Dundee, United Kingdom
Dundee, United Kingdom

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Stivanello E.,University of Bologna | Rucci P.,University of Bologna | Carretta E.,University of Bologna | Pieri G.,University of Bologna | And 5 more authors.
PLoS ONE | Year: 2011

Background: Caesarean delivery (CD) rates have been frequently used as quality measures for maternity service comparisons. More recently, primary CD rates (CD in women without previous CD) or CD rates within selected categories such as nulliparous, term, cephalic singleton deliveries (NTCS) have been used. The objective of this study is to determine the extent to which risk adjustment for clinical and socio-demographic variables is needed for inter-hospital comparisons of CD rates in women without previous CD and in NTCS deliveries. Methods: Hospital discharge records of women who delivered in Emilia-Romagna Region (Italy) from January, 2007 to June 2009 and in Tuscany Region for year 2009 were linked with birth certificates. Adjusted RRs of CD in women without a previous Caesarean and NTCS were estimated using Poisson regression. Percentage differences in RR before and after adjustment were calculated and hospital rankings, based on crude and adjusted RRs, were examined. Results: Adjusted RR differed substantially from crude RR in women without a previous Caesarean and only marginally in NTCS group. Hospital ranking was markedly affected by adjustment in women without a previous CD, but less in NTCS. Conclusion: Risk adjustment is warranted for inter-hospital comparisons of primary CD rates but not for NTCS CD rates. Crude NTCS CD rates are a reliable estimate of adjusted NTCS CD. © 2011 Stivanello et al.


Saia M.,Hospital Services | Giliberti A.,University of Padua | Callegaro G.,Medical Directorate | Baldovin T.,University of Padua | And 4 more authors.
BMC Public Health | Year: 2010

Background: This study evaluates the epidemiological impact of RVGE hospitalisation in the Veneto Region during the period spanning from 2000-2007 along with the associated costs. The analysis was conducted in an area where rotavirus vaccination is not included into immunization programmes and is an attempt to assess the potential benefits of such introduction. Methods: To update the estimates of acute RVGE hospitalisation rates in children ≤5 years in the Veneto Region, we conducted an 8 year retrospective observational population-based analysis (2000-2007). Results: Over the study period, a total of 4,119 admissions for RVGE were reported, with a mean hospital stay of 3.5 days. The population-based hospitalisation RVGE incidence rate was 195.8 per 100,000 children aged ≤5 years (lower than other European countries). Conclusions: RVGE is an important cause of paediatric hospitalisation in the Veneto Region. The data reaffirm the substantial burden of rotavirus hospitalisations in children and the potential health benefits of the vaccination as well as the possibility of adding rotavirus vaccination to the current schedule. © 2010 Saia et al; licensee BioMed Central Ltd.


Murphy D.J.,University of Dundee | Guthrie B.,University of Dundee | Sullivan F.M.,University of Dundee | Mercer S.W.,University of Glasgow | And 2 more authors.
BMJ Quality and Safety | Year: 2012

Background: Medical revalidation decisions need to be reliable if they are to reassure on the quality and safety of professional practice. This study tested an innovative method in which general practitioners (GPs) were assessed on their reflection and response to a set of externally specified feedback. Setting and participants: 60 GPs and 12 GP appraisers in the Tayside region of Scotland, UK. Methods: A feedback dataset was specified as (1) GP-specific data collected by GPs themselves (patient and colleague opinion; open book self-evaluated knowledge test; complaints) and (2) Externally collected practice-level data provided to GPs (clinical quality and prescribing safety). GPs' perceptions of whether the feedback covered UK General Medical Council specified attributes of a 'good doctor' were examined using a mapping exercise. GPs' professionalism was examined in terms of appraiser assessment of GPs' level of insightful practice , defined as: engagement with, insight into and appropriate action on feedback data. The reliability of assessment of insightful practice and subsequent recommendations on GPs' revalidation by face-to-face and anonymous assessors were investigated using Generalisability G-theory. Main outcome measures: Coverage of General Medical Council attributes by specified feedback and reliability of assessor recommendations on doctors' suitability for revalidation. Results: Face-to-face assessment proved unreliable. Anonymous global assessment by three appraisers of insightful practice was highly reliable (G=0.85), as were revalidation decisions using four anonymous assessors (G=0.83). Conclusions: Unlike face-to-face appraisal, anonymous assessment of insightful practice offers a valid and reliable method to decide GP revalidation. Further validity studies are needed.


Fothergill R.T.,Clinical Audit and Research Unit | Watson L.R.,Clinical Audit and Research Unit | Virdi G.K.,Clinical Audit and Research Unit | Moore F.P.,Medical Directorate | Whitbread M.,Medical Directorate
Resuscitation | Year: 2014

Objective: This study reports survival outcomes for patients resuscitated from out-of-hospital cardiac arrest (OHCA) subsequent to ST-elevation myocardial infarction (STEMI), and who were conveyed directly by ambulance clinicians to a specialist Heart Attack Centre for expert cardiology assessment, angiography and possible percutaneous coronary intervention (PCI). Methods: This is a retrospective descriptive review of data sourced from the London Ambulance Service's OHCA registry over a one-year period. Results: We observed excellent survival rates for our cohort of patients with 66% of patients surviving to be discharged from hospital, the majority of whom were still alive after one year. Those who survived tended to be younger, to have had a witnessed arrest in a public place with an initial cardiac rhythm of VF/VT, and to have been transported to the specialist centre more quickly than those who did not. Conclusion: A system allowing ambulance clinicians to autonomously convey OHCA STEMI patients who achieve a return of spontaneous circulation directly to a Heart Attack Centre is highly effective and yields excellent survival outcomes. © 2013 Elsevier Ireland Ltd.


Deakin C.D.,Clinical Directorate | Deakin C.D.,University of Southampton | Fothergill R.,Clinical Audit and Research Unit | Moore F.,London Ambulance Service NHS Trust HQ | And 2 more authors.
Resuscitation | Year: 2014

Introduction: The relationship between the neurological status at the time of handover from the ambulance crew to a Heart Attack Centre (HAC) in patients who have achieved return of spontaneous circulation (ROSC) and subsequent outcome, in the context of current treatment standards, is unknown. Methods: A retrospective review of all patients treated by London Ambulance Service (LAS) from 1st April 2011 to 31st March 2013 admitted to a HAC in Greater London was undertaken. Neurological status (A - alert; V - responding to voice; P - responding to pain; U - unresponsive) recorded by the ambulance crew on handover was compared with length of hospital stay and survival to hospital discharge. Results: A total of 475 sequential adult cardiac arrests of presumed cardiac origin, achieving ROSC on admission to a HAC were identified. Outcome data was available for 452 patients, of whom 253 (56.0%) survived to discharge. Level of consciousness on admission to the HAC was a predictor of duration of hospital stay (P<. 0.0001) and survival to hospital discharge (P<. 0.0001). Of those presenting with a shockable rhythm, 32.3% (120/371) were 'A' or 'V', compared with 9.1% (9/99) of those with non-shockable rhythms (P<. 0.001). Conclusion: Patients with shockable rhythms achieving ROSC are more likely to be conscious (A or V) compared with those with non-shockable rhythms. Most patients who are conscious on admission to the HAC will survive, compared with approximately half of those who are unconscious (P or U), suggesting that critical care is generally appropriate at all levels of consciousness if ROSC has been achieved. © 2014 Elsevier Ireland Ltd.


McNab D.,Medical Directorate | McNab D.,University of Glasgow | Bowie P.,Medical Directorate | Bowie P.,University of Glasgow | And 3 more authors.
Education for Primary Care | Year: 2016

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a 'systems approach' could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a 'Just Culture' where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame 'human error'. System complexity makes reduction into component parts difficult; thus attempting to 'findand- fix' malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a 'systems approach' that can increase learning and reduce the damaging effects on morale when 'human error' is blamed. This may result in 'human error' becoming the starting point of an investigation and not the endpoint. © 2016 Informa UK Limited, trading as Taylor & Francis Group.


Kersten P.,University of Southampton | Ellis-Hill C.,Bournemouth University | McPherson K.M.,University of Auckland | Harrington R.,Medical Directorate
Disability and Rehabilitation | Year: 2010

Background. Rehabilitation is highly complex, involving multiple processes, outcomes and stakeholders. The way we deliver our services and work with our clients and their families should be informed by research approaches that produce the wide range of knowledge needed. This article aims to explore the degree to which the dominant approach to 'evidence' (the randomised clinical trial or RCT) meets those needs and discuss alternate/additional ways of gaining evidence. Methods. A critical review of the literature allowing exploration of problems encountered in rehabilitation RCTs and alterative approaches. Findings. We discuss some problematic issues related to using RCTs in rehabilitation research (for example the large number of people excluded from trials, and the small numbers of people with some neurological conditions making RCTs non-viable). Alternative approaches are discussed including clinical practice improvement studies (sometimes called practice-based evidence or PBE), which provide data on patients treated in routine practice; qualitative research, which can provide an understanding of the users of health care services to ensure they are meeting their needs; and metasynthesis, which can be used to summarise several qualitative studies to enhance our understanding of the principles underlying service delivery. Finally, we explore how clinicians and commissioners often use evidence generated by forms of research other than the RCT. Conclusion. The best answers about how to enhance rehabilitation outcomes are likely to come from a combination and integration of the most appropriate methods. In conclusion, we urge for more joined up thinking, for learning from different fields so that we can develop more effective and appropriate health care and rehabilitation.


PubMed | Bar - Ilan University, Nephrology Unit, Medical Directorate and Clalit Health Services
Type: Evaluation Studies | Journal: Primary care diabetes | Year: 2014

To evaluate the performance of general practitioners (GPs) in the care of diabetic patients in areas represented or unrepresented by quality indicators.An observational study in primary care practices. The study population was comprised of GPs who cared for 1799 patients with diabetes mellitus co-existing with stage 3 chronic kidney disease, hypertension, and cardiovascular disease. The performance of GPs was monitored twice during a 6-month interval using a regional computerized clinical data base according to the measurement and treatment of blood pressure, LDL-cholesterol level, proteinuria, hematuria, and anemia.Those parameters which were familiar to the GPs for several years as part of the Quality Indicators Program (QIP) were measured and treated at a high rate compared to parameters not included in the QIP. For example, measurement of blood pressure and testing for glycosylated hemoglobin were 99% and 98% respectively at the end point. In contrast the rate of performance of specific kidney disease-focused activities, such as referral of patients with proteinuria to nephrologic consultation was 36% at the end point.Good performance in areas monitored by Quality Indicators does not imply good quality of care in other areas for the same patients. Attention should be paid to initiating activities to raise the awareness of GPs with respect to important health parameters which are not included in the Quality Indicators Program.


PubMed | Medical Directorate and NHS Health Scotland
Type: Journal Article | Journal: Scottish medical journal | Year: 2016

Small-scale quality improvement projects are expected to make a significant contribution towards improving the quality of healthcare. Enabling doctors-in-training to design and lead quality improvement projects is important preparation for independent practice. Participation is mandatory in speciality training curricula. However, provision of training and ongoing support in quality improvement methods and practice is variable. We aimed to design and deliver a quality improvement training package to core medical and general practice specialty trainees and evaluate impact in terms of project participation, completion and publication in a healthcare journal.A quality improvement training package was developed and delivered to core medical trainees and general practice specialty trainees in the west of Scotland encompassing a 1-day workshop and mentoring during completion of a quality improvement project over 3 months. A mixed methods evaluation was undertaken and data collected via questionnaire surveys, knowledge assessment, and formative assessment of project proposals, completed quality improvement projects and publication success.Twenty-three participants attended the training day with 20 submitting a project proposal (87%). Ten completed quality improvement projects (43%), eight were judged as satisfactory (35%), and four were submitted and accepted for journal publication (17%). Knowledge and confidence in aspects of quality improvement improved during the pilot, while early feedback on project proposals was valued (85.7%).This small study reports modest success in training core medical trainees and general practice specialty trainees in quality improvement. Many gained knowledge of, confidence in and experience of quality improvement, while journal publication was shown to be possible. The development of educational resources to aid quality improvement project completion and mentoring support is necessary if expectations for quality improvement are to be realised.


PubMed | Medical Directorate and Clinical Audit and Research Unit
Type: Journal Article | Journal: Resuscitation | Year: 2013

This study reports survival outcomes for patients resuscitated from out-of-hospital cardiac arrest (OHCA) subsequent to ST-elevation myocardial infarction (STEMI), and who were conveyed directly by ambulance clinicians to a specialist Heart Attack Centre for expert cardiology assessment, angiography and possible percutaneous coronary intervention (PCI).This is a retrospective descriptive review of data sourced from the London Ambulance Services OHCA registry over a one-year period.We observed excellent survival rates for our cohort of patients with 66% of patients surviving to be discharged from hospital, the majority of whom were still alive after one year. Those who survived tended to be younger, to have had a witnessed arrest in a public place with an initial cardiac rhythm of VF/VT, and to have been transported to the specialist centre more quickly than those who did not.A system allowing ambulance clinicians to autonomously convey OHCA STEMI patients who achieve a return of spontaneous circulation directly to a Heart Attack Centre is highly effective and yields excellent survival outcomes.

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