Concomitant pulmonologist and primary care for chronic obstructive pulmonary disease: a population study.

Background: Pulmonologists provide quality care, however, their number is not adequate to take care of all the chronic obstructive pulmonary disease (COPD) needs of the population and their services come with a cost. Their optimal role should be defined, ideally based on evidence, to ensure that their abilities are applied most efficiently where needed. Objective: To determine if concomitant pulmonologist and primary care physician care after COPD hospital or emergency department discharge was associated with better health outcomes than primary care services alone. Methods: A population cohort study was conducted in Ontario, Canada from 2004 to 2011. All individuals with a COPD hospital or emergency department discharge were included. Patients who visited both a pulmonologist and a primary care physician within 30 days of the index discharge were matched to patients who had visited a primary care physician alone using propensity scores. The composite outcome of death, COPD hospitalization or COPD emergency department visit was compared using proportional hazards regression. Results: In the propensity score matched sample, 39.7% of patients who received concomitant care and 38.9% who received primary care only died or visited the emergency department visit or hospital for COPD within 1 year (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17). The former, however, were more likely to receive diagnostic testing and medications. Conclusion: Patients who received concomitant care after COPD emergency department or hospital discharge did not have better outcomes than those who received primary care alone, however, they did receive more testing and medical management.

Screening high-risk populations for lung cancer: guideline recommendations.

INTRODUCTION: The aim of this practice guideline was to develop evidence-based recommendations for screening high-risk populations for lung cancer. METHODS: The guideline was developed using the methods of Cancer Care Ontario's Program in Evidence-Based Care. The core methodology of the Program in Evidence-Based Care's guideline development process is systematic review. A systematic review had recently been completed by a collaboration of the American Cancer Society, the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. The evidence from that systematic review formed the basis of the recommendations, which were reviewed, and amended where necessary, by clinical experts in the fields of medical and radiation oncology, radiology, lung disease, and population health. RESULTS: The systematic review included eight randomized controlled trials and 13 single-arm studies evaluating screening with low-dose computed tomography (LDCT) in patients at risk for lung cancer. One large randomized trial reported a statistically significant reduction in lung cancer mortality with LDCT at 6 years compared with chest radiography. The practice guideline recommendations generally align with the parameters of the National Lung Screening Study. Deviations were described and justified by the guideline working group. The recommendations support screening persons at high-risk for lung cancer with advice for determining a positive result on LDCT, appropriate follow-up, and optimal screening interval. CONCLUSION: The benefits of screening high-risk populations for lung cancer with LDCT outweigh the harms if screening is implemented in a strictly controlled manner.

Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician.

BACKGROUND: One in seven pages are sent to the wrong physician and may result in unnecessary delays that potentially threaten patient safety. The authors aimed to implement a new team-based paging process to reduce pages sent to the wrong physician. METHODS: The authors redesigned the paging process on general internal medicine (GIM) wards at a Canadian academic medical centre by implementing a standardised team-based paging process (pages directed to one physician responsible for receiving pages on behalf of the entire physician team) using rapid-cycle change methods. The authors evaluated the intervention using a controlled before-after study design by measuring pages sent to the wrong physician before and after implementation of the redesigned paging process. RESULTS: Pages sent to the wrong physician from the GIM (intervention) wards decreased from 14% to 3% (11% reduction), while pages sent to the wrong physician from control wards fell from 13% to 7% (6% reduction). The difference between the intervention wards and the control wards was significant (5% greater reduction in the intervention group compared with the control group, p=0.008). Nurses were more satisfied with team-based paging than the existing paging process. Team-based paging may, however, introduce changes in communication workflow that lead to increased paging interruptions for certain members of the physician team. CONCLUSIONS: The authors successfully redesigned the hospital's paging process to decrease pages sent to the wrong physician. They recommend that the frequency of pages sent to the wrong physician is measured and changes be implemented to paging processes to reduce this error.