the development of national operating policies in similar settings.
DESIGN/METHODOLOGY/APPROACH: Preinterventional study was conducted in one-month period of January 2019, followed by intervention period from February to March 2019. Postintervention study was conducted from April to July 2019. The CLABSI rates were compared between pre and postintervention periods. A multifaceted intervention bundle was implemented, which comprised (1) educational program for healthcare workers, (2) weekly audit and feedback and (3) implementation of central line bundle of care.
FINDINGS: There was a significant overall reduction of CLABSI rate between preintervention and postintervention period [incidence rate ratio (IRR) of 0.06 (95 percent CI, 0.01-0.33; P = 0.001)].
PRACTICAL IMPLICATIONS: CLABSI rates were reduced by a multifaceted intervention bundle, even in non-ICU and resource-limited setting. This includes a preinterventional study to identify the risk factors followed by a local adaption of the recommended care bundles. This study recommends resources-limited hospitals to design a strategy that is suitable for their own local setting to reduce CLABSI.
ORIGINALITY/VALUE: This study demonstrated the feasibility of a multifaceted intervention bundle that was locally adapted with an evidence-based approach to reduce CLABSI rate in non-ICU and resource-limited setting.
OBJECTIVES: This study aimed to assess the feasibility and acceptability of integrating clinical pharmacists into the multidisciplinary team (MDT) to manage cancer pain and assess preliminary outcomes in cancer patients receiving pain treatment. This pilot study was undertaken to inform a future definitive randomized controlled trial (RCT).
METHODS: The protocol was registered with ClinicalTrials.gov (NCT05021393). The PharmaCAP trial was conducted in two oncology centers in Nepal, where patients were randomly enrolled into usual care (UC) or an intervention group (PharmaCAP). The latter received a clinical pharmacist-led medication review, which involved a comprehensive assessment of the patient's current medications, identification of potential drug-related problems, and personalized recommendations for optimizing pain management. This was accompanied by pain assessment, education and counseling on pain management strategies. Baseline and 4-weeks post-intervention assessments measured primary outcomes, i.e., feasibility metrics (recruitment of the patients, retention of patients, patient satisfaction). Secondary outcomes included pain intensity, health-related QoL, anxiety, depression, barriers to pain management, and medication adherence at 4 weeks.
RESULTS: Out of 140 screened patients, 108 were evaluated for eligibility, with 16 opting out primarily due to lack of interest (n = 11) and communication barriers (n = 5). A total of ninety-two participants with cancer pain were randomized into two groups, with 91 patients successfully recruited and 85 (93.4%) completing 4 weeks post-intervention assessment). Completion rates for the UC and PharmaCAP groups were 91.3% and 93.4%, respectively. The primary feasibility outcomes were positive: 100% of patients found random allocation acceptable. Retention rates were high, with 91.3% in the UC group and 93.4% in the PharmaCAP group, despite a few dropouts due to being unreachable, COVID-related issues, and changes in treatment centers. No evidence of contamination between groups was found, as participants did not discuss interventions or influence each other's attitudes, ensuring effective isolation of interventions The PharmaCAP intervention showed significant improvement in QoL (P patients. These findings support the feasibility of conducting a full-scale RCT. Enabling clinical pharmacists to assist with cancer pain management in low-resource settings can benefit patients, healthcare teams, and health systems.
TRIAL REGISTRATION: ClinicalTrials.gov NCT05021393. Registered on 25th August 2022.