Kathryn A. Martinez

Promoting a Culture of Safety as a Patient Safety Strategy: A Systematic Review

Developing a culture of safety is a core element of many efforts to improve patient safety and care quality. This systematic review identifies and assesses interventions used to promote safety culture or climate in acute care settings. The authors searched MEDLINE, CINAHL, PsycINFO, Cochrane, and EMBASE to identify relevant English-language studies published from January 2000 to October 2012. They selected studies that targeted health care workers practicing in inpatient settings and included data about change in patient safety culture or climate after a targeted intervention. Two raters independently screened 3679 abstracts (which yielded 33 eligible studies in 35 articles), extracted study data, and rated study quality and strength of evidence. Eight studies included executive walk rounds or interdisciplinary rounds; 8 evaluated multicomponent, unit-based interventions; and 20 included team training or communication initiatives. Twenty-nine studies reported some improvement in safety culture or patient outcomes, but measured outcomes were highly heterogeneous. Strength of evidence was low, and most studies were pre-post evaluations of low to moderate quality. Within these limits, evidence suggests that interventions can improve perceptions of safety culture and potentially reduce patient harm.

Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review

Introduction Patient-centeredness is central to healthcare. Hospitals should address patients’ unique needs to improve safety and quality. Patient engagement in healthcare, which may help prevent adverse events, can be approached as an independent patient safety practice (PSP) or as part of a multifactorial PSP. Objectives This review examines how interventions encouraging this engagement have been implemented in controlled trials. Methods We searched Medline, CINAHL, Embase and Cochrane from 2000 to 2012 for English language studies in hospital settings with prospective controlled designs, addressing the effectiveness or implementation of patient/family engagement in PSPs. We separately reviewed interventions implemented as part of selected broader PSPs by way of example: hand hygiene, ventilator-associated pneumonia, rapid response systems and care transitions. Results Six articles met the inclusion criteria for effectiveness with a primary focus on patient engagement. We identified 12 studies implementing patient engagement as an aspect of selected broader PSPs. A number of studies relied on patients’ possible function as a reporter of error to healthcare workers and patients as a source of reminders regarding safety behaviours, while others relied on direct activation of patients or families. Definitions of patient and family engagement were lacking, as well as evidence regarding the types of patients who might feel comfortable engaging with providers, and in what contexts. Conclusions While patient engagement in safety is appealing, there is insufficient high-quality evidence informing real-world implementation. Further work should evaluate the effectiveness of interventions on patient and family engagement and clarify the added benefit of incorporating engagement in multifaceted approaches to improve patient safety endpoints. In addition, strategies to assess and overcome barriers to patients’ willingness to actively engage in their care should be investigated.

Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer: Perception of Cure After Surgery

The objective of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. The authors sought to assess patient‐level, tumor‐level, and communication‐level factors associated with the perception of cure.

Continuity, Coordination, and Transitions of Care for Patients with Serious and Advanced Illness: A Systematic Review of Interventions

OBJECTIVES Continuity, coordination, and transitions of care are key to high-quality medical care for patients with serious and advanced illness. We conducted a systematic review to evaluate the impact of interventions targeting these areas in this population. METHODS We searched PubMed, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through 2011. We included prospective controlled studies targeting continuity, coordination, and transitions for patients with advanced illness that reported patient centered outcomes. Of 13,014 citations, 23 studies met inclusion criteria. Two investigators extracted and checked data on population, interventions, methods, outcomes, and methodological quality. RESULTS Four of the six studies evaluating patient satisfaction (67%) and four of the six studies evaluating caregiver satisfaction (67%) showed statistically significant improvements in these outcomes in the intervention compared to the control group. Only three of the nine studies (33%) measuring quality of life and five of the 16 (31%) measuring health care utilization showed improvement. Results were similar across different types of interventions. CONCLUSIONS Many studies were limited by methodologic issues such as use of measurement tools not developed for patients with advanced disease and small sample size. Interventions and outcomes were too heterogeneous for meta-analysis. We found moderate evidence that interventions targeting continuity, coordination, and transitions in patients with advanced and serious illness improve patient and caregiver satisfaction, but low evidence for other outcomes. Further research is needed on how to target these domains for outcomes such as health care utilization.

Methods for Improving the Quality of Palliative Care Delivery: A Systematic Review

Background: The effectiveness for improving the outcomes across palliative care domains remains unclear. We conducted a systematic review of different types of quality improvement interventions relevant to palliative care. Methods: We searched PubMed, CINAHL, PsycINFO, and Cochrane for relevant articles published between 2000 and 2011. Results: A total of 10 randomized controlled trials and 7 nonrandomized controlled trials were included. Of the 5 studies using relay of clinical information, 1 reported significant improvement in patient quality of life. Of the 5 studies targeting education and self-management, 4 found significant improvements in quality of life or patient symptoms. Conclusion: A minority of quality improvement interventions have succeeded in improving the quality of palliative care delivery. More studies are needed on specific quality improvement types, including organizational change and multiple types of interventions.

A Systematic Review of Health Care Interventions for Pain in Patients With Advanced Cancer

Purpose: Poorly controlled pain is common in advanced cancer. The objective of this article was to synthesize the evidence on the effectiveness of pain-focused interventions in this population. Methods: We searched MEDLINE, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through December 2011. We included prospective, controlled health care intervention studies in advanced cancer populations, focusing on pain. Results: Nineteen studies met the inclusion criteria; most focused on nurse-led patient-centered interventions. In all, 9 (47%) of the 19 studies found a significant effect on pain. The most common intervention type was patient/caregiver education, in 17 (89%) of 19 studies, 7 of which demonstrated a significant decrease in pain. Conclusions: We found moderate strength of evidence that pain in advanced cancer can be improved using health care interventions, particularly nurse-led patient-centered interventions.

Gender differences in correlates of colorectal cancer screening among black Medicare beneficiaries in Baltimore

Background: Previous research has shown colorectal cancer (CRC) screening disparities by gender. Little research has focused primarily on gender differences among older Black individuals, and reasons for existing gender differences remain poorly understood. Methods: We used baseline data from the Cancer Prevention and Treatment Demonstration Screening Trial. Participants were recruited from November 2006 to March 2010. In-person interviews were used to assess self-reported CRC screening behavior. Up-to-date CRC screening was defined as self-reported colonoscopy or sigmoidoscopy in the past 10 years or fecal occult blood testing in the past year. We used multivariable logistic regression to examine the association between gender and self-reported screening, adjusting for covariates. The final model was stratified by gender to examine factors differentially associated with screening outcomes for males and females. Results: The final sample consisted of 1,552 female and 586 male Black Medicare beneficiaries in Baltimore, Maryland. Males were significantly less likely than females to report being up-to-date with screening (77.5% vs. 81.6%, P = 0.030), and this difference was significant in the fully adjusted model (OR: 0.72; 95% confidence interval, 0.52–0.99). The association between having a usual source of care and receipt of cancer screening was stronger among males compared with females. Conclusions: Although observed differences in CRC screening were small, several factors suggest that gender-specific approaches may be used to promote screening adherence among Black Medicare beneficiaries. Impact: Given disproportionate CRC mortality between White and Black Medicare beneficiaries, gender-specific interventions aimed at increasing CRC screening may be warranted among older Black patients. Cancer Epidemiol Biomarkers Prev; 22(6); 1037–42. ©2013 AACR.

Patient-reported quality of care and pain severity in cancer.

OBJECTIVE Despite treatment availability, many cancer patients experience severe pain. Although patient assessments of care are increasingly employed to evaluate quality of care, little is known about its association with cancer symptom burden. The objective of our study was to examine the association between patient-reported quality of care and pain severity in a nationally representative cohort of cancer patients. METHOD Quality of care was measured in three domains: physician communication, care coordination/responsiveness, and nursing care. Quality scores were dichotomized as optimal versus nonoptimal. Pain was measured on a scale of 0 (least) to 100 (worst). We utilized multivariable linear regression to examine the association between patient-reported quality of care and pain severity. RESULTS The analytic sample included 2,746 individuals. Fifty and 54% of patients, respectively, rated physician communication and care coordination/responsiveness as nonoptimal; 28% rated nursing care as nonoptimal. In adjusted models, rating physician communication as nonoptimal (versus optimal) was associated with a 1.8-point higher pain severity (p = 0.018), and rating care coordination/responsiveness as nonoptimal was associated with a 2.2-point higher pain severity (p = 0.006). SIGNIFICANCE OF RESULTS Patient-reported quality of care was significantly associated with pain severity, although the differences were small. Interventions targeting physician communication and care coordination/responsiveness may result in improved pain control for some patients.

How is race/ethnicity associated with patient reporting of cancer pain in recently diagnosed colorectal and lung cancer?

50 Background: Racial and ethnic disparities in the quality of cancer pain treatment are widely documented. The purpose of this study was to examine adjusted differences by race/ethnicity in the odds of reporting pain and differences in pain severity. METHODS This study used data from Cancer Care Outcomes Research and Surveillance Consortium (CanCORS), a nationally representative cohort study of colorectal and lung cancer patients. Patients were identified following incident colorectal or lung cancer diagnosis via rapid case ascertainment. Surveys were administered between three and five months following diagnosis. Pain was assessed via patient self-report using the Brief Pain Inventory. Control variables included sex, age, education, wealth, fatalism, marital status, survey language, self-reported health status, depression, cancer stage, and care at a Veterans Administration (VA) facility. Each control variable was first individually assessed as a potential mediator in the relationship between race/ethnicity and pain severity. Final models were fully adjusted with all control variables. RESULTS Among 3,216 individuals with colorectal cancer (16.4% black), 40% reported pain; among 2,545 with lung cancer (12% black), 57% reported pain. The odds of reporting pain did not differ by race/ethnicity in lung or colorectal cancer patients in adjusted analyses. None of the included covariates significantly mediated this relationship. However, among those reporting pain, pain severity was higher for black relative to white patients in both lung (p=0.002) and colorectal cancer (p=0.000). CONCLUSIONS The odds of reporting presence of pain did not differ by race/ethnicity. However, among those reporting pain, blacks reported higher pain severity than whites in both cancer types, even after adjusting for patient and health status characteristics. Differential pain severity by race/ethnicity, particularly for black patients, may be an important consideration in assessing the quality of cancer pain management.