Lixin Ou

A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting

BackgroundDespite growing interest and urges by leading experts for the routine collection of patient reported outcome (PRO) measures in all general care patients, and in particular cancer patients, there has not been an updated comprehensive review of the evidence regarding the impact of adopting such a strategy on patients, service providers and organisations in an oncologic setting.MethodsBased on a critical analysis of the three most recent systematic reviews, the current systematic review developed a six-method strategy in searching and reviewing the most relevant quantitative studies between January 2000 and October 2011 using a set of pre-determined inclusion criteria and theory-based outcome indicators. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to rate the quality and importance of the identified publications, and the synthesis of the evidence was conducted.ResultsThe 27 identified studies showed strong evidence that the well-implemented PROs improved patient-provider communication and patient satisfaction. There was also growing evidence that it improved the monitoring of treatment response and the detection of unrecognised problems. However, there was a weak or non-existent evidence-base regarding the impact on changes to patient management and improved health outcomes, changes to patient health behaviour, the effectiveness of quality improvement of organisations, and on transparency, accountability, public reporting activities, and performance of the health care system.ConclusionsDespite the existence of significant gaps in the evidence-base, there is growing evidence in support of routine PRO collection in enabling better and patient-centred care in cancer settings.

The impact of implementing a rapid response system: A comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia

AIMS To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia. METHODS For the period 2002-2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002-2008; (2) before-after difference between 2008 and 2009; (3) after implementation in 2009. RESULTS During the 2002-2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period. CONCLUSIONS Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs).

Health services utilisation disparities between English speaking and non-English speaking background Australian infants

BackgroundTo examine the differences in health services utilisation and the associated risk factors between infants from non-English speaking background (NESB) and English speaking background (ESB) within Australia.MethodsWe analysed data from a national representative longitudinal study, the Longitudinal Study of Australian Children (LSAC) which started in 2004. We used survey logistic regression coupled with survey multiple linear regression to examine the factors associated with health services utilisation.ResultsSimilar health status was observed between the two groups. In comparison to ESB infants, NESB infants were significantly less likely to use the following health services: maternal and child health centres or help lines (odds ratio [OR] 0.56; 95% confidence intervals [CI], 0.40-0.79); maternal and child health nurse visits (OR 0.68; 95% CI, 0.49-0.95); general practitioners (GPs) (OR 0.58; 95% CI, 0.40-0.83); and hospital outpatient clinics (OR 0.54; 95% CI, 0.31-0.93). Multivariate analysis results showed that the disparities could not be fully explained by the socioeconomic status and language barriers. The association between English proficiency and the service utilised was absent once the NESB was taken into account. Maternal characteristics, family size and income, private health insurance and region of residence were the key factors associated with health services utilisation.ConclusionsNESB infants accessed significantly less of the four most frequently used health services compared with ESB infants. Maternal characteristics and family socioeconomic status were linked to health services utilisation. The gaps in health services utilisation between NESB and ESB infants with regard to the use of maternal and child health centres or phone help, maternal and child health nurse visits, GPs and paediatricians require appropriate policy attentions and interventions.

Ethnic and Indigenous access to early childhood healthcare services in Australia: parents’ perceived unmet needs and related barriers

Objective: To evaluate the parents’ perceived unmet needs in early childhood healthcare services among Indigenous, non‐English‐speaking background (NESB) and English‐speaking background (ESB) children and the related barriers.

The comparison of Health status and Health services utilisation between Indigenous and Non-Indigenous infants in Australia

Objective: To examine the differences in health services utilisation and the associated risk factors between Indigenous and non‐Indigenous infants at a national level in Australia.

Delayed Emergency Team Calls and Associated Hospital Mortality: A Multicenter Study.

Objective:We tested the hypothesis that responses to physiologic deterioration in hospital ward patients delayed by more than 15 minutes are associated with increased mortality. Design, Setting, and Participants:We used data from a 23-hospital cluster randomized trial (January 2004 to December 2004) of implementation of rapid response teams (intervention) versus standard practice with conventional cardiac arrest team-based responses to emergencies (control). We examined emergency calls in all hospitals. In intervention hospitals, we also examined such calls in the period before, during the introduction, and after the full implementation of a rapid response system. We studied the statistical association between such delayed calls and mortality. Main Outcomes and Measures:Hospital outcomes (mortality, unplanned ICU admissions, and cardiac arrests). Results:There were 3,135 emergency team calls in all hospitals. Overall, almost one third of such calls were delayed. In intervention hospitals, the proportion of delayed calls was similar before and after implementation of rapid response teams. Compared with control hospitals, in intervention hospitals, there was a significant decrease in the proportion of delayed calls during both the introduction (27.3% vs 34.3% weekly rate; incidence rate ratio, 0.84; p = 0.001) and the full implementation period (29.0% vs 34.5% weekly rate; incidence rate ratio, 0.84; p = 0.023). Delayed calls more likely occurred at night, in high dependence or coronary care units, in patients older than 75 years, in those with a decrease in Glasgow Coma Scale, or in those with hypotension as the reason for the call. Finally, in all hospitals, delayed calls were associated with an increased risk of unplanned ICU admissions (adjusted odds ratio = 1.56; 95% CI, 1.23–2.04; p ⩽ 0.001) and death (adjusted odds ratio = 1.79; 95% CI, 1.43–2.27; p < 0.001). Conclusions:Among ward patients, emergency team activation in response to acute deterioration triggered more than 15 minutes after detection and documentation of instability is independently associated with an increased risk of ICU admission and death.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

Objectives Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals. Setting A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002–2009 in New South Wales, Australia. Participants Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included. Outcome measures VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR). Results 2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE. Conclusions VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.

Impact of a standardized rapid response system on outcomes in a large healthcare jurisdiction

AIM To assess the impact of a standardized rapid response system (RRS) implemented across a large health care jurisdiction on reducing serious adverse events, hospital mortality and unexpected deaths. METHOD We conducted an interrupted time series (2007-2013) population-based study in the state of New South Wales (NSW), Australia to evaluate the impact of introducing a statewide standardized RRS (the between-the-flags [BTF] system) which employed a five-component intervention strategy. We studied 9,799,081 admissions in all 232 public hospitals in NSW. We studied changes in trends for annual rates of multiple key patient-centered outcomes before and after its introduction. RESULTS Before the BTF system (2007-2009), there was a progressive decrease in mortality, cardiac arrest rates, cardiac arrests related mortality, and failure to rescue rates, but no changes in mortality rate among low mortality diagnostic related group (LMDRGs) patients. After the BTF program (2010-2013), the same trends continued for all outcomes with an overall (2013 vs 2007) 46% reduction in cardiac arrest rates; a 54% reduction in cardiac arrest related mortality rates; a 19% reduction in hospital mortality; a 35% decrease in failure to rescue rates (all Ps<0.001) over seven-years. In addition, there was a new 20% (p<0.001) mortality reduction among LMDRG patients (2013 vs 2007). CONCLUSIONS The BTF program was associated with continued decrease in the overall cardiac arrests rates, deaths after cardiac arrest, hospital mortality and failure to rescue. In addition, among patients in the LMDRC group, it induced a new and significant post-intervention reduction in mortality which was never reported before.

Trends and variations in the rates of hospital complications, failure-to-rescue and 30-day mortality in surgical patients in New South Wales, Australia, 2002-2009.

Background Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator. Methods We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics. Results The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group. Conclusions The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities.