Optimisation of hepatocellular carcinoma surveillance in patients with viral hepatitis: a quality improvement study.

BACKGROUND: Surveillance for hepatocellular carcinoma (HCC) with 6-monthly ultrasound is a standard of care for higher-risk patients with viral hepatitis. Adherence to screening guidelines is an important quality indicator in hepatology, but multiple studies have demonstrated poor HCC surveillance practices in real-world settings. AIMS: The aim of this project was to audit and then optimise HCC surveillance of viral hepatitis patients, who fulfilled criteria for screening, associated with a large tertiary hospital. METHODS: Clinical practice improvement principles were utilised. A baseline audit of 22 consecutive viral hepatitis patients was performed. Major barriers preventing adequate surveillance were identified and three interventions to improve adherence to guidelines were introduced. These included: improved doctor education, system redesign and improved patient education. The effects of interventions were measured by serial random audits of patients. A final audit occurred over 3 years after the initial baseline audit. RESULTS: At baseline, 46% and 0% of patients had appropriate surveillance performed during the prior 6 months (one surveillance cycle) and 2 years (four surveillance cycles) respectively. Three years after initiation of these strategies, a final audit revealed 92% (vs 46% at baseline) and 64% (vs 0% at baseline) of patients had appropriate HCC surveillance performed during the preceding 6 months and 2 years intervals respectively (P < 0.001 in each case). CONCLUSIONS: Simple and low-cost interventions can considerably improve the clinical effectiveness of HCC screening programmes in real world settings. Clinical practice improvement principles appear to be a valid methodology for achieving this positive change.

Single centre experience with pegylated interferon and ribavirin for hepatitis C: looking back before moving forward.

BACKGROUND: Hepatitis C treatment is successful in 40-80% of patients in drug sponsored registration trials. However, few studies have examined treatment outcomes in non-trial, routine clinical practice settings. AIM: The aim of this study was to investigate the treatment outcomes and predictors of a sustained virological response in a routine clinical setting. METHODS: Data were collected retrospectively on patients treated for hepatitis C between January 2004 and March 2010 in a tertiary hospital setting. Demographics, treatment outcomes and potential predictors of outcome (viral genotype, viral load, virological response, platelet count, alanine transaminase level, glucose, ferritin, weight, fibrosis and cirrhosis, compliance, dose reductions, adverse events, psychiatric and alcohol history) were recorded. Univariate and multiple logistic regressions were performed. RESULTS: A total of 405 patients was treated during the study period. On an intention to treat basis, sustained virological response rates were 55%, 82% and 72% in genotypes 1, 2 and 3 respectively. Predictors of response were gender, age, genotype, weight, fibrosis, cirrhosis, platelet count and alanine transaminase on univariate analysis. Age, genotype, cirrhosis and platelet count were independently associated with sustained virological response on multiple logistic regression. CONCLUSION: In our cohort, treatment outcomes for genotype 1 and 2 were similar to results from clinical trials but results for genotype 3 were inferior. Clinicians should not assume that results from registration trials are transferable to their own clinical practice. This has particular relevance for the new era of triple therapy regimens containing direct antivirals.

Accessing residential care from an acute hospital: can we be more efficient?

Hospitalized patients who require admission to residential care are often thought to make prolonged and inappropriate use of hospital resources. There are no Australian data on the factors that contribute to length of hospital stay for such patients. The aim of this study was to determine the timing of critical steps in discharge planning for hospitalized patients who need residential care. We prospectively audited 100 consecutive referrals to an Aged Care Assessment Team (ACAT) from one acute hospital in South Australia. Case notes were examined to determine the timings of critical events in discharge planning. We found 47% of patients were discharged to a nursing home, 16% to a hostel, 11% died, 10% returned home and 16% went to another facility. The average length of hospital stay was 27.2 days, and an average of 8.4 days elapsed before a decision to seek residential care was first recorded. A further 4.5 days elapsed before ACAT referral, 4.6 days before ACAT approval and 9.7 days before a residential care bed became available. We conclude that people admitted to our hospital from the community and who subsequently need residential care, spend 36% of their stay awaiting a residential care bed. Most of their hospital stay has elapsed before residential care is considered necessary and referral and approval processes have been activated. Strategies to reduce length of stay should perhaps focus on the earlier recognition of the need for residential care and accelerated referral and assessment processes. Earlier involvement by social work and occupational therapy should be considered.

Use of in-patient hospital beds by people living in residential care.

BACKGROUND: There is concern that people living in residential care in Australia make significant and often inappropriate use of acute in-patient hospital services. To date, no factual information has been collected in Australia and its absence may allow myths and negative stereotypes to proliferate. OBJECTIVE: To determine how and why people living in residential care in Australia use in-patient hospital beds. To determine the outcome of hospitalisation and functional status at 3 months following discharge. METHODS: Prospective study of 184 consecutive admissions to hospital following Emergency Department (ED) attendance involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Information was obtained from the facilities' transfer letters, and where these were inadequate or absent, telephone interviews were held with residential care staff. RESULTS: 153 people accounted for the 184 admissions. They had a mean age of 84 years and 69% were female. 61% came from hostels and 35% from nursing homes. They had a wide range of clinical problems and twice as many were admitted to medical than to surgical units. Their mean length of hospital stay was 7.9 days, 2.3 days higher than for non-same-day patients and was higher for hostel than for nursing home residents. All but two admissions were considered unavoidable though the provision of specialised care within residential care could have prevented a further 19 (10%) admissions. 96% of admissions resulted in survival to leave hospital and in 74%, people returned directly to their place of origin. At 3 months follow-up, a further 20% of the group had died while 5% were in hospital. In all, 14% of the original group were in a different long-term care facility while 56% were living at their former residence. CONCLUSIONS: People living in residential care are often hospitalised because of acute illness. In the vast majority of cases hospitalisation is both appropriate and unavoidable. Most did not require prolonged hospitalisation and were discharged alive, usually to their original residence. However, within 3 months many had died or had functionally declined. Strategies that prevent health breakdown in the residential care setting need to be developed and trialed.

Profile of people referred to an emergency department from residential care.

BACKGROUND: Elderly people in residential care are among the most infirm in society and are at high risk of developing acute medical problems. There are no Australian data on the use of acute hospital emergency services by this group. AIM: To determine patterns of use of a major public hospital's Emergency Department (ED) by elderly people living in residential care, their presenting problems and the outcome of attendance. METHODS: Prospective study of 300 consecutive referrals to a teaching hospital's ED involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Case records were examined and residential care staff were interviewed by telephone when information required clarification. This occurred in 25% of referrals. RESULTS: The 300 referrals were seen over a three month period and accounted for 2.43% of the 12,371 ED attendances during this period. During this time, at least 4.9% of people in residential care in the region were referred to the ED. The referrals involved 239 residents, 196 (82%) who were referred once only, 32 (13%) twice and 11 (5%) three or more times. Residents had a mean age of 84 years and 70% were female. A broad range of acute medical problems precipitated referral and 61% of people referred were immediately hospitalised. There was no general practitioner (GP) involvement in the management of the presenting illness in 58% of all referrals and in 45% of those where symptoms had been present for over three days. CONCLUSIONS: People living in residential care are frequently referred to an ED service, often bypassing their GP in the process. They present with a wide range of acute medical problems for which most are hospitalised. Strategies that anticipate, prevent and manage health breakdown in residential care and so minimise the need for ED referral should be trialed.